NIH rethinks elective caesarean births

It may be ''reasonable" for many women to deliver by caesarean section even without a medical need, an influential federal panel said in a draft report yesterday.

The National Institutes of Health panel concluded there is not enough evidence to assess the risks of ''maternal request" C-sections compared with natural births, but said that for now doctors should discuss the known pros and cons with a woman if she brings up the option, and decide on a patient-by-patient basis.

''We don't believe it should be discouraged or encouraged," said Dr. Mary D'Alton of Columbia, the panel's chairwoman.

The report is being released as caesarean sections have reached an all-time high: 29 percent of deliveries nationwide and 31 percent in Massachusetts, levels that have raised some concern about whether the operation is being overused.

But the members of the ''State of the Science" panel argued that there should not be a target rate for C-sections like the current federal goal of 15 percent. The goal is healthy births, not some ideal rate, they said.

The report is likely to tip the balance further in favor of C-sections, some obstetricians say.

''For many years, within the profession of obstetrics and gynecology, this has been the unthinkable: The idea that a patient should be permitted to request a caesarean delivery" with no medical need, said Dr. Michael Greene, director of obstetrics at Massachusetts General Hospital. ''I think what this conference says -- in sort of reading between the lines -- is that it allows people to think the unthinkable."

The report concluded that for women who want large families, choosing C-sections is a bad idea, because the scars they leave on the uterus can lead to complications in future births. But for women who plan only one or two children, it may be worth considering.

Groups that advocate natural births reacted to the report by warning of the known dangers of C-sections. The panel's findings have left a great many ''I don't knows," said Deanne Williams, executive director of the American College of Nurse-Midwives. But one thing is clear, she said: ''Once you have a scar on your uterus, you don't get to take it away, and we know that those scars are putting women at risk over time."

There are little good data on how many C-sections are done purely upon request, but they appear to be rising. Estimates run from 4 percent to 18 percent of all C-sections, and the reasons for such requests are believed to vary widely, from scheduling convenience to fear that the baby could be hurt during labor.

The phenomenon has spread in Europe as well, where British papers use headlines like ''Too posh to push." Tabloids have reported that many celebrities have opted for planned C-sections, including singer Britney Spears, actress Elizabeth Hurley, and model Claudia Schiffer.

''I think it's really a personal decision," said Jennifer Giovanella, a nurse from Blackstone, Mass., who had one child by C-section for medical reasons and three vaginally. ''I think many women may have elective C-sections for many reasons, and not just because they think it's the easier way out."

One contributing factor, said Greene, who was not on the panel, may be that many mothers prefer to risk themselves rather than their babies, and C-sections appear to pose more risks for the mother but fewer for the baby than vaginal birth.

The panel did its best to gather data on the pros and cons for mother and child, but much of the evidence was weak.

Among its findings: Mothers who deliver by C-section tend to stay in the hospital longer than those who deliver vaginally. Also, mothers who delivered by C-section incurred double the risk of having an abnormal placenta in a future birth.

The panel warned that women should be at least 39 weeks' pregnant before having the operation.

For the babies, elective C-sections seemed to reduce the risks of stillbirth, brain hemorrhage, asphyxia, and other complications associated with the rigors of labor or with staying in the womb longer than 39 weeks.

The panel did not examine the economic implications of maternal choice C-sections. Insurance coverage appears unlikely to change in view of the panel's findings: as it is, coverage of C-sections does not require proof of medical justification, according to officials at Harvard Pilgrim Health Care and Blue Cross and Blue Shield of Massachusetts.

Panelists wrote that women who want a natural birth should be supported in that goal.

Carey Goldberg can be reached at goldberg@globe.com.