Should women be able to request a caesarean section? Yes

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d7570 (Published 23 November 2011)
Cite this as: BMJ 2011;343:d7570

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I believe that the women should not ask for an elective c-section in certain circumstances, particularly those which have no medical reasons attached to their decision making.

Choosing c-sections to enable planning around work commitments (when maternity leave is otherwise available), and coinciding c-sections with particular auspicious/memorable dates does not justify the increased risk to the mother during subsequent pregnancies.

While the autonomy of the patient should always be respected, these reasons do not outweigh the associated risks, and in this case, patient safety should come first. Mothers should be fully informed on their decision making and the potential harm that can be incurred. Ideally, their family members should be counseled alongside the mother, and two obstetrician opinions would be valuable in these situations.

Concerning the extra cost incurred to the NHS from c-sections compared to vaginal deliveries, if there is no valid medical ground for this decision, then the patient could be asked to pay the extra cost for their decision.

Competing interests: None declared

KS Amir, Medical student

St George's Hospital, St Georges, SW17 0BE

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Patient choice and participation in decision making is not always that straightforward.
Rita Haworth Senior Lecturer Social Policy
The University of Salford
E mail r.haworth@salford.ac.uk

Patient choice and participation in health care decision making processes have been central to government health policy from both the right and left since the 1970’s. Policy documentation such as The NHS and Community Care Act (1990), The Patients Charter (1995) and subsequent legislation such as The New NHS: Modern and Dependable (1997), The Local Government and Public Involvement Act, and more recently the NHS and Social Care Bill (2011) all state patients and the public should be more involved in health care decision making processes regarding the health care they receive. However, research evidence to date, for example Garliardi et el (2008) Steniszewska et el (20012) Suggest patient participation in health care decision making processes have been minimal.
Therefore, if women are really to be given ‘choice’ on types of delivery (caesarean verses virginal) clinicians and midwifery staff need to concede autonomy, share more knowledge with patients and address this issue in a more collaborative manner.
When considering patient/lay participation in the decision making process within the NHS it is important to look at what forms of knowledge and expertise are valorised in governance. (Newman and Clarke 2009) Culter and Waine suggest there is a ‘generic management’ practice within organisational governance such as medicine that ‘ordinary people’ in this instance expectant mother, with lay knowledge who do not fit this model. Without appropriate training to equip them with necessary Knowledge and attributes to participate in decision making processes women’s choice in decisions related to modes of child birth will if one applies Arnstein’s theory of participation unfortunately remain tokenistic.
References
Arnstien, Ladder of citizen participation. In Lupton. Peckham,S. Tylor,P. (1999) Managing Public involvement in health care purchasing. Buckingham. OUP p. 47
Cutler, T. Waine, B. (1997) Managing the Welfare State. Oxford. Berg.
DH (1990) The NHS and Community Care Act. London: DH.
DH (1995) The Patients Charter. London: DH.
DH (1990) The New NHS: Modern and Dependable. London: DH
DH (2007) The Local Government and Public Involvement Health Act. London: DH
Gagliadi, A. Lemieux-Charles, L. (et al) (2008) Barriers to patient involvement in health service planning and evaluation: an exploratory study. Patient Education and Counselling. 70 (2) pp234-241
Haworth, R. Melling. B. (2009) From Rhetoric to Reality: Breaking down the Barriers. To What Extent are Service users Collaborating in Decision Making Processes within the NHS? Proceedings of the 13th International conference, 10-11 September, Dilemmas in Human Services. University of Staffordshire pp 50-58
Lupton, C. Pheckham, S. Taylor, P. (1999) Managing Public Involvement
in health Care Purchasing. London. Sage
Newman, J. Clarke, J (2009) Publics, Politics &Power: Remaking Public Services. London. Sage
Staiszewska, S. Mockford,C. (et al) (2012) Moving Forward : Understanding the Negative Experiences and Impacts of Patient and Public Involvement in Health Service Planning, development and evaluation. In Barnes, M. Cottrell, P. (edt) Critical Perspectives on User Involvement. Bristol. Policy Press. Pp129-142

