Intended for healthcare professionals

Rapid response to:

Dr Foster's Case Notes

Social class and elective caesareans in the English NHS

BMJ 2004; 328 doi: (Published 10 June 2004) Cite this as: BMJ 2004;328:1399

Rapid Response:

Dr Foster is cheap and offensive

Jarman and colleagues show their ignorance of obstetrics. Their
article implies that "elective" caesarean section means a caesarean
section performed solely at the request of the pregnant woman.
Traditionally an elective caesarean section is one carried out in the
absence of labour. Many caesarean sections are performed to save the life
of the woman and her infant, for example, in severe pre-eclampsia or
placenta praevia. Because they are carried out in the absence of labour
they are often labelled as "elective" in operation notes, even though they
are performed for good medical reasons. Women who have had a previous
caesarean section after a long labour may wish to avoid the uncertain
hazards of another labour, and prefer to have an elective caesarean
section. In this situation the woman's choice of an elective caesarean
section is in the setting of an important medical consideration, a
previous caesarean section. Very few women actually have a caesarean
section performed solely at her request. In a survey of caesarean section
in Scotland, 31 of 3150 (1%) elective caesarean sections were performed
solely at the request of the woman.(1)

Jarman's study investigates the relationship between the odds of an
elective caesarean section and social deprivation. The study also shows a
much stronger relationship between elective caesarean section and maternal
age, there being a ten-fold increase in the frequency of elective
caesarean section in women older than forty compared with women younger
than sixteen. Although the authors adjusted the odds ratios for maternal
age, almost certainly, with such a strong association with age, the
adjustment was insufficient. What this study really shows is the effect of
maternal age on caesarean section.

It is well known that older women are more likely to undergo
obstetric intervention, including elective caesarean section, than younger
women, even in the absence of obstetric complications.(2) Perhaps
increasing maternal age induces an innocent but irrational fear in
obstetricians and the pregnant women in their care, a fear which may be
allayed by education of the actual risks of maternal age. In their paper
Jarman and colleagues have said something trivial, when they could have
said something important.

Incidentally, the slogan "too proletarian for a caesarean" is cheap
and offensive.


1. Wilkinson C, McIlwaine G, Boulton-Jones C, Cole S. Is a rising
caesarean section rate inevitable? Br J Obstet Gynaecol, 1998; 105: 45-52.

2. Bell J, Campbell DM, Graham WJ, Penney GC, Ryan M, Hall MH. Can
obstetric complications explain the high levels of obstetric interventions
and maternity service use among older women? A retrospective analysis of
routinely collected data. BJOG, 2001; 108: 910-8.

Competing interests:
None declared

Competing interests: No competing interests

14 June 2004
John M Grant
Consultant Obstetrician and Gynaecologist
Wishaw General Hospital, 50 Netherton Street, WISHAW, Lanarkshire ML2 0DP