Monday, June 10, 2013

Why do women choose cesarean?

I still get annoyed when those who just don't get it attempt to speculate why women choose a cesarean delivery for their child, particularly in the absence of a medical indication for one. They continue to speculate that it is because some celebrities have chosen it. Or because they need to choose a particular day for their child to be born. Or because they need to schedule the rest of their lives to accommodate the arrival of their child. Or that women who choose cesarean are just uneducated and ignorant of the wonders of vaginal birth. The paradoxical bemoaning of cesarean being "major surgery that is much harder to recover from", while at the same time being "the easy way out" continues to boggle my mind.

The reality is that the women who choose cesarean are among the most informed women I have ever encountered - not only on the specifics of delivery by planned cesarean, but also the realities of planned vaginal deliveries. They have seriously considered both options and have decided that they prefer the risks and benefits of cesarean delivery over the risks and benefits of vaginal delivery for themselves in their own circumstances. Most of them have encountered significant resistance and challenge to their choice from family, friends and their own care providers. Few women who choose cesarean (particularly among primiparous women), simply choose an elective cesarean delivery and then have that choice respected and facilitated without challenge throughout their pregnancy. Women who choose cesarean, particularly without a medical indication for one, have to be strong advocates for themselves in order to survive the inevitable criticism of their choice and to overcome barriers to realizing that choice.

The reality is that women who choose cesarean, are not doing it to emulate some celebrity idol.

The reality is that women who choose cesarean, are not generally doing it to achieve some favourable birth day for their child as most women who choose cesarean also choose a delivery that is at 39 weeks gestation unless there is a medical indication for an earlier delivery.

Some women who choose cesarean are doing it out of an unreasoning dread of vaginal delivery. Sometimes this can be addressed with counselling, sometimes it cannot. For these women, a planned cesarean provides a tremendous amount of psychological relief and enables them to enjoy their pregnancies.

Some women who choose cesarean are doing it to avoid the vagaries of vaginal delivery. It's generally accepted that an uncomplicated vaginal delivery is easier to recover from and considered better for both mother and baby - but knowing that an uncomplicated vaginal delivery will actually materialize is something that can only be known retrospectively. Many women who choose cesarean are knowingly sacrificing a chance at the ideal outcome, in the hopes of maximizing the chance of a good outcome.

Some women who choose cesarean are doing so to protect the integrity of their pelvic floors and to reduce the risk of urinary and/or fecal incontinence later in life. It is true that pregnancy on it's own poses a significant challenge to the pelvic floor - but a vaginal delivery further increases the risk of damage. Often the solution to pelvic floor problems is surgery but unfortunately surgery often fails - incontinence products and pessaries are also an option to manage the symptoms. To some women, a cesarean is a fair price to pay to minimize the risk.

Some women choose cesarean because of serious doubts about the availability of effective epidural pain relief at their planned facility of delivery. For facilities that do not have dedicated obstetric anaesthesiology - there might be delays or complete lack of availability of epidural pain relief. Sometimes this can be addressed with a planned induction, sometimes it cannot.

Some women choose cesarean because of prior birth experiences that were traumatic. Birth experiences that resulted in extensive tearing. Birth experiences that had unmanaged and intolerable amounts of pain. Birth experiences that might have lead to urinary or fecal incontinance. Birth experiences that might have resulted in long term or permanent injury to their children (HIE, brachial plexus injuries). Birth experiences that might have resulted in PTSD.

Saying that women who choose cesarean do so because celebrities choose cesarean, or to fit a child into their busy schedules, trivializes what is a very serious choice for many women. It discounts the real reasons women choose cesareans and it makes life that much more challenging for those who are wanting to choose cesarean for the delivery of their child.

We don't say women choose vaginal delivery just because "they want an easier recovery" and go on to decry the choice of planned vaginal delivery as being selfish - so why do we trivialize and disparage moms who choose cesarean, after all for many moms who are choosing cesarean, their reasons for doing so are just as valid as the moms who are choosing a vaginal delivery?


  1. Thank you for this excellent discussion! I recently delivered by maternal choice cesarean for many of the reasons you cover. I had dreaded having to explain my choice to the staff at the hospital -- I wish I could have printed out this blog post and brought it with me! -- but as it turned out, there were fewer questions than I expected, and no untoward comments.

    Friends and acquaintances (and even strangers) do ask why I had a cesarean. I am able to discuss my reasons with most people, but there are a few who are so deeply invested in the "cesareans of convenience" trope that I've let/helped them believe the surgery was medically necessary. It's cowardly and does not help the broader discussion, I know. But sometimes the bias is so strong that the consequences (e.g., to employment) are too great to risk.

    Thank you again for your tireless work on this issue!

  2. BC AnesthesiologistJune 12, 2013 at 9:13 AM

    Thank you for creating an open dialogue on these important issues, and for all your efforts arguing for better access to non-judgemental childbirth care.

    As far as friends, acquaintances, and strangers, another suggested answer to the probing questions is: "I'd like to maintain the confidentiality of my medical care, but I'm confident that my baby and I will be receiving the best care possible."

    As far as those looking after you for the cesarian, please realize that there are medical reasons why we "need" to ask you about the reason for your cesarian. For example, as an anesthesiologist (who is completely non-judgemental about maternal choice), I always ask about the reason. During the cesarian, I'm making sure that mom is comfortable, but even more I'm also busy making sure that mom's and baby's medical condition are safe. Each reason for cesarian (breech, maternal choice, placenta previa, prior cesarian, etc.) has its own medical considerations; and that knowledge helps me ensure that I am providing the best medical care for mom and baby. So, although I recognize that cesarian moms arrive at the hospital already having faced the "inquisition" by the lay public, realize that we have to ask those questions, and it's not necessarily a "judgemental" issue for us. (By the way, I'd guestimate that 50% of my OR nurses choose cesarian for their delivery, so that should speak to the mindset of those who are actually looking after you during the procedure.)

    Keep up this excellent discussion.

    1. That is an excellent point and speaks to why the stigma around maternal request cesarean needs to be addressed - women need to be straight forward with their care providers. I should note the care I received with respect to the CDMR delivery of my son was excellent - and the anesthesiologist was awesome! Thank you for the work you do.