Saying 'No' to Hard Labor
SHANGHAI -- Wang Jiapin spent the months leading up to the birth of her son agonizing about whether she should have a Caesarean section. Ms. Wang's view of natural childbirth had been formed by seeing women give birth in soap operas and in "Hibiscus Town," a Chinese film in which the leading character, a streetsweeper, nearly dies during a difficult labor.
"They are all very dramatic, with lots of sweating and screaming," Ms. Wang says. "The only picture you get is a woman's suffering face ... so the only idea I had about childbirth was suffering and great pain." But fear of pain wasn't the only thing on the 27-year-old Shanghai advertising firm manager's mind. Independent Shanghai women have a modern approach to motherhood, says Ms. Wang, as her two-year-old son Qi Qi, who was born by Caesarean section, tosses toys around the family's high-rise apartment. "Women don't want to feel wasted after delivery. They want the same sex life as before."
MEDICAL VIEWS
The Doctors Have Their Say
Ms. Wang is one of a soaring number of Chinese women -- up to 6.5 million a year -- who are choosing to go under the knife for Caesarean surgery.
China now has the highest rate of Caesarean births in the world. Researchers at the World Health Organization estimate that 47% of births in China are "C-sections." Just a decade ago the figure was less than 20%.
China isn't alone in the rush to the operating theater. Around the world, healthy pregnant women, frightened of problems such as sexual dysfunction, pelvic-floor damage and labor pain, are spurning natural deliveries: in the U.S., the Caesarean rate hit an all-time high of 26.2% in 2002. In Thailand, the rate jumped from 14.8% in 1990 to about 20% in 1997. In Canada, it leapt from 15% in 1994 to 19% in 1997. In Britain, the rate went from 10% in 1985 to today's 22% figure.
In China, a confluence of unusual factors has caused the Caesarean epidemic. The country's one-child policy means the stakes are high. Chinese parents-to-be are deciding that C-sections are the safest birthing option to protect the one, precious offspring they are allowed. Colliding with that is China's obsession with anything that seems modern or high-tech. After years of basic medical facilities, the increasing availability of advanced medical technology is seducing newly affluent families who want the best that money can buy for their only children.
Frightening Episiotomy
For Ms. Wang, the Shanghai advertising manager, making the decision to have a Caesarean section operation was protracted and difficult. "Giving birth in traditional Chinese culture is a huge affair," says Ms. Wang. "Entering the door of birth is to straddle two sides: one foot is in life, and the other is in death."
Her regular gynecologist told her she was "perfectly suitable for a natural childbirth," and until late in her pregnancy she was willing to follow his advice. Still, Caesareans were in the back of her mind. Two years earlier, she had used the medical connections of her husband's family to help her elder sister find a gynecologist willing to perform an elective C-section. Afterwards, her sister repeatedly pointed out her C-section scar. "It was low and small and horizontal ... I thought maybe a C-section was not so bad," recalls Ms. Wang.
Then her mother, who had suffered through a "frightening" episiotomy (an incision in tissue near the vagina that helps facilitate childbirth), started to pile on the pressure. "In my mother's day there was not the level of care and there was a high rate of death with childbirth," says Ms. Wang. "My mother begged me: 'Please, please, look at your sister, she's kept fit and her baby is nice.' "
Families have a great influence on such matters, says Wang Qi, medical director of obstetrics at Beijing Obstetric and Gynecological Hospital. "Women usually listen to the people around them before making a decision, and women from a family with more C-sections will likely choose a C-section."
But even if no family pressure was brought to bear, Chinese women, knowing that they will only have one child, are increasingly taking advantage of the availability of Caesareans to avoid the risk and uncertainties of natural childbirth. "Women think, 'I will only have one baby, so I want it to be healthy and of high quality,' " says Dr. Wang Shanmi, director of obstetrics at People's Hospital of Peking University. "They think it is possible for their babies to suffer because of an absence of oxygen and that doctors could not predict all emergencies like (the) umbilical cord surrounding the baby's neck."
In many Western countries, childbirth is still considered a rite of passage, a painful event one must endure to reach the happy conclusion. Not so in China now. "Women here are more pragmatic," says Michael Moreton, a Canadian doctor working at the private Beijing United Family Hospital. "They see it as a modern update, and that pushing a baby out a vagina is medieval."
Coupled with that belief is the increasing availability of advanced medical technology. The medical system in China has changed a lot since the 1980s, says Wang Shanmi, of Peking University. Then, hospitals had few facilities; many didn't even have basic black-and-white ultrasonic diagnosis and fetal heart monitors, and Caesarean section technologies were immature.
