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Moms who planned C-sections report high satisfaction, study says

Dawn Cofiell was adamantly opposed to delivering her son Donovan by cesarean section three years ago, but a complication made it unavoidable.

The experience was so smooth, pain-free and convenient that she surprised her doctor with requests to plan the major abdominal surgery for her next two children, Brayden and Kaitlyn.

"At first I was bummed about the fact that I had to have a C-section," said the Parkville mother, who delivered her children at Greater Baltimore Medical Center in Towson. "But I had such a good recovery and experience that I decided to go with what worked for the second and third."

Cofiell's experience has become relatively common, helping to accelerate the number of the C-sections nationwide — they've increased 53 percent from 1996 to 2008, the most recent data available. That trend has alarmed many doctors and public health officials, who are concerned about the surgery's risks. But it's also a sign that new mothers' satisfaction is now a real consideration in birthing decisions.

Doctors at GBMC and Johns Hopkins Bayview Medical Center who studied the issue say emotional well-being is important because a negative birth experience has been linked to postpartum depression, which afflicts one in 10 women, government data shows.

The doctors found that women who planned C-sections were much more satisfied with their experiences than those who planned vaginal births — partly because more than a quarter of the latter group ended up with unplanned cesareans.

"There is not enough evidence that we should offer everyone a C-section; we're not at that point," said Dr. Joan Blomquist, an obstetrician-gynecologist at GBMC, which has the fourth-busiest maternity department in Maryland.

"But for the right patient, it might be the right decision," said Blomquist, who was Cofiell's doctor. "At least we need to make sure they understand all the possibilities, that they don't have unrealistic goals."

The findings, reported in a recent issue of the American Journal of Perinatology, were surprising in that C-sections have been linked to higher rates of postpartum depression in past studies and vaginal births have been found to be more satisfying for mothers.

The research by Blomquist and Dr. Victoria Handa, an obstetrician-gynecologist at Johns Hopkins Bayview Medical Center, grew out of a conference at the National Institutes of Health about the growing number of C-section requests. The officials wanted to know what women were expecting from cesareans, and they funded the doctors' investigation.

The study polled 160 women planning vaginal delivery and 44 planning C-sections. The women were asked eight weeks after delivery about their fulfillment, distress and difficulty. They rated their satisfaction with the childbirth experience on a scale from one to 100 and how they felt right after birth using descriptors such as "disappointed," "enthusiastic" and "cheated."

Those planning C-sections reported higher satisfaction, higher fulfillment and lower distress and difficulty, and a more favorable overall experience than those planning vaginal birth.

The federal Centers for Disease Control and Prevention reported that about one-third of U.S. women giving birth had C-sections in 2008, the latest data available. The number crossed all races and ages.

Most of the busiest baby hospitals in Maryland were near the national average. GBMC had the highest rate at 45 percent, a number officials there attributed to women such as Cofiell who chose C-sections for subsequent deliveries, a higher number of high-risk pregnancies and requests for tubal ligations after delivery. Bayview had the lowest rate of cesareans among the busy baby hospitals with 18.5 percent.

Doctors say mothers are demanding more frequently to have labor induced, which makes them twice as likely to have a C-section. Doctors who fear malpractice lawsuits also may turn to cesareans more. A higher number of twins and triplets might be a factor, and obese mothers who are often hypertensive or diabetic.

In recent years, there has been a push by many hospitals, physician associations and government agencies to slow the use of C-sections for nonmedical reasons. Doctors say the surgery can lead to complications that include hemorrhaging and infections, and it takes the mothers longer to recover.

The National Institutes of Health said last year that it is safe for women to have a vaginal birth after C-section, known as VBAC, and should be encouraged. But some hospitals still do not regularly perform them. GBMC, for example, has started offering free classes on the subject, and Cofiell said she was counseled about VBAC but declined.

The demand for C-sections shows how times have changed, said Dr. Nada Stotland, a Chicago psychiatrist and former president of the American Psychiatric Association. Fifty to 60 years ago, women were much more upset about the procedure because they knew they had a major complication or felt they had failed in some way, she said. Even after a resurgence of support for natural childbirth, a C-section carries no stigma today.