Competing interests: None declared

Rita Haworth, Senior Lecturer

The U niversity of Salford, Allerton Building Frederick Road Salford M6 6PU

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Wherever possible all pregnant women should be fully involved in decisions about their care, but they will need support and encouragement in this role. This should include access to reliable, balanced evidence-based information in the form of patient decision aids, together with decision counselling from sympathetic clinicians. I hope both NICE and the RCOG have active plans to ensure this support is provided.

Competing interests: I also work part-time for the Foundation for Informed Medical Decision Making, Boston, USA, which develops and promotes the use of patient decision aids and shared decision making.

Angela Coulter, Health services researcher

University of Oxford, Department of Public Health, Rosemary Rue Building, Old Road Campus, Oxford OX3 7LF.

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As having an elective caesarean section is a relatively safe procedure, we see no reason why a woman cannot choose to have one. After all, at the other end of the pregnancy time line women are freely allowed to choose termination of pregnancy and destroy an unborn life. This right to choice for abortion is exercised 180,000 times per year in the UK

As such, we simply could not understand as to why women were permitted control over some aspects of pregnancy but not permitted choice in mode of delivery. We applaud this decision by NICE to allow the right to choice

Competing interests: None declared

Malcolm John Dickson, Consultant Obstetrician & Gynaecologist

Sam Cox, Amna Hussain, Rachelle Gent

The Royal Oldham Hospital

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Caesarean sections are comparatively safe but nevertheless, these are major surgeries. There are intrinsic risks involved due to surgery and anaesthesia in these type of deliveries. When NICE guidelines follow a restrictive use of episiotomy in spontaneous vaginal deliveries then why should it liberalize major surgeries like caesarean sections. Caesarean section has both short term (Infection, heavy blood loss, thromboembolism, Nausea, vomiting, and severe headache after the delivery (related to anesthesia and the abdominal procedure), ileus) and long term consequences (Placenta accreta and repeat caesarean). Decision of performing a Caesarean section should be a doctor’s mandate rather than of expecting mother. Even if a doctor wants to comply with Woman’s choice of caesarean delivery, he or she should counsel her about the pros and cons of caesarean delivery as we do in case of contraception.

Competing interests: None declared

Neeru Gupta, Scientist E

Shalini Singh, Nomita Chandhiok, Anuradha Jaswal

Indian Council of Medical Research, Div.of RHN, Indian Council of Medical Research, Ansari Nagar, New Delhi-110029

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NICE guidelines and the debate about caesarean section on women'd demand without judicious indication continues to be a highly controversial and debatable topic. Although most obstetricians offer elective caesarean section on woman's demand, the practice should be discouraged. A thorough scientific evidence should be told to the woman including higher complications of caesarean section as compared with vaginal delivery. An honest opinion is mandatory and we should try to reduce the rate of caesarean section as far as possible considering the fact that prestigious institutions like World Health Organisation and American College of Obstetricians and Gynecologists have strongly argued to lower the caesarean section rates to less than 15 percent throughout the world. Sky high rates of caesarean section throughout the world has increased the compications rates of caesarean section like morbidly adherent placenta in future pregnancies often leading to life threatening postpartum hemorrhage and need for caesarean hysterectomy. There is another peculiar problem in countries like India where women often demand caesarean on a particular auspicious time of a day supposedly for better future of the baby as happened on 11th November 2011 ( 11.11.11) when we had great demand for elective caesarean section by many women. Hence we should not encourage caesarean on demand but should counsel them against it . However if they insist we have to probably accept their demand.

Competing interests: None declared

J B Sharma, Additional Professor of Obstetrics and Gynaecology

All India Institute of Medical Sciences, New Delhi , Ansari Nagar, New Delhi 110029, India

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