Should women who elect to have caesarean sections pay for them?
BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7190.1070 (Published 17 April 1999) Cite this as: BMJ 1999;318:1070
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Dear Sir
Re: Obstetricians reject Caesarean Section on “request”
MacKenzie wrongly claims that there is wide support for elective
Caesarean without a medical indication(1). This was certainly not our
reading of the lively correspondence in the BMJ(2). Two recent debates
about this very issue at the British Maternal Fetal Medicine Society (York
18th March 1999) and the Royal College of Obstetricians &
Gynaecologists meeting on the Modern Management of Labour (Liverpool 27/28
April 1999) had overwhelming votes against Caesarean Section without
indication and for supposed “choice”. Both meetings were attended by large
numbers of the more obstetrically committed consultants in the UK. These
votes reflect real concern about maternal and neonatal dangers of
unnecessary surgery and iatrogenic premature delivery, in particular, the
risk to the neonate.(3,4)
Thus MacKenzie’s proposal, that women requesting Caesareans should
pay, is dangerously wrong. The subliminal message is that there is no
danger, possibly even a benefit, but only available to those who can pay.
The issue of harm must not be clouded by creating a public concern that
women might be denied their legitimate choices because of rationing.
Serious surgical interventions on normal mothers and babies without
medical indication, is potentially harmful and may even be lethal. The
debate must be clarified by better data, which presently lacks support for
safety. Traditionally, doctors have a poor track record of introducing new
procedures and indications, before evidence is available and we would be
wise to be cautious if we wish to first of all “do no harm.”
Yours sincerely
Dr Susan Bewley MD MRCOG
LEAD CLINICIAN IN MATERNAL FETAL MEDICINE
Guy's and St.Thomas' Trust
Mr Steve Walkinshaw
Consultant
Liverpool Women's Hospital
1)MacKenzie I.Z Should women who elect to have Caesarean Sections pay
for them? Dr Med J 1999;318:1070
2) De Zuleta P; Norman B, Crowhurst JA, Plaat F; Stirrat GM, Dunn PM;
Idama TO, Lindow SW; Van Roosmalen J; Rosenthal A; Howard RJ. Elective
Caesarean Section on request (letters) BMJ 1999;318:120 (9 January)
3) Morrison J J, Rennie J M, Milton P J. Neonatal Respiratory Morbidity
and Mode of Delivery at term: influence of timing of elective Caesarean
Section, BRJ obstet gynaecol 1995; 102:010-106
4) Annibale DJ, Hulsey TC, Wagner CI, Southgate WM. Comparative Neonatal
Morbidity of Abdominal and Vaginal Deliveries afte Uncomplicated
Pregnancies. Arch paediatrics & adolescent med 1995;149:862-867
Competing interests: No competing interests
Mackenzie suggests introducing a "small charge" for women who elect
to have a caesarean section where no compelling "obstetric" indication
exists, in order to bring to the attention of women the cost of this
option.
Like any "small charge," and independently of the precise amount,
this charge would be irrelevant to the wealthy and insurmountable to the
poor. This is inequitable.
In addition, the idea of charging as an incentive carries the clear
implication that the decision to have a caesarean section is viewed by
women as a "no cost" option. This seems unlikely. Much more likely is that
a decision in favour of elective caesarean section results from a
personal "cost minimisation analysis" where the very obious discomforts of
a wound and a scar, aswell as less obvious risks and more serious risks
which will have been explained, are balanced agaisnt powerful deterrents
to vaginal delivery. Suce deterrents might include anxiety about serious
long term consequences such as future pelvic floor pathology or sexual
dysfunction, aswell as short term motivations such as distress,
exhaustion, or pain.
Clearly, all societies need to avoid irresponsible use of healthcare
resources, and rationing is with all of us, to stay. Difficult decisions,
such as who may have access to caesarean section or other desirable
resources, should be made in a way which is fair, explicit, and
representative of the wider population served.
It would appear that there is a worldwide increasing among those
women who have the choice in the numbers electing caesarean section,
often for perfectly rational reasons. Among them are many female
obstetricians - perhaps modern obstetrics is becoming a victim of its own
success. But in any case, decisions to restrict access by whatever means
must be made explicitly by a constituency which includes representatives
of parturient women's interests, as well as those of obstetricians,
healthcare purchasers and patient groups with competing interests.
