What's wrong with this picture? A healthy woman having her first baby tells her doctor that she'd prefer to have a cesarean birth rather than experience labor. She doesn't want to wait and wonder when the baby is coming, or how much labor would hurt. The woman's doctor discusses it with her, and consents to her wishes. Wait a minute. Have we entered an alternate universe? Is this Alice Through the Looking Glass where everything is the opposite of normal? What happened to cesarean as the choice made when all else has failed and the baby must be delivered?

Recently published articles in the medical literature about incontinence in women and whether planned cesarean births provide a "sparing of the perineum," while important to study scientifically, have been of concern to me. Isn't a cesarean birth major abdominal surgery anymore? I am alarmed that the time seems to have arrived when any woman who chooses abdominal surgery for childbirth will be afforded that option. I can't help but feel that some of this rise in interest for primary cesarean birth (and of course for cesarean birth ever after, the era of the VBAC having seemingly disappeared along with the hoola hoop) is somehow anti-woman. Isn't our anatomy exactly correct for childbirth? When did it happen that women's bodies became so defective that birth must occur through surgical methods routinely? Yes, incontinence is a problem for many women. But is it vaginal birth that causes incontinence? The jury is still out on that question. A recent article reports a study of 15,307 women, finding the risk of urinary incontinence to be "higher among women who have had cesarean sections than among nulliparous women, and even higher among women who have had vaginal deliveries" (p. 900). This suggests that any birth might be associated with incontinence later in life. I was pleased to read their concluding statement: "these results...should not be used as an argument for the increased use of cesarean delivery...for the surgery itself might carry a risk of incontinence..." (p. 907). I'm betting, however, that their results will be used in exactly that way, despite the fact that other studies have found no statistically significant differences in incontinence in primiparous women who elected a primary cesarean birth and those who did not (Farrell, Allen, & Baskett, 2001).

There was also a thought-provoking article in the same issue of the New England Journal of Medicine by Minkoff & Chervenak (2003) about the ethics of planned primary cesarean births. Written as a theoretical ethical treatise only, the authors presented benefits and risks for primary cesarean birth for both the mother and the fetus. They also proposed that "...accumulating data have suggested increasing potential benefits and decreased risks associated with its performance...although the evidence does not support the routine recommendation of elective cesarean delivery, we believe it does support a physician's decision to accede to an informed patient's request for such a delivery" (p.946).

Is this the future? Just as planned primary labor inductions have become so commonplace, I don't think there's any doubt that routine planned primary cesarean births without "medical" justification are on the horizon. All of this seems to be cloaked in the name of women's autonomy, stating that women should be given a choice in these matters. But are these choices really informed? Do women who have never experienced labor and birth understand these issues a priori?

I have so many questions. First, where is nursing's outrage over this? Aren't we the patient advocates? Are we standing idly by while Rome burns, or is this newest wrinkle in labor and birth merely the liberation of women from the rigors of labor? What are nurses telling women who ask them about this? Are women being helped or hurt by suggesting that birth by cesarean is merely a choice they should be given? Has the medicalization of birth finally reached its zenith? Have women totally relinquished their control of birth to others who would now suggest that birth by major abdominal surgery is perfectly acceptable, and not a complication? I'd like to hear your thoughts about this.

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