Are Women Having Too Many C-sections?

At 30 percent of all deliveries, the current national Caesarean-section rate in the United States is twice the 15 percent maximum rate recommended by the World Health Organization and three times the preferred rate cited by many researchers.

All of which Dr. Bruce Flamm, an obstetrician with Kaiser Permanente in Riverside, Calif., says is remarkable.

But he isn't sure if it's remarkably good or remarkably bad.

Flamm says that notwithstanding the WHO recommendation -- which followed the same official U.S. health recommendations in the Healthy People 2000 initiative -- there isn't enough data to say what the appropriate C-section rate should be.

"Some of my colleagues think it should be higher," Flamm says. "I have heard some doctors say that all women should have babies by C-section, that vaginal births are archaic. Some docs have a C-section rate of 50 percent because they believe in their hearts it's the best thing for their patients."

Flamm does not include himself in the group of doctors who think vaginal births are archaic, but he does agree with the October 2006 recommendation by the American College of Obstetricians and Gynecologists -- to which he belongs -- issued against out-of-hospital births.

Even though the chance of something going wrong is very small, Flamm thinks it's safer to have all necessary equipment and personnel immediately available in case of an unforeseen emergency, which can happen even in low-risk pregnancies.

The physician organization's recommendation -- combined with the rising rate of C-sections -- is a hot topic among midwives.

Nurse-Midwife Protest Letter

The American College of Nurse-Midwives sent a letter in late November 2006 to the physician's organization taking issue with the idea that safety could only be provided in a hospital.

"The safety of birth in any setting is of utmost priority," the letter read. "The implication that there is insufficient evidence to support the safety of planned out-of-hospital birth is unsubstantiated ... Furthermore, we are not aware of evidence supporting the assertion that the hospital is the safest setting for labor, birth and the immediate post-partum period for low-risk women."

The letter went on to say that by discouraging support for out-of-hospital birth providers the organization's position could harm the culture of safety around birth, for patients and providers. It appealed for collaboration to ensure women's safety.

Stacy Brooks, a spokeswoman for the physicians' organization, says the decision to recommend only hospital births was not based on data showing home births are dangerous, but just to minimize any possible complication.

The midwives' organization, on the other hand, lists multiple studies on its Web site supporting the safety of home births.

One large study, published in June 2005 by the British Medical Journal, concluded that the safety of "planned home birth for low-risk women" in North America involving certified midwives "was associated with lower rates of medical intervention but similar mortality to that of similar hospital births."

Many midwives also say that the growing preference for hospital settings automatically leads to unnecessary and often uncomfortable interventions. A prime example is the fetal monitor, which Flamm says he thinks is used on virtually all women who labor in hospitals.

Fetal Monitors Studied

Meredith Goff, a practicing midwife on the faculty of the Yale School of Nursing, is writing a paper about the reliability of fetal monitors versus the old-fashioned fetoscope.

The former is an electronic device, usually attached to the outside of a woman's belly and less often attached through the vagina to the baby's head. The latter is a hand-held instrument a medical provider moves over the women's belly to periodically check the baby's heartbeat.