The American College of Obstetricians and Gynecologists' ethics committee on Friday issued a statement saying that it is ethical for doctors to perform elective caesarean sections on pregnant women who face no known risks from vaginal delivery, the Washington Post reports. The statement represents the first time ACOG has addressed the growing trend among pregnant women to undergo c-sections despite lack of medical necessity; approximately 25% of all infants in the United States today are delivered by c-section -- an all-time high since delivery data were first collected in 1989 -- according to the Post. The increase is fueled in part by the growing number of women who choose to have a c-section not because of labor complications but because of convenience, fear of the pain of childbirth or concerns about possible long-term complications from vaginal delivery. Proponents of elective c-sections say that the practice "pose[s] no serious risks for most women" and that pregnant women should have the freedom to choose their method of delivery, the Post reports. Opponents of the practice say that c-sections are more expensive and require longer recoveries than vaginal deliveries and that unnecessary surgery and anesthesia put women at risk of complications.

ACOG Recommendations
In its statement, the ACOG ethics committee said that the risks associated with c-section relative to the risks of vaginal delivery are unclear, and the lack of data indicates that it is not "ethically necessary to initiate discussion regarding the relative risks and benefits of elective (caesarean) birth versus vaginal delivery with every pregnant patient," according to the Post. The committee warned against "actively advocating" non-medically necessary c-sections, according to the Post. However, the committee concluded that "if the physician believes that (caesarean) delivery promotes the overall health and welfare of the woman and her fetus more than vaginal birth, he or she is ethically justified in performing" a c-section. "The burden of proof should fall on those who are advocates for ... the replacement of a natural process with a major surgical procedure," the committee wrote. ACOG ethics committee member Robert Lorenz, vice chief of obstetrics at William Beaumont Hospital in Royal Oak, Mich., said the statement was not intended to encourage elective c-sections but was intended to "provide an ethical context for making" a decision about delivery methods, according to the Post. Laura Riley, a physician at Massachusetts General Hospital and chair of ACOG's committee on obstetric practice, said the group will issue more specific guidelines on elective c-sections when more research on risks and benefits has been completed, according to the Post.

Reaction
ACOG's statement could make doctors more willing to perform elective c-sections, the Post reports. W. Benson Harer, medical director of the Riverside County Regional Medical Center in Moreno Valley, Calif., and former ACOG president, said the statement was "a step to where we're going," adding that he expects elective c-sections to become "a more accepted procedure" as more evidence about the risks of both c-sections and vaginal deliveries surfaces. David Walters, an OB/GYN in Mount Vernon, Ill., said he was disappointed that ACOG's statement did not go further, adding, "They should have said that in the absence of compelling evidence to support the superiority of either vaginal birth or caesarean section that either one is a reasonable alternative for delivery and should be considered equally." But Lorenz said, "My concern is that people will take this as a carte blanch 'Let's do caesarean sections on everyone.'" Tonya Jamois, president of the International Cesarean Awareness Network, voiced similar concerns, saying, "What I'm worried about is that this will be interpreted to justify ethically a physician agreeing to give a woman a caesarean when there's no medical indication. I think it is a bad thing for society" (Stein, Washington Post, 10/31).