“Let us ensure that in improving maternity care, the natural process of birth is upheld with a knowledge that medical care is there to aid women when there are complications, not to prevent litigation or to salve a midwife’s lack of confidence in her practice and skills, or in women’s ability to give birth naturally”
ACCORDING to Sultan and Stanton (1996): `there is an increasing awareness among obstetricians of requests for delivery by elective caesarean section.’ The suggestion that every woman should have the right to demand that her baby be delivered by caesarean section is an emotive and contentious issue. While certainly some women with a relative rather than an absolute indication for caesarean section are involved in decision making about their preferred mode of delivery (Mould et al, 1996), for example, women with a breech presentation or having had a previous caesarean, the idea that a woman with no medical, obstetric or psychological risk factors can demand that her child be delivered surgically, at increased risk to herself and her fetus and increased cost to the NHS has no parallel in any other area of medical or surgical care. Johnson et al (1986) found that 10% of obstetricians surveyed would perform a caesarean section for no other reason than that the woman requested it, and this figure may well have increased in the intervening decade.
Indications for Caesarean section
Women are almost three times more likely to have a caesarean birth now than they were twenty years ago (Francome et al, 1993). This rise is attributable to many factors, not least the vastly improved safety of the operation itself and of anaesthetic techniques, but including also fear of litigation (Savage and Francome, 1993). Absolute indications for caesarean birth include cephalopelvic disproportion, transverse or oblique lie of the fetus, placenta praevia, major placental abruption, prolapse of the umbilical cord and severe pre-eclampsia, and these conditions, in which mother or fetus or both would die without surgical intervention, account for between 5.8% and 8.5% of all births (Francome et al, 1993). A 1993 study found that the overall caesarean rate for England was 12.1% (Savage and Francome, 1993), suggesting that not all caesareans are absolutely indicated.
Relative indications include `fetal distress’ and `failure to progress’ in labour (both loosely defined conditions), multiple births, particularly large and particularly small babies, breech babies and women who have had a previous caesarean (Francome et al, 1993). Non-physical indications are less well documented but may include fear of vaginal delivery, fear of pelvic floor damage or previous bad experience of vaginal delivery (Ryding, 1991). Some women may feel that a caesarean section is the `best way’ to have a baby – a view that `is being created by some obstetricians’ according to Hemminki (1997). Whether an obstetrician, faced with a woman demanding delivery by caesarean in the absence of any indication, should be able to accede to her request is the focus of this debate. Although midwives do not make decisions regarding caesarean sections, they have a pivotal role in giving women clear and unbiased information regarding choices for labour and delivery, and are also influenced by changes in the caesarean section rate, as will be demonstrated.
Decision making in obstetrics, as in any other area of health care, must be influenced by the perceived risks of a procedure. Elective lower segment caesarean section has been demonstrated to carry a greatly increased risk of maternal death – mortality is approximately 4.5 times as high after elective caesarean than vaginal delivery (Hall,1994) even after controlling for pre-existing medical problems or obstetric complications (Lilford et al, 1990). In fact it is estimated that approximately 140 women die every year in the United States following caesarean sections which were not medically indicated (Savage and Francome, 1993).
Maternal morbidity is also increased by surgical delivery. Postoperative complications include wound infection, pain, uterine infection, urinary tract infection, deep vein thrombosis, chest infection, pyrexia, the need for urinary catheterisation and the need for blood transfusion, and only 9.5% of women in one study had no postoperative problems (Hillan, 1995). Long term problems can include formation of adhesions, intestinal obstructions and bladder injury, and increased risk of placenta accreta and scar dehiscence in subsequent pregnancies (Sultan and Stanton). Psychosocial complications of caesarean birth can include increased hospital stay causing separation from family and other children, separation from the newborn at birth, lengthy physical recovery periods interfering with the relationship with the child (Treffers, 1993) and feeling `too ill’ to breastfeed despite having previously wished to do so (Francome et al, 1993).
Neonatal morbidity is also significant following elective caesarean section, with the incidence of respiratory distress syndrome and transient tachypnoea of the newborn significantly increased after caesarean section, particularly where the woman has not laboured at all (Morrison et al, 1995). This risk is greatly increased in caesarean sections before 39 completed weeks gestation and, related to this, where the estimated date of delivery has been in dispute (Parilla et al, 1993). The neonate may also sustain injuries at caesarean delivery such as scalpel lacerations and joint dislocation (Sultan and Stanton).