Competing interests: No competing interests
Editor
Whilst discussing the immediate financial implications of women who
request a caesarean section, MacKenzie (1) suggests that it would be
reasonable to make a small charge. Would MacKenzie think fit to make a
small charge to women requiring a pelvic floor repair, sustained as a
result of not requesting an elective caesarean section?
I have the honour to remain,
Sir,
Your obedient servant.
Malcolm John Dickson
Senior Registrar
Dept of Obstetrics & Gynaecology
Wythenshawe Hospital
1 Mackenzie I Z Should women who elect to have caesarean sections pay
for them?[letters]. BMJ 1999;318:1070
Competing interests: No competing interests
Mr MacKenzie raises the financial implications inherent in Caesarean
section following maternal request and like many others warns that we must
inform women of the dangers of elective Caesarean section compared to
vaginal delivery. Unfortunately, this argument is becoming increasingly
difficult to justify. The data on the increased postoperative
complication rate which all obstetricians quote are historical and based
upon all Caesarean sections, both elective and emergency. The latest
report on the Confidential Enquiry into Maternal Death(1) reported no
deaths from elective Caesarean section.
Until we have up to date data on the incidence of haemorrhage, DVT and
infection from elective and emergency Caesarean section reported
separately we will not be sure of the position but it is becoming
increasingly obvious that elective Caesarean section if probably much
safer than was previously thought. If so, then our much loved arguments
in favour of vaginal delivery become difficult to defend.
1 Why mothers die. Report on the Confidential Enquiry into Maternal
Death. HMSO 1998
Competing interests: No competing interests
Mackenzie's article regarding surcharges for elective caesars for non
-medical indications highlights a major issue in any health care system
where there is no cost signal feedback to the patient.
I myself have witnessed cases where women have had repeated antenatal
ultrasounds for the sole purpose of obtaining their "first home video" of
their child via ultrasound. All it took was a few moments with a genial
doctor who had nothing to lose by referring the patient off for another
scan at a private radiology clinic which had the added attraction of a
video recorder.
It didn't cost him anything either, and refusing the request may have
cost him a patient.
And so Medicare paid for the repeat GP consultation and a repeat
scan, for no reason other than that the parents wanted a video of their
child in utero.
This is a somewhat extreme example, but it does show that when there
is complete separation between costs of a service and those who receive
them, then abuse of the system is to be expected. That, to me, seems to be
the real issue.
Peter Schuller
Competing interests: No competing interests
Cesarian culture
Dear Sirs,
I have just accessed the BMJ website and discovered the
articles and correspondence regarding the debate on cesarians and whether
women should be charged for a cesarian on request.
I am an anthropologist, and have spent the last two years researching
cesarian section in Vitoria, a coastal city in south east Brazil, where
the cesarian rate is currently around 25%in public hospitals, and around
98% for women who have access to private medicine (mainly through health
insurance schemes). The "cesarian culture" took hold in Brazil over thirty
years ago (in 1970 the cesarian rate was 20.2%).
The situation is very complex, and involves questions, not only of
the history of obstetric procedures, but also cultural questions, specific
to Brazil. However, I believe that some comparisons can be made.
1. all births are attended by obstetricians:
despite the tentative training of nurse midwives they
find it difficult to obtain employment
2. due to a long period of high cesarian rates,
obstetricians receive very little training and practice
in handling even marginally difficult vaginal deliveries and
choose cesarian as an "easy option"
3. doctors are now paid the same rate for both normal and
cesarian births, by both the public health system and private
health insurance schemes. However, they are not prepared to wait hours
for their patients to deliver when they can do a cesarian in an
hour.
4. cesarian has a certain status symbol. In a society which
places a high value on modernity and technology cesarian is equated
with these qualities, whereas normal birth is now seen as
"alternative" if opted for by a middle class woman, and is
generally associated with the
lower classes, black people and the poor.
5. Brazilian concepts of the body as cultural rather than
natural. Womens bodies are perceived as sexual rather than maternal;
despite an intense Marian culture, the genitals are for sex rather
than for childbearing.
I find it worrying that childbirth in Britain is being discussed in
the terms of this debate. Most European countries are held up as an
example of "human" birth. It would be ironic if Britain were the follow
the Brazilian path, especially with the increase of private medicine, when
the high cesarian rate here is at least acknowledged, even if
obstetricians have no intention of trying to reduce it.
Yours faithfully,
Christine Nuttall.
Competing interests: No competing interests