Pencil Me In -- for a C-Section?

Despite fine health and no bad birth experiences, Michelle Brandi insisted -- months before giving birth -- that her baby be delivered by Caesarean section. A Shelton resident, Brandi grew up in Brazil, a nation known for elective Caesarean rates of up to 90 percent in some of its elite hospitals. Her doctor, Ronika Choudhary, an obstetrician/gynecologist with Women's Obstetrics and Gynecology in Trumbull, struggled to understand why Brandi would request this major abdominal surgery and asked her, "Why 90 percent?"

"That's because in Brazil the other 10 percent fall out when their mothers are on their way to the hospital," Brandi joked.

But seriously, could this be America's future?

Rather than fighting for natural births -- the rage in the U.S. just a decade ago -- a growing number of pregnant moms such as Brandi are now calmly telling their doctors long before delivery that they want to schedule a C-section. "Back when I started, if someone requested a C-section we would've sent them for psychological counseling" says Pat Burn, program director for Women and Children's Services at Greenwich Hospital.

Yet OB/GYNS throughout Fairfield County are remarking on the sudden and rapid rise of elective C-sections. And rates are up for women of all ages, all races and throughout the U.S., reports the American Journal of Public Health.

"In my first 10 years in practice, this never happened," says Dr. Michael Schechter of Putnam Gynecology & Obstetrics of Greenwich, who has been in practice for 19 years. "I saw it one or two times during the following five years. Now it happens about a half a dozen times a year out of about 600 deliveries."

The percent of moms electing C-sections with no medical necessity is still small, between 6 and 12 percent of all live births, according to a study published in March by the New Jersey Department of Health, the closest and most comparable state for which HealthyLife could find statistics about the number of C-sections performed. But since doctors say that virtually no pregnant women made this decision a decade ago, it represents an up to 12-fold jump -- and the numbers are growing fast.

Physicians struggling to accommodate this new movement have added counseling sessions about the pros and cons of what some now call "Caesareans on demand." And just six months ago, Schechter's practice added a separate hospital consent form for pregnant women who make this choice. So far, insurance companies have been paying for these elective procedures, he says. "It may be because of the potential for backlash and poor publicity if they said `no' and the patient had a bad outcome after a vaginal delivery."

While no formal data exists to explain this growing phenomenon of Caesareans on demand, OB/GYNS on the front lines say they have noticed a consistent variety of motivations.

For some, such as Brandi, the reasons may be cultural. "Every time I'd think about a normal delivery or a C-section, I didn't feel good about a normal delivery," she says.

For others, it may be fear of pain. Another of Choudhary's patients, Priya Williams of Bridgeport, seven months pregnant with her third baby, says she worried that birthing her latest baby would be as painful as her first two experiences.

But for the vast majority of pregnant moms now requesting C-sections, the number-one reason they give their doctors is that they want to protect their yet unborn baby, says Dr. William Cusick, chairman of the Department of Obstetrics and Gynecology at St. Vincent's Medical Center in Bridgeport. "The most frequent motivation relates to avoiding the potential complications of labor that may impact the baby's health," he says.

Take the perspective of a Yale-trained epidemiologist from Greenwich who asked that her name not be used for fear that her family would disapprove of her decision. "This is something I thought about even before I conceived," she says. Her studies in preventative medicine convinced her that babies -- as long as they are allowed to develop to full term (39 weeks gestation) -- have a better chance of surviving the birth experience when delivered by a planned C-section.

A less frequent reason doctors hear from moms choosing C-sections is convenience, particularly among professional women with busy lives. "The closer you get to New York City, the greater the concentration of professional women and the higher the number of elective Caesareans," Cusick says. This smaller group of pregnant moms has led to the perhaps unfair rap that women choosing elective Caesareans cesareans are "too proud to push."

A small group of women also say they worry that natural births could cause sexual or urinary problems. Numerous studies, however, including a comprehensive 2004 analysis published in the American Journal of Obstetrics and Gynecology, dispute this, concluding that pregnancy itself, "not the mode of delivery," increases this risk.

And finally, doctors say, women have started electing C-sections because they can.

In the past, the U.S. College of Obstetricians and Gynecologists, the nonprofit association representing these physicians, promoted natural births over Caesarean sections. But in 2003, the organization, placing a high value on patient choice, concluded that doctors could ethically perform Caesareans on demand as long they inform patients of the risks involved and as long as the decision does not place the mom's or baby's health in danger. The organization's decision took into account the already overwhelming rates of largely non-elective/emergency Caesareans performed and their normally positive outcomes. In Connecticut, for example, nearly 35 percent of all births are delivered by C-section, according to U.S. Department of Health statistics.

ACOG's stand, however, has been criticized and contradicted by numerous studies. The World Health Organization, the United Nations coordinating authority on international public health, for example, completed an international survey in 2010. It concluded that in both developed and developing nations, elected surgical deliveries without a medical reason put both mother and child at greater risk.

Moms, however, who safely delivered their bundles of joy by C-section, tend to dismiss this advice. Michelle Brandi recently cuddled now 8-month-old Marcus in their Shelton townhouse. "I feel great," she says, as he babbled and she played with the little guy's ringlets of brown hair. "And if I have another pregnancy I will go with a C-section again." HL

C-section risks to mother

The following are risks posed to mothers who undergo a Caesarean section in lieu of a vaginal delivery, according to a September 2011 report issued by HealthGrades:

• Blood clots

• Infection

• Excessive bleeding

• Injury to the bladder, uterus or bowel

• Longer hospital stay

• Increased recovery time -- typically 6 weeks compared with several days

• Increased risk of future infertility

• Surgical scarring

• Increased medical costs

C-section risks to baby

The March of Dimes offers this list of risks to babies born by Caesarean section:

• Babies delivered pre-term (Note: Pinpointing a baby's date of conception can sometimes be difficult. An error of one to two weeks can result in premature birth.)

• Breathing problems

• Feeding problems

• Difficulty maintaining body temperature

• Jaundice

• Babies delivered full-term

• Breathing problems

• Anesthesia-caused problems including sluggishness, inactivity and difficulty nursing