"Today's natural delivery is almost the same as in the past ... however (the) C-section has seen significant improvements," says Wang Qi, of Beijing Obstetric and Gynecological Hospital. "The whole procedure only lasts for 20 to 30 minutes; anesthetic starts from the very beginning; doctors, usually a hospital's experts, will do the surgeries."
Vertical belly incisions were the norm until the late '80s, whereas in the West, doctors started to make low horizontal cuts below the panty line in the early '70s. (The low cuts are smaller and less visible once scarring has healed, and also damage no muscle, whereas vertical, or "midline" cuts, slice through multiple muscle tissue.) In addition, facilities for sophisticated medical care are increasing: the number of specialty obstetric hospitals in China has jumped from 49 to 81 in just eight years and the number of beds has increased by 50%.
There are other factors abetting the Caesarean epidemic: Chinese women have little access to information about childbirth, and there are no organizations such as the La League Leche lobbying for natural childbirth as they do in the West. And the increasing size of Chinese babies is playing a part. "We have found that Chinese women's body structure hasn't changed much during the recent years, which means their pelvises are about the same size as before; but the size of newborns are bigger," says Wang Qi, of Beijing Obstetric and Gynecological Hospital. Doctors are reluctant to deliver large babies naturally because of the increased potential for the need for intervention techniques such as episiotomy or forcep or vacuum deliveries.
Traditional Beliefs
The Caesarean increase may also be motivated by greed. "Hospitals don't earn any money from a natural delivery," says Wang Shanmi of Peking University. "I once said that if all the women at our hospital choose C-section, we could cut off half of the nurses and half of the hospital wards at the obstetrics department." In Beijing's big hospitals, the cost of a regular birth is between 3,000 and 5,000 yuan ($362 and $604), while Caesarean deliveries cost between 5,000 and 6,000 yuan. "Because each family only has one child, parents don't care about paying a few more thousand yuan for a one-time operation," Dr. Wang adds.
Caesareans also make it possible for families of Chinese origin to factor in traditional beliefs. Busy Hong Kong bank employee Faustina Chan had a C-section earlier this year so she could better plan her maternity leave and vacation. But she also liked the fact that she could choose an auspicious day for the birth of her child. Her feng shui master, a man who also helped her rearrange her home so there was better energy flow through the rooms, chose April 9. If she was born on that day, her daughter would be smart, attentive to her parents, and able to snag a rich husband, says Ms. Chan.
Most doctors will only allow their patients to plan a C-section a couple of weeks before the due date. Earlier than that, and there can be harmful effects to the baby, as 39-year-old Bangkok beautician Senee Wongbualuang discovered. Ms. Senee badgered her doctor into delivering her baby by Casearean section two months early so it would be born on an auspicious day. "My husband's father, who is Chinese Thai, wanted his eldest granddaughter born in the year of the golden dragon," she says, referring to a year considered especially lucky. Her doctor complied and the baby spent one month in intensive care. Ms. Senee says she was worried about the early delivery of her daughter, who is now a teenager, but "maybe the C section was good because right now my daughter is big, strong and intelligent."
Such practices alarm Viroj Tangcharoensathien, a Bangkok-based senior researcher for the International Health Policy Program (an NGO funded in part by the Thai government). To halt such births, Dr. Viroj has written a discussion paper proposing that doctors in Thailand submit all requests for Caesareans to a peer review group. "It is unethical and sub-standard medical practice for a preemie outcome from such elective C-section upon demand by the women for an auspicious day," says Dr. Viroj.
Hot Debate
According to the World Health Organization, if Caesarean operations were performed only during life-threatening emergency situations such as in the case of multiple births, when fetuses were too big, in breech position, or when the placenta blocked the cervical opening, a country's rate of Caesareans should only be 15%.
The safety of Caesarean sections has long been a subject of hot debate in the medical community and the spiraling global figures have fueled it. Many doctors are alarmed by the numbers, believing women undergoing the operation have an increased chance of serious complications, while babies are at risk if doctors miscalculate the due date and the baby is delivered prematurely.
A report issued in November last year by the American College of Obstetricians and Gynecologists has further polarized the medical community. The report, which many experts see as a subtle softening of the college's position on C-sections, may even contribute to a further increase in rates in the U.S. The organization's "committee opinion" came out in support of the permissibility of elective Caesarean delivery in a normal pregnancy "if the physician believes that Caesarean delivery promotes the overall health and welfare of the woman and her fetus more than does vaginal birth."