Although the change in attitude is good news for women who need C-sections, Stotland said, it encourages others to undergo potentially risky surgery for nonmedical reasons such as convenience or fear of pain. Women who requested a C-section because they were overwhelmed by their fear of labor pain remain afraid, even though modern medicine means no one has to endure pain, she said.

"How much this figures into an individual's psyche is nothing we can measure, because we can't do randomized studies by making some women have C-sections and some vaginal births," she said. "Instead, we absolutely should have more counseling. Labor is OK, and they'll survive. Most births go very well; there's no good evidence now to circumvent Mother Nature."

But while many doctors seem to agree that too many C-sections are performed for nonmedical reasons, they might not understand how birthing options affect patients.

The GBMC study can help doctors with that, said Dr. George A. Macones, professor and chair of the department of obstetrics and gynecology at Washington University in St. Louis. He has studied labor induction and VBAC, and has worked closely with the American College of Obstetrics and Gynecologists.

Though he'd like to see more studies — and, indeed, Blomquist and Handa plan to continue the research — Macones' initial reaction is that counseling is likely lacking in some doctors' offices. He said women who have more information might be less likely to opt for C-sections or inductions, and less likely to be disappointed if they end up with an unplanned surgery.

"I personally do think there are too many C-sections, and the moms and babies aren't any better off," said Macones. "In my career I've done one completely elective C-section [though] many people have asked."

Still, for a woman's mental well-being, "I'd be willing to do it if I felt the patient understood the risks and had been counseled fully," he said.

At Mercy Medical Center, Baltimore's busiest baby hospital and among the busiest in the state, the focus will remain on lowering the C-section rate, said Dr. Robert Atlas, chairman of the department of obstetrics and gynecology. Data show that Mercy performs a slightly below-average number of cesareans and has one of the highest rates of vaginal births after C-sections in the state.

Atlas said a discussion could reveal a woman's true motivation for requesting a cesarean section. A mother might have a fear of labor, or might want to ensure that her doctor delivers the baby and not the practice's on-call physician. A meet-and-greet with the other doctors could help, he said. Counseling could help others with different fears.

"The issue is, we're not always listening to the patients," he said. "But sometimes what they want isn't what's best for them. We should be talking to our patients, but we should also be counseling them."

Handa, a professor of obstetrics and gynecology at Johns Hopkins, said doctors in general are making an effort to listen to their patients, and that is why some are agreeing to more cesareans.

She said women are getting information from many sources, including the Internet and television, though they might not be attending traditional childbirth classes as much as they once did. And they seem more accepting of C-sections and have no guilt or ill feelings.

"With respect to women's preferences, this study is reassuring," Handa said. "It suggests when women choose, along with their doctors, a cesarean, it's a satisfying experience. Of course, satisfaction shouldn't be the only measure, but it has to be one piece of the puzzle."

C-section rates

About 32 percent of U.S. babies were born via C-section in 2008, up 53 percent from 1996. In Maryland, the average was just over 33 percent. Rates for the state's top hospitals for deliveries and the total number of deliveries (in parentheses) from July 2009-June 2010:

Holy Cross Hospital: 35 percent (8,450)

Anne Arundel Medical Center: 37 percent (5,265)

Shady Grove Adventist Hospital: 35 percent (4,939)

Greater Baltimore Medical Center: 45 percent (4,406)

Howard County General Hospital: 33 percent (3,377)

Johns Hopkins Hospital: 23 percent (2,907)

Mercy Medical Center: 31 percent (2,766)

Franklin Square Hospital Center: 30 percent (2,546)

Frederick Memorial Hospital: 30 percent (2,378)

Prince George's Hospital Center: 30 percent (2,248)

Johns Hopkins Bayview Medical Center: 19 percent (2,227)

Sources: Maryland Health Care Commission; U.S. Centers for Disease Control and Prevention