Complications, or fear of complications?
Bell et al. [BMJ 2001; 322:894-895] have shown that the strong and
consistent relationship between age and abdominal delivery remain even
when obstetric complications are controlled for. In other words,
unless any unrecognised confounding variables are at work, the larger
numbers of caesarean sections amongst older women cannot entirely be
explained by their tendency to have more complicated pregnancies and
births. The authors speculated that physician and maternal preference
might be contributory factors. However a related factor might not be real
complications that older women experience, but uncertainties related to a
perceived potential for complications.
In a rapid response to the Bell paper Quadros summarises a thesis on
the rising caesarean section rate in two words: convenience and fear. As
part of our research into women's choice and decision-making in caesarean
section  we have interviewed obstetricians and midwives as well as
women who had, or considered having, a caesarean. Nearly all the
obstetricians have told us that, in their experience, the numbers of women
they see who ask for caesarean purely for convenience are comparatively
low. It is difficult to see where convenience lies in caesarean section
for the woman, with a postoperative recovery period of weeks rather than
the days it usually takes to recover from normal birth. To sacrifice
postnatal well-being for the perceived convenience of knowing the date of
the birth seems short sighted. We found that, whilst they might not be
aware of the morbidity associated with major abdominal surgery, women are
usually aware of the debilitating effect of the operation. Thus it must be
assumed that, if convenience is an issue, it is largely the convenience of
The fear issue is more complex. Our research (both qualitative and
sociological - as van Teijlingen recommends) highlights a high level of
fear about childbirth amongst some women. Nevertheless this perception of
vaginal birth as hazardous and frightening is often held in tension with a
view of vaginal birth as an ideal to aspire to [2,3]. The fear may arise
out of many things, not least the way in which pregnancy and birth is
managed. In large obstetric units, this often involves many
investigations, and a high level of monitoring for potential problems.
This hyper-vigilance can make a younger woman feel that the whole birth
process must be a risky process for both herself and her baby. Older
women, as reported by Bell et al, are labelled a priori as complicated,
just by virtue of their age. It is possible that the additional
psychological stress of being considered high risk and, as a result,
possibly being subjected to even more monitoring than average, might
underlie the fear of both vaginal birth itself and of things going wrong.
Together these lead to requests for caesarean section from women, and
possibly an increased willingness to perform them from obstetricians.
Each caesarean performed on an older woman, will not only enter
statistics that purport to show that older women have more problems giving
birth vaginally, but will also become part of the 'culture of childbirth'
that instils fear of birth in other pregnant women. Thus fear perpetuates
fear. This is not to suggest that older women do not have extra problems,
but rather that fear of complications might be as much of a problem as the
Senior Research Associate
Centre for Family Research, Cambridge
1. Weaver JJ. RCM Research Network. A study of choice and decision
making in caesarean section. RCM Midwives Journal 2000; 3(3): 77.
2. Weaver JJ. Talking about caesarean section. MIDIRS Midwifery
Digest 2000; 10 (4): 487-490.
3. Statham H, Weaver J, Richards M. Why choose caesarean section? The
Lancet 2000; 357 (9256): 635.
N.B. For more information on the 'Choice and Decision Making in
Caesarean Section' project, e-mail firstname.lastname@example.org
Competing interests: No competing interests