The opinion doesn't sit well with groups such as the National Alliance of Midwives of North America. "They weren't completely endorsing elective Caesareans, but the truth is that's the way they are going," says Susan Moray, press officer for the midwives' association. "Our response is -- it's a slippery slope."
Dr. Ben Harer, past president of the American College of Obstetricians and Gynecologists, believes it is unethical for a doctor to refuse to perform a Caesarean operation: "The time has come that we respect women's choice." Dr. Harer has long argued that it is possible that the benefits and costs are so balanced between Caesarean and vaginal delivery that the deciding factor should be the mother's preference for how her baby is delivered. It is only a matter of time before U.S. rates climb to 40%, he says. "It's a losing fight for those who've been strongly opposed to it."
Robert Lorenz, vice chief of obstetrics at the William Beaumont Hospital in Royal Oak, Michigan, was part of the organization's ethics committee that issued the opinion but doesn't advocate Caesarean sections on demand unless there are exceptional circumstances: "It's major surgery and the rate of serious complications such as pulmonary embolism and infection is high," he says. "There's also a potential risk to the baby if the doctor isn't certain of the due date and the baby is delivered a couple weeks earlier and ends up in the intensive care unit with problems." But the most dangerous potential problem is a uterine rupture during pregnancy, which can occur in women who have had prior Caesareans, he says. "It can be catastrophic, with the loss or permanent injury to the baby; hemorrhage and possible hysterectomy for the mother."
Despite the concerns however, the trend around the world -- and especially in China -- appears irreversible.
One week after she learnt she was pregnant, Beijing midwife Tian Yin decided to have a Caesarean section. Ms. Tian had no interest in experiencing natural delivery herself. But first, she had to convince her doctor, Dr. Wang Shuzhen, director of the obstetrical department at Beijing Chaoyang Hospital, who was reluctant to perform the procedure.
