Intended for healthcare professionals


Should women who elect to have caesarean sections pay for them?

BMJ 1999; 318 doi: (Published 17 April 1999) Cite this as: BMJ 1999;318:1070
  1. I Z MacKenzie, Reader in obstetrics and gynaecology
  1. Nuffield Department of Obstetrics and Gynaecology, John Radcliffe Hospital, Headington, Oxford OX3 9DU

    EDITOR—The issue of whether doctors should perform elective caesarean sections on request confronts obstetricians almost daily.1 Neither the original articles in the BMJ on elective caesarean section nor the correspondence that followed quantified the problem in the United Kingdom. 1 2

    The table illustrates the primary indications for 978 caesarean sections performed before labour in 1976, 1986, and 1996 at the John Radcliffe Hospital in Oxford. The information was collected prospectively as part of a larger study.3 The most dramatic change has been the increase in the proportion of elective caesarean sections performed during labour at the woman's request. Of 911 caesarean sections performed during labour in 1976 and 1986 none were done at the woman's request but in 1996, 6% were done at the mother's request.

    Primary indications for 978 caesarean sections performed at the John Radcliffe Hospital. Values are numbers (percentages)

    View this table:

    The added morbidity and mortality associated with caesarean sections compared with vaginal delivery are clearly relevant2 but personal experience suggests that the patient's awareness of this does not reduce the demand.

    The cost to the NHS for a caesarean section is not established2 but it has been calculated for the John Radcliffe Hospital at £668 ($1069), which includes the preoperative check (£6), the operation (£188), and a mean 4.2 days in the postnatal ward (£475).4 The cost of inducing labour has been calculated at £644 for a nulliparous woman and £494 for a multiparous woman which includes the induction, intrapartum care with delivery, and a mean 2.1 days in the postnatal ward.4 Using these figures, it would be reasonable to make a small charge for those women who request a caesarean section that is not medically indicated. Since it is widely accepted that women should be allowed to choose delivery by caesarean section,2 labour induction as term approaches should also be accepted despite current opposition from obstetricians and midwives. The risk of caesarean section to a woman's health and life should, however, be made clear.