Should women be able to request a caesarean section? YesBMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d7570 (Published 23 November 2011) Cite this as: BMJ 2011;343:d7570
- Michael Turner, professor of obstetrics and gynaecology
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 with expertise in providing perinatal mental health support, if available. There is little evidence, however, that such support decreases the number of caesarean sections.
Unknown causes and effects
Any debate about extending a woman’s choice is hindered by the lack of evidence about caesarean section on request.5 In women who request a caesarean section, it is important to distinguish between those who have a complicated obstetric or medical history and those who do not. We also know little about what influences the request and whether a preference expressed in early pregnancy may be changed in the light of additional information. We do not know how such requests are managed by obstetric teams in different healthcare settings.
Caesarean section has the potential to benefit or harm the woman and her offspring. There are limitations, however, in assessing the trade-off between the benefits and harm in a woman who requests a caesarean section. Women with both planned vaginal birth and planned caesarean section may end up having an emergency caesarean section, which carries increased risk compared with a planned operation. The risk of an emergency caesarean section also depends on the healthcare setting. One of the key determinants of clinical risk is a history of caesarean section. One of the challenges in determining risk, however, is that the outcome of childbirth for any individual woman is highly unpredictable.
Longer term outlook is needed
Clinical decisions may focus too much on the short term benefits and harm without considering the long term for the woman and her offspring. Agreeing to a request for a caesarean section may, for example, prevent urinary incontinence later in life but increase the risks of complications during any future abdominal surgery. It is also important to focus on outcome measures that are important priorities for service users rather than the service providers. Does the evidence that a woman who requests a caesarean section is less likely to be breast feeding at three months matter if the woman has already decided that she is not going to breast feed irrespective of the mode of delivery?6
One of the arguments made against caesarean section on maternal request is economic.4 7 8 NICE estimates that a planned vaginal birth is about £800 (€925; $1250) cheaper than a caesarean section at maternal request, and a 1% reduction in the caesarean section rate nationally could save the NHS £5.6m annually.4 This is attractive to fundholders, given the growing demand on resources and budgetary constraints.
One of the lessons of the current international crisis is that economic modelling is an inexact science. Health economics is no exception. The assignment of healthcare costs to an intervention is often focused on the short term.4 9 10 Any economic evaluations of the mode of delivery must include the long term care of the baby. If a requested caesarean section prevented a single case of cerebral palsy associated with substandard intrapartum care, the medicolegal savings would probably exceed the savings attributed to the 1% decrease in the caesarean section rate. This is aside from the human cost to the child and the family. If the argument was simply about economics, the increased costs of a planned caesarean section could be minimised by reducing the average length of stay after delivery. Theoretical evaluations of cost contribute little to a woman’s decision about her mode of delivery.
Women’s views are important
If a woman has had a negative experience or a serious adverse clinical outcome in the past, whether related to childbirth or not, I believe that it is reasonable to accede to her request for a caesarean section. If a woman has a pathological fear of childbirth that persists despite psychological support, no one would want to put her through the experience. Finally, there may be women who are in full health with no pregnancy complications, who have informed themselves fully about the benefits and harm of caesarean section and yet decide to request delivery by caesarean section. The number of such women, in my experience, is small, maybe accounting for less than 1% of deliveries.11 Their personal needs and preferences, perhaps not always fully expressed, should be respected. The evidence that a planned caesarean section based on a woman’s request increases the harm to either her or her baby is scant. Who is to say that mother does not know best? However, it is also important to ensure that maternal request for caesarean section is the carefully considered right choice for each woman and is not used to disguise the easy choice for her obstetrician.
Cite this as: BMJ 2011;343:d7570
Competing interests: The author has completed the ICJME unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from him) 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.