"I think natural delivery is better for the mother and baby." says Dr. Wang. But Ms. Tian was persistent and Dr. Wang finally agreed to perform a Caesarean section because of the baby's large size. The 30-year-old mother has no regrets. "It allowed me to focus my attention on my job," she says. It also meant she could choose an auspicious day. "June 15 is a lucky day on the Chinese lunar calendar," she adds.
向痛苦的生育说不
在儿子出生前几个月，王佳苹（音）心里一直矛盾重重，拿不定主意要不要选择剖腹产。她对自然分娩的印象都来自肥皂剧和电影《芙蓉镇》，电影里的女主角差点死于难产。
“这些场景都非常激烈惊人，剧中人汗流满面，尖叫不已。”王佳苹说，“屏幕上只有孕妇痛苦挣扎的面庞......所以我对生孩子的唯一印象就是要承受巨大的痛苦。”但对这位27岁的上海某广告公司经理来说，怕痛并不是唯一的原因。在她的高层公寓里，一边看著她两岁的儿子齐齐（音）玩耍，一边向记者说，独立的上海女性对分娩自有一套现代观点，“女人并不想在生育后就觉得自己被废掉了，她们想要从前一样的性生活。”
在中国，选择剖腹产的孕妇迅速增加，年剖腹产手术达到650万例。王女士只是其中之一。
中国是目前全世界剖腹产比例最高的国家。据世界卫生组织(World Health Organization)研究人员估算，中国47%的孕妇选择剖腹产，而10年前这个比例还不到20%。
但中国并不是剖腹产手术迅速增加的唯一国家。纵观全世界，2002年美国选择剖腹产的健康孕妇比例达到26.2%的历史高点；在泰国这个比例从1990年的14.8%升至1997年的约20%；加拿大的比例从1994年的15%升至1997年的19%；英国1985年的比例是10%，现在已经升至22%。让这些孕妇放弃自然分娩的原因多种多样，包括担心产后性机能不良、骨盆底部受损，或者对生育痛楚心怀恐惧等等。
中国的剖腹产热另有特色。独生子女政策意味著巨大的风险。待产的父母认为剖腹产是保护这个珍贵的唯一后代最安全的方式。另外，中国人对一切看似现代或者高科技的东西趋之若鹜也是原因之一。以往中国老百姓只能得到基本的医疗护理，但如今先进的医疗技术日益普及，刚刚富余起来的小家庭不免情愿为这个唯一的宝贝一掷千金。
令人恐惧的外阴切开术
对王佳苹来说，选择剖腹产是一个漫长而艰难的决策过程。“分娩在中国传统文化中可是一桩大事。”她说，“一进产房就等于一只脚踏入了鬼门关。”
产科医生告诉她，她的情况非常适合自然分娩。直到预产期前不久，她都一直愿意听从医生的建议。不过，剖腹产一直在她的脑海里萦绕不去。两年前，通过丈夫家族的关系，她帮她的姐姐找了一位愿意作剖腹产手术的产科大夫。后来，她姐姐好几次给她看术后的伤疤。王女士回忆道，“切口很低，很小，是横向切开的......我觉得剖腹产也许不错。”
然后是王的母亲。因为亲身经历过“令人恐惧”的外阴切开术（切开阴道附近的组织以助分娩），王女士的母亲开始向她施加压力。她说，“在我妈妈那个年代，生育不是护理水平的问题，而是生死攸关的事情。我妈妈不停地央求我，“看一看，就看看你姐姐好了。她身体一直不错，孩子也很好。”
北京妇产医院(Beijing Obstetric and Gynecological Hospital)的产科主任王琦（音）说，在这些事上家庭的影响力很大。女性通常会听取周围人的意见再做决定。亲友中有人作过剖腹产手术的孕妇更容易选择剖腹产。
但即使没有家庭压力，中国的孕妇们深知自己只能生一个孩子，所以会有越来越多的人选择剖腹产，以免遭自然分娩的种种风险和不确定性。“孕妇会想，我只能有一个孩子，所以要健康优生。”北京大学附属人民医院(People's Hospital of Peking University)产科主任王山米说，“她们觉得，自然分娩过程中如果缺氧会对婴儿不利，而且大夫恐怕也很难把脐带绕颈等各种风险因素都考虑充分。”
在很多西方国家，人们将生育看作人生的必要过程之一，为了获得圆满的人生结局所必须经历的苦痛。如今的中国人可不这么想。“她们更务实，”私立北京和睦家医院(Beijing United Family Hospital)的加拿大医生迈克尔。默顿(Michael Moreton)说，“她们把这看作是现代的新式做法，传统的自然分娩在她们看来已经落后了。”
除了这些观念上的变化之外，先进医疗技术的普及也是中国剖腹产数量迅速增加的原因之一。人民医院的王山米说，80年代以来，中国的医疗系统发生了很大变化。以前，医疗设备紧缺，许多孕妇连最基本的黑白两色超声波检测都作不了，也没有胎儿心脏监测器。当时，剖腹产技术也刚刚起步。
北京妇产医院的王琦说，“现在的自然分娩还同以往一样并无变化，但剖腹产手术已经有了很大的提高。整个过程只需20-30分钟，产妇从一开始就被麻醉，主刀医生往往都是本院专家。”
直到80年代末期，纵向切开还是常见的剖腹产手术方式。而在西方国家，产科医生们从70年代初就已经开始尝试在更低的位置横向开刀。这样，伤口愈合后的疤痕更小，更不易被看到，而且也不会损害任何肌肉组织。而纵向开刀就需要切开多层肌肉组织。
此外，先进的医疗护理设施也越来越多了。短短8年时间里，中国的妇产科专科医院就从49家激增到81家，床位数量更是激增了50%。
