Caesarean on demand
Better unsaid
In 2011 the National Institute for Clinical Excellence’s (NICE) Caesarean section guideline (here & NICECS) startled obstetricians; the authors had discovered a “right” to give birth that way.
“For women requesting a CS, if after discussion and offer of support (including
perinatal mental health support for women with anxiety about childbirth), a vaginal
birth is still not an acceptable option, offer a planned CS.”
Even NICE baulked at chaining a reluctant surgeon to the operating table, so they included a conscience clause:
“An obstetrician unwilling to perform a CS should refer the woman to an obstetrician who will carry out the CS.”
Some apologists have since claimed that NICE was referring to women with severe anxiety about vaginal birth, and indeed the guideline includes good advice about them, but it’s clear the recommendation also applies to women who request Caesarean for other reasons; those who for example believe it is safer, easier, or reduces perineal injury. The NICE authors didn’t like it, but the tabloids knew who they meant, women who believe it will keep their vaginas “honeymoon fresh” or are “too posh to push”.
NICE quoted well-established evidence of the safety of Caesarean for most women, and a tiny non-randomised study from Sweden (Wiklund et al., 2007) which they rightly judged as low quality. The latter suggested that Caesarean on maternal request was associated with a longer hospital stay but no difference in fetal risks, breast feeding at two days, maternal depression or rate of resumed coitus at three months. It was associated with higher maternal satisfaction, but lower breast feeding and rate of planning another child at three months. An economic analysis, based on these flaky data found that vaginal delivery was £700 cheaper than maternal request Caesarean. It certainly wasn’t strong evidence that drove NICE’s advice. But it’s not really clear what did.
Perhaps, wanting to make a strong statement that women had the right to refuse Caesarean, they felt the need for symmetry. They did not cite any evidence that women were being refused maternal request Caesarean, they were more concerned about the opposite issue; that women were feeling bullied or scared into unnecessary ones. Many wise people argue that for reasons of convenience, money or pressure from lawyers with their own financial agendas, doctors are normalising Caesarean as a valid option for birth.
I guess I’m one of those doctors. I agree with NICE, that Caesarean is pretty safe for the mother. It may even be slightly safer for this baby. People have small families these days and we can usually deal with the complications. The evidence that it causes infertility, atopy or stillbirths in subsequent pregnancies is fairly weak. I worry that we may lose the skills for natural birth, but can hardly expect women to have vaginal births so I can keep my skills honed for their sisters. If asked to do a Caesarean against my personal judgement, I ensure the gestation is over 39 weeks, and do the deed, rationalising that no-one’s being forced to do anything they don’t want.
But even I fret a bit. Modern obstetrics is on a hopeless quest for perfect safety. Every randomised trial, plausible theory, or half-baked idea seems to justify more interventions. Late complications and side effects are played down, just like I did above. Freedom to choose is important, but a right to choose Caesarean against the better judgement of the surgeon is not symmetrical with the right to refuse one. Patients can refuse any operation they like, but they don’t usually have a right to one against the surgeon’s judgement. They may seek a second opinion, but abortion is the only other operation with a conscience clause mandating that the second opinion comes from a surgeon who will say yes. Even the offer of choice is not neutral – it removes the option to birth in ignorance. And don’t get me started on the baby risks.
Maternal request Caesareans have wide ramifications. They have been debated by parents, obstetricians, midwives and pressure groups for years. I don’t have the answer, and nor does NICE. A final resolution of the debate is neither possible, nor desirable.
But then, almost it appears on a whim, the world’s most prestigious health advisory organisation placed its thumb on the scales. That’s a pity.
Jim Thornton
Ripe-tomato.org 
As usual you are spot on Jim. And glad to see the snowflakes are back.
I’ve got mixed feelings about the snowflakes. They come on automatically this time of year. But if you like them, I’ll keep ’em.
Really interesting.
Personally I welcomed the NICE guidelines, I had been told by a consultant obstetrician not long before they were released that I would have to attempt a VBAC for my second child and would not be allowed an elective C section. Something which I found very distressing after a difficult labour and emergency CS first time around.
I’ve always wondered though if there are many women requesting C sections because they are too posh to push etc? (Perhaps you can answer this as you’re far more likely to have met them than me!).
I think the comparison should also be made between maternal request CS and other maternal requests which may require a doctor (or midwife) to do something against their better judgement – should the NHS be required to provide a home birth midwife for a high risk birth for example? Both types of birth could be argued to be a woman’s “right” and both come with risks which will be acceptable to some but not others.
I’m surprised that any consultant would have insisted on a VBAC, even before the NICE guidelines came out, so I confess I didn’t read the recommendation to accede to maternal request Caesarean, as referring to VBAC at all. Perhaps I’ve led a sheltered life and misread the recommendation.
For the avoidance of doubt, and excluding situations like preterm or already advanced labour, I think if a woman, after full discussion, requests a repeat planned Caesarean, the obstetrician should do it. If they’re unwilling to do it, they should not be referring to a colleague who will. They should change jobs.
“Too posh to push” is tricky. It’s a perjorative term. I’ve never met someone like that.
Your question about the whole business of “rights” to home birth and things like that, and consequent “duties” on midwives and perhaps doctors to attend, fills me with gloom. Not because I’m opposed to home birth, or because I’d support midwives not attending if they thought hospital was safer. I just don’t find the language of rights helpful for dealing with these situations. But I’m not a lawyer and I know that’s rather an old fashioned view. I guess it’s where this discussion started.
In a recent letter to OBGYN MANAGEMENT we outlined the association between the increase in c/sections rates since 1973 to 2014 and the increase in maternal mortality. Obviously there are comorbidities, but if one looks at the primary causes of maternal death a close look should be addressed to the rising c/section rates. We believe c/section rates have resulted indirectly in the maternal mortality in the US now equal to the maternal mortality in 1973 when the section rate was 8%. Unintended consequences may be related to reported safety of the procedure, fetal heart rate monitoring, alleged improved neonatal outcomes ( primarily due to advanced neonatal care), and litigation. We must lower the world wide increase in c/section rates.
Some of the rise is artefact from better registration. But you’re right. I had my tongue in my cheek when I said we can usually deal with the complications – praevias, accretas and percretas are no fun for anyone. Women still die from them.