Transcript for the to the Good Morning America’s
Tues. June 20, 2000
program with Diane Sawyer
The "Maternal Choice" elective Cesarean Section
(medically unnecessary) to 
avoid the infrequent and 
non-fatal complications
of normal childbirth

with Dr. Marsden Wagner and Dr. Benson Harer,  president
of the American College of Obstetricians and Gynecologists

(1) Transcript 6/20/00 show ~  Responses & Rebuttals by (2)  Citizens for Midwifery

(3) International Cesarean Awareness Network  ~  (4) California College of Midwives

(5) Failure of Elective Cesarean Surgery to Prevent Pelvic Floor dysfunction

(6) Health Advantages of Physiological Management 
and Increased Medical Risks of Cesarean Surgery

Diane SAWYER: There is a great debate beginning to emerge in the medical community. Each year, one in every five babies in America today comes into the world through a cesarean section, the country's most common surgery

It's also fast becoming the country's most controversial procedure because the conventional wisdom that women should avoid cesarean section may in fact be shifting and some obstetricians are now calling the cesarean section preferable to vaginal births. And they believe that women should at the very least have the option to choose between the two and that insurance companies should basically pay for the same equally and treat them equally.

Well joining us now, Dr. W. Benson Harer, the president of the American College of Obstetricians and Gynecologists, who is in favor of giving women the choice to have c/sections. And with an opposing view, Dr. Marsden Wagner, former director of Women's & Children's Health for the World Health Organization.

Good to have you both here, it's like weighing in on each side here. And I want to say Dr. Harer that you are not speaking for the American College of Obstetricians and Gynecologists....

HARER Thank you. It's my personal views.

SAWYER are speaking for yourself. One in five now have cesarean sections but you say cesareans are safer and in fact better, and that in the future, women should be able to choose and in fact that maybe they should be routine.

HARER That's not quite exactly it, but what I say is that women should be given the facts and then given the choice.

SAWYER But you said that there are 3 to 4 times more problems...


SAWYER ...a higher rate of problems, with vaginal birth than with cesarean section.

HARER: For the baby, the risks are far higher for vaginal delivery than for an elective cesarean section at term. For the mother, the immediate risks for a cesarean section are a little higher, but the longer term risks of pelvic dysfunction, urinary incontinence, anal incontinence, pelvic dysfunction--those risks are higher for vaginal birth and over the long time I think that the risk balance out that there really is no big difference.

SAWYER What about this, Dr. Wagner, if it's better for the baby, if over the long term, it balances out to better for the mother, why shouldn't women at least be able to choose it?

WAGNER Because in fact if you really study the scientific literature carefully, there can be no doubt, that to say that cesarean section is perfectly safe for the baby has to be labeled a lie. It is absolutely not true.

SAWYER Why? What is the risk?

WAGNER Well, let me give you the risk. First of all, when the surgeon picks up the scalpel and cuts open the woman's belly, in 2 to 6 percent of cases, he also cuts into the baby. There's a risk. Secondly of all, there's good scientific data that if the baby is born by cesarean there is a much greater risk of something called Respiratory Distress Syndrome, which is a big killer of babies, and..

SAWYER It's because when the baby comes vaginally it presses the lungs and forces...

WAGNER There you go.

SAWYER ...the mucous out of the lungs.

WAGNER There you go.

SAWYER [to Harer] What about this?

HARER The difference is with most of the statistics for cesarean come out of emergency cesareans where there is a problem with the mother. What I'm talking about is an elective cesarean section at term with a healthy baby where she's had good prenatal care and we know that the baby's condition is good. In that case this condition is extremely rare.

SAWYER But why change...

WAGNER All of what I am saying about risk for the woman and baby I am using elective cesarean not emergency cesarean. The cutting of the baby happens, the Respiratory Distress Syndrome does happen more often with cesarean than with vaginal birth and so does prematurity which is another big killer of babies.

SAWYER I don't know whether we can solve these statistics here although we'll look into them and try. [to Wagner] But I want to ask you this--you think the motive is a little suspicious. You think that doctors want surgeons present at every birth. You think that at the end of the day that it's less litigation for the doctor. Right?

WAGNER Anybody who thinks that those obstetricians that promote cesarean are promoting it because they suddenly discovered women's rights, well, I'm ready to sell some swampland in Florida to those people because that's extremely naive. Because there are compelling reasons why obstetricians prefer more cesarean. First of all, it means....excuse me.

SAWYER I was just going to let Dr. Harer answer you to these charges.

WAGNER First of all, it means that there is convenience. You see, an obstetrician--the average birth is 12 hours, a cesarean is 20 minutes!

SAWYER Dr. Harer, what about this, is this for your convenience?

HARER No, not at all, I really believe that physicians are motivated to do what's best for their patients and I believe that the average patient can make her own decision about what's best for her.

SAWYER Don't you worry that something has worked well for, well, 50,000 known years at least in the species, has a reason?

HARER Until this last century, 1 out of every 100 women who got pregnant died and its still that way today in Nigeria, or in Gambia, and the third world nations.

