PROMINENT UROGYNECOLOGIST OFFERS PERSPECTIVE ON ELECTIVE C-SECTION

Approximately one-third of American births are now carried out by cesarean section. This increase is largely due to a philosophical change within the practice of obstetrics and gynecology that has begun to view elective cesarean as an ethically sound practice in the prevention of pelvic organ prolapse, urinary and fecal incontinence, and sexual dysfunction.

In a recently published article (i) pelvic reconstructive surgeon Ingrid Nygaard gave the reasons she believes suggesting to women that elective cesarean delivery will eliminate the lifetime risk of urinary and fecal incontinence is “disingenuous.” Nygaard states, “There is no doubt that many factors exist to support the contention that a global policy of elective cesarean delivery is ill-advised.”

To prove her point, Nygaard employs the widely accepted definition of single-cause disease.

“In single-cause diseases, the cause (in this case, vaginal delivery) is both necessary and sufficient to cause the disease. Vaginal delivery would be necessary for pelvic floor disorders, if (and only if) the non-occurrence of vaginal delivery guarantees the non-occurrence of pelvic floor disorders. Vaginal delivery would be sufficient for the development of pelvic floor disorders, if (and only if) the occurrence of vaginal delivery guarantees the occurrence of pelvic floor disorders. Nearly eight in nine women deliver babies, usually via the vaginal route. However, according to a regional study, only one in nine undergoes surgery for pelvic floor disorders (ii). Clearly, vaginal delivery itself is not sufficient to cause the endstage disease of operable pelvic floor disorders. In addition, nulliparous women [women who have never been pregnant] also get pelvic floor disorders (albeit at a lower rate), demonstrating that vaginal delivery is not necessary to cause such disorders.”

Nygaard unequivocally states that treating pelvic floor disorders as a single-cause disease obscures the truth and also obviates the need for research into this area of women’s health because, “If one considers vaginal delivery to be the sole cause for pelvic floor disorders, why look for other etiologies?”

A large population-based Norwegian study from 2003 suggests that if all her deliveries were via cesarean section, a woman’s risk of subsequently developing moderate to severe urinary incontinence would decrease only slightly from 10% to 5% (iii). The risk would not be eliminated.

The author makes the case that in beneficence-based or justice-based clinical judgment elective cesarean cannot be supported. She cites the important work of Sharma and colleagues (iv) who argue that obstetricians should “neither offer nor recommend it.”

Using operative birth as a prevention strategy for avoiding pelvic floor disorders is medically and ethically unsound. Nygaard offers an alternative strategy: “Researchers must continue to sort out which specific obstetric factors are most deleterious, and to what extent various environmental, physical and genetic factors place women at higher risk.”

i. Nygaard I Should women be offered elective cesarean section in the hope of preserving pelvic floor function? International Urogynecology Journal 16: 253-254 2005

ii. Olsen Al et al. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence Obstetrics and Gynecology 89: 501-505 1997

iii. Rorteit G et al. Urinary incontinence after vaginal delivery or cesarean section. Norwegian Journal of Medicine 348: 900-907 2003

iv. Sharma G et al. Ethical considerations in elective cesarean delivery Clinical Obstetrics and Gynecology 47: 404-408 2004