The Delivery Debate

We both still vividly remember the moment we found out we were having our first babies. It was incredibly joyful—and also very scary. We knew that decisions we made during pregnancy would have a lifelong impact on our children's health. Like most mothers-to-be we were bombarded with sometimes unwanted and often conflicting advice from relatives, friends, and colleagues. No topic seemed immune to dispute. Apricot nectar or ginger ale for morning sickness? Asparagus or grapefruit for swollen ankles? But those debates paled before the most critical question: who would we trust to bring our children into the world?

Because we were young and healthy, we were considered low-risk for problems during pregnancy or delivery, and we had some choices. Barbara selected a hospital-based midwifery practice. Pat decided on an obstetrician. Both of us were grateful to the people we picked, especially when we unexpectedly ran into trouble. Early blood tests indicated that Barbara's son might have serious birth defects, and the midwives immediately referred her to a neonatologist who helped her and her husband understand the issues they might face. It was an anxious pregnancy, and the midwives were an important source of support. Fortunately, her son was born healthy. Pat had what seemed to be a perfect pregnancy until her water broke at 23 weeks. Her husband rushed her to the hospital, where her first son was born weighing little more than a pound. The staff of the neonatal intensive care nursery used every resource they had to keep him alive and minimize damage and, thanks to their heroic efforts, her miracle baby survived and prospered.

Two decades later our sons are grown. But the issues surrounding the choice of a childbirth provider seem even more fraught, primarily because the number of women giving birth via cesarean section has increased 50 percent in the last 10 years, according to the National Center for Health Statistics. Cesareans now account for nearly a third of all U.S. births—a record high. Though they can be life-saving to both mother and baby in an emergency, and are also vital when a mother is suffering from a potentially fatal condition like preeclampsia, there are concerns that too many may be elective—a matter of choice, not medical necessity. It's not clear precisely what accounts for the overall increase in cesareans. Various reports have blamed greedy hospitals or doctors, who make more money from surgery, working mothers who schedule births in between business meetings, and the rising rate of health problems like obesity and diabetes that can lead to complications during delivery. Whatever the reason, the statistic alarms many women and has prompted many childbirth providers to wonder if mothers-to-be are getting enough information on all their delivery options.

The need to avoid unnecessary cesareans is one of the main messages of "The Business of Being Born," a new documentary by former talk show host Ricki Lake that explores various methods of childbirth. It is also fueling a national campaign, led by The Big Push for Midwives 2008, to license more midwives to preside over births at home in an effort to lower the chances of unneeded surgery. But the home-birth method, which now represents only about 1 percent of all U.S. births, has its own critics. The American College of Obstetricians and Gynecologists (ACOG) recently reiterated what it describes as its "long-standing opposition" to the practice—a statement that angered home-birth advocates, who accused ACOG of trying to limit women's choices. Between the controversy over elective cesarean sections and the debate about home births, it can be especially confusing these days for women trying to decide how and where to have their babies—and who will help them deliver. Here's a rundown of the options.

Obstetricians: With more than 50,000 members, ACOG is the major professional organization representing obstetricians. In this country, doctors preside over about 90 percent of all births, with virtually all doctor-assisted births taking place in hospitals. Dr. David Redfern, an obstetrician for 19 years who is Missouri section chair for ACOG, said the organization believes that choosing a provider with a standardized medical education—whether doctors or certified nurse-midwives—is the surest route to a safe delivery. "We are concerned about the complications that quite often arise without warning," he says. "The home-birth advocates want you to believe that they can recognize these major catastrophic things and hit the hold button while they transport the patient to the hospital and everything will be OK. That hasn't been our experience."

If you choose a doctor and hospital setting but are still concerned about the possibility of an unnecessary cesarean, ask lots of questions. Maureen Corry, executive director of Childbirth Connection, a nonprofit group, advises women to interview potential doctors and hospitals about their C-section rates. "If a doctor wouldn't talk to me about it, I would have concerns," she says. If you've already had a first child through a cesarean, you can still ask if the doctor will help you try for a vaginal delivery this time. The main concern for women who have had previous cesareans is uterine rupture, so discuss the risks and benefits with your provider.