当然还有其他因素：中国妇女对生育知识了解不多，也没有La League Leche这样的团体宣传自然分娩，新生儿个头越来越大也是个问题。北京妇产医院的王琦说，“我们发现这几年中国妇女的身体结构基本没有变化。也就是说，她们的骨盆还和以往一样，但新生儿的个头却越来越大了。”医生们也不愿推荐大个头的胎儿以自然分娩方式出生，因为这会增加实施外阴切开术、产钳助产和真空吸引分娩等辅助手术的风险。
传统观念
贪婪可能也是中国剖腹产手术增加的原因。人民医院的王山米说，“医院从传统接生中赚不了钱。我曾经说过，如果我院所有产妇都选择剖腹产，那么护士和产科病房的病床数量都可以减少一半。”北京的大医院对自然分娩的收费是人民币3,000-5,000元（合362-604美元），而剖腹产的费用是人民币5,000-6,000元。王山米还说，“由于每个家庭只能生一个孩子，父母并不在乎为这种一次性的手术多花上几千块钱。”
剖腹产也让那些中国血缘的家庭可以顺应传统观念的要求。工作繁忙的香港银行职员Faustina Chan今年初就做了剖腹产手术，这样更便于安排产假和休假。但她喜欢的却是这样做可以为婴儿出生的选择一个吉日。她说，风水师傅帮她择定了4月19日，说如果女儿在这一天出生，就会更聪明，孝顺父母，还能钓个金龟婿。她的居室布置也听从了这位风水师傅的建议。
大多数医生只会允许孕妇将剖腹产的日期确定在预产期前几周。否则，正如39岁的曼谷美容师Senee Wongbualuang发现的那样，更早进行手术会对婴儿有害。她就恳求产科医生在自己预产期前两个月进实施剖腹产手术，为的是让孩子出生在良辰吉日。她说，“孩子的爷爷是个泰籍华裔，他希望自己的长孙女能在龙年出生。”在中国人心目中，这是一个非常吉祥的年份。医生同意了她的要求，但婴儿一出生就接受了一个月的特别看护。女儿现在已经10多岁了，她很担心早产对女儿的影响。“但剖腹产也许是对的，因为我女儿现在健壮聪明，”她说。
这种做法引起了Viroj Tangcharoensathien的警觉。他是国际健康政策项目(International Health Policy Program)驻曼谷的高级研究员。这是泰国政府参与资助的一个非政府组织的项目。为了阻止这类分娩方式，Viroj医生撰写了一份研讨报告，建议泰国的产科医生将所有剖腹产手术的申请提交给一个由同行组成的评审小组。他说，只为迎合孕妇对吉日的要求，就施行这样有选择的剖腹产手术是有违医生职业道德的。
激烈争论
根据世界卫生组织的建议，如果只在危及生命的紧急情况下进行剖腹产，那么一个国家的剖腹产比例只会在15%左右。这里的紧急情况指多胞胎妊娠、巨胎或婴儿胎位不正等。
医学界对剖腹产是否安全一直争论不休，而全球各地剖腹产手术有增无减更是火上浇油。许多医生对剖腹产的数量感到吃惊，他们认为这些产妇更容易染上并发症。而对胎儿来说，如果医生算错了预产期，过早进行剖腹产的话，对婴儿就更加不利。
美国妇产科医生协会(American College of Obstetricians and Gynecologists)去年11月公布的一份报告加深了医学界对剖腹产的意见分歧。许多业内专家都认为这份报告微妙地软化了该协会对剖腹产手术的立场，甚至可能导致美国的剖腹产比例进一步上升。该协会的“专家委员会意见”是支持在特定条件下选择剖腹产，那就是医生相信剖腹产比自然分娩更能全面提高产妇和新生婴儿的健康状况。
这个意见与National Alliance of Midwives of North America等团体的看法相左。协会新闻主管苏姗。默利(Susan Moray)说，“他们（美国妇产科医生协会）并未完全认可选择性剖腹产手术，但事实是他们正在往这条路上走。对此，我们的反应是：这可是个险境。”
美国妇产科医生协会的前任总裁本。哈尔医生(Dr. Ben Harer)则认为，医生拒绝施行剖腹产手术是违反职业道德的。他说，“现在是尊重妇女的时代了。”哈尔医生一直在驳斥那些反对观点，他认为剖腹产和自然分娩的利弊可以达到平衡，这样产妇的偏好就是选择分娩方式的决定性因素了。他说，美国的剖腹产比例升至40%只是时间问题，“那些强烈反对的人必败无疑。”
密歇根州William Beaumont医院的产科副主任罗伯特。罗伦兹(Robert Lorenz)是美国妇产科医生协会职业道德委员会的委员，但他并不支持顺应产妇的请求施行剖腹产手术，除非情况特殊。他说，“剖腹产是一项大手术，肺栓塞和感染等严重并发症的几率很高。如果医生不能确定预产期，婴儿就有早产几周的风险，然后就得呆在特护病房。”但是，最大的危险是有剖腹产史的孕妇在妊娠过程中有可能出现子宫破裂。他说，“这非常危险，胎儿可能流产或留下终生障碍；产妇会大出血，甚至切除子宫。”
尽管忧虑重重，这种趋势在全球各地──尤其在中国──看来已经不可逆转了。
刚刚得知怀孕后一周，北京的中年产妇田吟（音）就决定剖腹产。她自己根本就不想经受自然分娩的痛楚，但首先要说服大夫。她的围产大夫是北京朝阳医院(Beijing Chaoyang Hospital)的产科主任王淑珍，王大夫并不愿意给她做剖腹产手术。
王大夫说，“我认为自然分娩对母婴双方都有好处。”但田吟很坚决，最终以胎儿过大为由说服了大夫。这位30岁的产妇并不觉得任何遗憾。她说，“这可以让我专心工作。”这也意味著她可以选择一个良辰吉日。田吟说，“农历6月15日是个好日子。”