SAWYER And you have also said that today babies are bigger and that that is increasing.

HARER That's true. The weight of babies has been going up and as the babies get bigger the risk of damage to the mother is very high. Six percent will have fecal or urinary incontinence after deliveries today.

WAGNER There is no scientific evidence that doing over 10 percent of births with a cesarean improves the outcome for the woman or improves the outcome for the baby. There's data from all over the world, including the US and Germany and France...

SAWYER Here's my promise to our viewers out there since we have, as I say, these irreconcilable positing of the facts here. We're gonna see if we can reconcile them and we'll come back to you later on and let you know what we conclude. But we appreciate you setting up this debate for us. 'Cause it's not gonna end, it's just beginning.**

** No future programs on this subject have been aired in the following 2 years . 

Revealing the failure of Cesarean to Prevent Pelvic Floor Dysfunction

Cesarean surgery does not prevent all or even the greater part of pelvic organ prolapse, which occurs in about 1% of women who have carried a pregnancy to term, regardless of the method of delivery. (Ob.Gyn.News Aug 1, 2002, Vol 36, No 16 "Elective C-Section Revisited")

This mother had such a dense epidural that she had great difficulty in pushing her baby out. After the birth, she experienced  a temporary but total incontinence for the first month following delivery.  

According to one study, women undergoing elective C-section have a 2 or 3 fold higher risk for pelvic organ prolapse and incontinence compared with woman who have never carried a pregnancy to term. A recent study in Brazil showed a 3.5 fold increase for urinary incontinence later in life after elective C-section, roughly equivalent to the rate after one vaginal delivery. In a study in Australia of more than 3,000 patients, pelvic floor dysfunction was significantly associated with all modes of delivery. Another study reports that about 11% of women have surgery for urinary incontinence.

Using the above figures on incidence of surgery for prolapse or incontinence it would be necessary to perform 23 cesareans to prevent one pelvic floor surgery later in life. 


The best strategy to prevent post-pregnancy pelvic floor dysfunction 
is Physiological Management of
labor and birth 
for healthy mothers with normal pregnancies

The elements of success for normal labor and spontaneous birth are the same regardless of location -- home, hospital or birth center. The use of physiological management makes childbearing safer, less expensive and more satisfying for both parents and the baby. 

Physiological management is statistically associated with an increase in normal labors, spontaneous births, happy mothers, healthy babies and families who are empowered and better prepared to take on the awesome task of parenting. Spontaneous labor and birth is associated with increased maternal self-esteem and a decrease in postpartum depression.

Physiologically-sound practices (midwifery model) includes: 

Continuity of care, full-time presence of the primary caregiver during active labor, social and emotional support, recognition of the sexual nature of spontaneous labor, providing psychological privacy, an upright and mobile mother during active labor, non-pharmaceutical pain management such as deep water tubs, absence of arbitrary time limits, vertical postures and the right use of gravity for pushing. 

The routine use of physiological management -- the philosophy, principles, techniques and skills of the midwifery model of care -- prevents maternal deaths from medically-unnecessary Cesarean deliveries. One does not have to be a woman or a midwife to utilize midwifery-based management techniques.   

Non-pharmaceutical pain management and natural promotion of progressive labor


Upright Positions, Walking, Social Support, Patience, One-on-One Labor Breathing,


Touch Relaxation, Tubs and Showers, Pushing on the Toilet and a Supported Squat


Right Use of Gravity

 Health Advantages of   Physiological Management 
and Increased Medical Risks of Cesarean Surgery

The advantages of normal (non-medical) management of the intrapartum includes significant reduction in the need for Pitocin augmentation of labor, narcotics pain meds, epidural anesthesia, forceps, vacuum extraction, Cesarean section surgery, post-operative complications and the serious and potentially fatal complications occurring in post-cesarean pregnancies.  

There is a measurable reduction in the mother's level of self-confidence and feelings of self-esteem after Cesarean delivery. Operative deliveries are also associated with more frequent and more sever postpartum depression.  

Immediate surgical complications of Cesarean surgery include 2 to 3 times greater incidence of maternal morbidity (illness such as hemorrhage, infection or drug reactions) & death of the mother during or after Cesarean delivery. The excess maternal mortality, disabilities and serious complications are the result of a 3 times greater rate of infection, hemorrhage, and emergency hysterectomy, 2 to 5 times increased risk of serious or fatal blood clots and 1% rate of surgical injury.  

Babies delivered by Cesarean have a higher risk of lung disorders and operative lacerations. As adults, they have a tripled rate of asthma.   

Additional risks for women delivered by Cesarean is spontaneous abortions, ectopic pregnancies and decreased fertility. 

Long-term complications arising in post-cesarean pregnancies included increased risk of placental previa, accreta, and the rarest but most serious type of abnormal placental implantation which always requires an emergency hysterectomy -- placenta percreta (fatal in approximately 7 to 10% of cases), other surgical injuries including accidentally cutting ureter, bladder or bowel; uterine rupture before or during labor, fetal death or permanent neurological disability and postpartum depression

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