Unlike other types of surgery, caesarean section generates remarkable interest not only among the general public but among healthcare professionals, fundholders, analysts, and advocacy groups. Caesarean section is an easily defined pregnancy outcome that has been measured widely over time. Within a generation there has been both a relentless rise and a remarkable variation in caesarean section rates reported worldwide.1 2 The explanation for this evolution in caesarean section rates is complex, but it is unlikely to have occurred without substantial improvements in surgical safety during the 20th century in developed countries.3

The revised National Institute for Health and Clinical Excellence (NICE) guideline on caesarean section makes recommendations on the increasing proportion of caesarean section being undertaken at maternal request.4 Rates of preference for caesarean section are quoted as 6-8%.4 Obstetricians are estimated to agree to maternal request for caesarean section about half the time, although the basis for their decisions is unknown.4 When women request a caesarean section because of a fear of childbirth, NICE recommends involving another healthcare professional …