Head To Head

Should women be able to request a caesarean section? No

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d7565 (Published 23 November 2011) Cite this as: BMJ 2011;343:d7565
  1. Hanna Rouhe, senior resident
  1. 1Department of Obstetrics and Gynaecology, Helsinki University Central Hospital, Helsinki, Finland
  1. hanna.rouhe{at}helsinki.fi

Michael Turner (doi:10.1136/bmj.d7570) argues that a fully informed decision to choose a caesarean section should be accepted, but Hanna Rouhe believes surgery should be restricted to women with clinical need

Although every childbirth carries a risk for both mother and child, these risks are very small in Western countries.1 Yet obstetricians around the world have started to think that the “requested” caesarean section is an acceptable prophylactic response to the uncertainty of vaginal delivery. Effects of this changed practice can be seen in caesarean section rates around the world, which have risen above the optimal amount—for example, 33% in Italy or over 50% in Brazil. Have we forgotten, or do we simply neglect, the much higher risks of complications for caesarean sections?2 I hope that doctors do not agree to women’s requests for a caesarean simply for the transient convenience. There is no evidence that an elective caesarean section is safer than vaginal delivery, and risks of caesarean section are not only the primary complications but also the secondary consequences.3 4 These non-indicated caesarean sections might cause more harm than good, and therefore should not be performed.

Major surgery must be warranted

As the guidelines from the International Federation of Gynecology and Obstetrics’s committee on the ethical aspects of human reproduction state, it is unethical to do a caesarean section without medical indication. A caesarean section is a major abdominal surgical procedure. Does any other surgical specialist—excluding aesthetic plastic surgeons—accept such a huge informed choice by a patient as part of clinical practice? Doesn’t this actually debase our clinical knowledge and wisdom? Patients have, of course, the right to refuse treatment but not to claim an operative procedure over normal clinical practice. Surgical treatment should never be seen like an item you can select from a supermarket. If obstetricians really consider caesarean section to be a safer method of delivery they should offer it to all pregnant women. In my opinion, and I believe also most of my colleagues’, it is difficult to find evidence to support this practice.

Fear can be treated

Fear of childbirth is often behind a woman’s request for caesarean section.5 In this case, we should focus on the fear of childbirth and not just the request for a caesarean. The request is often a cry for help in a situation where the woman is not able to confront her fears and prepare for the forthcoming childbirth. With help she can be shown other possibilities and will often withdraw her request. Caesarean section is seldom a solution to a fear of childbirth and related anxiety or depression. If obstetricians discuss only the caesarean and do not deal with the fear, women are left without proper treatment.6

For the past 10 years in Scandinavia it has been established clinical practice for women with a fear of childbirth to attend special maternity clinics where they are treated by trained midwifes, psychologists, obstetricians, and group psychoeducation. Studies have shown that up to 87% of women who initially requested a caesarean have chosen vaginal delivery after treatment of their fear of childbirth.7 8 Fearful women should both be encouraged to confront their fears and receive support for vaginal delivery. In confronting their fears during pregnancy, women learn to accept insecurity. This might improve their self confidence,9 help them cope with being a mother,10 and possibly improve their mental health later in life.11

Of course, if the fear is not relieved with proper treatment, it is ethical to perform a caesarean section. In my clinical experience, fearful women get longstanding benefits from this support during pregnancy. They experience a more satisfying delivery, adjust better to being a mother, and have improved general wellbeing after delivery, even if they end up having a caesarean section either electively or for obstetric reasons after a trial of vaginal delivery.

We have to ask whether obstetricians are also afraid of natural birth. Otherwise, what is the reason to support this new fashion of caesarean section without medical indication? Instead of performing caesarean section on request, we should offer proper treatment for women with fear of childbirth and also focus on better maternity care during pregnancy, delivery, and the postpartum period.

Notes

Cite this as: BMJ 2011;343:d7565

Footnotes

  • Competing interests: The author has completed the ICJME unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from her) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References