Mothers aren't behind a vogue for caesareans

''TOO POSH to push." The headline, which originated in British tabloids, has been used to capture what is claimed as a trend toward an increasing number of medically elective caesareans requested by upper-class mothers. A just concluded National Institutes of Health meeting on the topic of ''Maternal Request Caesareans," both by the mere title of the conference and its draft report, suggests such a trend exists and that it contributes to a record caesarean rate in the United States.

The problem is that there is no systematic evidence of such a trend. Although some studies do describe an increase in caesareans without any medical indication, this phenomenon may not represent real ''maternal request" at all. These studies, based on birth certificates or hospital billing records, have no way of documenting whether the caesarean was initially sought by the mother, whether it was based on physician advice, or whether there was simply poor record keeping.

Moreover, there has been only one representative national study, entitled ''Listening to Mothers," that directly surveyed mothers about their birth experience, including those who had a caesarean section. It found that far less than 1 percent of mothers who had a first caesarean had requested it. Thus, although there are undoubtedly some women who do seek elective caesareans, they are hardly enough to increase the number of caesareans by 400,000 nationally since 1996. An NIH meeting that uses the title ''Caesarean Delivery on Maternal Request" may unfortunately only reinforce a public perception that women are now seeking caesareans in large numbers, without good evidence that this is the case.

The emphasis on maternal request is easy to understand. With caesarean rates at an all-time high -- accounting for 1.2 million surgeries (29% of all births) in 2004 -- there is naturally interest in seeking new explanations, and ''patient choice caesareans" makes for great media coverage. Such stories often include human interest elements, involve broader ethical issues, and briefly summarize a major social change. Notably, mothers with the highest caesarean rates in the United States -- African-American women over 35 -- are rarely featured in such coverage.

So what then is causing the increase in caesareans? Primarily changes in obstetrical practice. The world of obstetrics has changed considerably since the days when a single obstetrician handled a caseload of women to whom he or she made an extraordinary commitment -- to be at her birth no matter when that woman went into labor. Now, the overwhelming majority of obstetrical practices are group-based, substantially reducing that individual bond with a mother.

Another factor is the increasing concern about malpractice and the reality of lawsuits that may be brought even in instances when an obstetrician is not really to blame for a bad outcome. It is not surprising that in the gray area of clinical decision-making during labor, many obstetricians have substantially lowered the threshold for when they would perform a caesarean.

Caesareans, especially scheduled caesareans, allow obstetricians to exercise their surgical skills, appear to decrease the likelihood of malpractice suits, and provide more control over the scheduling of hospital and office hours. Advocates of medically-elective caesareans will also cite an array of health benefits for mothers and infants from caesareans, although the NIH conference made clear that solid evidence on the benefits of caesareans is not yet available.

Nonetheless, many women do hold erroneous assumptions about elective caesareans. For example, they may think of caesareans as reducing the pain that they will experience, and although regional anesthesia such as epidurals can reduce the experience of pain during childbirth, there is ample evidence of substantial pain after birth by caesarean.

There is much we still don't know about the impact of caesarean or vaginal birth on health outcomes. What is clear, however, is that the growth in caesareans -- which includes mothers of all ages, races and across all medical conditions -- is the result of a complicated shift in professional practice that deserves careful scrutiny. It is not primarily about mothers pressuring doctors for caesareans, as contemporary media coverage would have us believe.

Gene Declercq is assistant dean for doctoral education at the Boston University School of Public Health. Judy Norsigian is executive director of Our Bodies Ourselves.