Risks of vaginal birth
Vaginal delivery, however, is not without risk for all women. Sultan and Stanton list possible sequelae to vaginal delivery as emotional and psychological trauma, inadequate perineal repair leading to perineal discomfort or dyspareunia and extension of an episiotomy or perineal tear into the anal sphincter, although this is most likely to be associated with a forceps delivery (Sultan et al, 1994). However, as Magill-Cuerden (1996) points out, `if childbirth results in long-term [pelvic floor] problems, why are we not researching methods of prevention and treatment at the time of birth?’ It is not so long ago that compulsory episiotomy was regarded as a universal preventative for pelvic floor damage, and now prevention of potential problems with incontinence and dyspareunia may increasingly be seen as justification for caesarean section.
Another factor related to decision making must be the cost of a procedure in relation to its benefits. Caesarean sections in the UK cost the NHS approximately Â£760 more than a vaginal delivery, and it is estimated that every 1% decrease in the caesarean rate nationally would save the NHS five million pounds (Audit Commission, 1997). Five million pounds would pay for approximately 167 more midwives. Caesarean birth on average trebles the amount of time a woman spends in hospital during the postnatal period (7 days compared to 2.5 days) and so results in a greatly increased outlay of midwifery time (Audit Commission, 1997). While expense alone cannot be used to justify the refusal of treatment, it must surely be a factor if morbidity and mortality are shown to be increased rather than reduced by that treatment.
Why women ask
Women’s reasons for requesting caesarean section must be examined closely when deciding whether to accede to their request. Ryding (1991), in a study of women asking for caesarean section on psychosocial grounds, found that among the primiparous women, reasons for the request ranged from three women with unwanted pregnancies who planned to have their child adopted at birth and wished to have a caesarean under general anaesthetic, to two women who were themselves doctors who were convinced (despite their obstetrician’s advice to the contrary) that vaginal delivery was unsafe for their child.
This is similar to the findings of Al-Mufti et al (1996) who surveyed obstetricians and their partners and found that 31% of female obstetricians would request caesarean section for an uncomplicated pregnancy. The other women cited `fear of giving birth’ as the reason for their request. Among the multiparous women, reasons given were previous emergency caesarean, previous perinatal death, previous labour and delivery with obstetric complications and the development of serious health problems following a previous pregnancy. At that clinic, women requesting caesarean on psychosocial grounds were then offered counselling by a psycho-therapeutically trained member of the obstetric staff, following which about half of them decided to choose a vaginal birth (Ryding, 1991). `Labour debriefing’ of women who have had previous traumatic deliveries may also be helpful (Robinson, 1995).
This approach – treating a psychological problem with psychological care, rather then unnecessary surgery, appears to be useful and cost-effective, and there may be a role for midwives in providing labour debriefing and counselling following proper training. Chamberlain (1994) comments that women requesting a caesarean section are `making a cry for help,’ but then goes on to say that he would agree to their request – surely counselling or therapy would be a preferable first option?
There may be sociocultural reasons why women request caesarean section. Souza (1994) describes how in Brazil some obstetricians have caesarean rates of up to 75% and Sultan and Stanton comment on the: “vicious circle of cultural phenomena and economic influence, enhanced by convenience for the obstetrician,” which has led to vaginal delivery being regarded as: “archaic, painful, disfiguring and a cause of diminished sexual performance.”
Conversely, caesarean delivery, despite being major surgery involving severe pain and permanent scarring, is sometimes seen as the `easy’ way to give birth. Oakley and Richards (1990) discuss how the operation is now conceptualised very differently that other forms of surgery, euphemistically called a `section’ rather than an `operation’ and how it is not expected to carry any of the physical and psychological morbidity associated with surgery (despite evidence to the contrary). Francome et al (1993) point out that obstetricians’ lack of concern about the after-effects of caesareans may reflect the fact that they spend very little time postnatally with women who have had them. Hemminki (1997), referring to the study by Al-Mufti et al in which 31% of female obstetricians stated they would prefer caesarean birth, comments that: “if this view of caesarean section as a good alternative… a view in contradiction with scientific literature… spreads to lay people, the demand for caesarean deliveries is likely to explode at this time of emphasising patient choice.”
Should obstetricians accede?
If women are indeed choosing to request caesarean over vaginal delivery in the absence of any recognised indication, should their wishes be met, particularly now that maternal choice is emphasised in the maternity services as never before? Changes in social policy over the last few years, particularly the Winterton Report and Changing Childbirth, have now embraced women’s right to be at the centre of decisions about their maternity care, and it was on these grounds that the idea that: “it is every woman’s right to demand a caesarean section” became accepted.
However, it can be argued that if women choose caesarean over vaginal delivery, obstetricians and midwives may not be giving them enough information about maternal and neonatal morbidity and mortality following surgical delivery (Viccars, 1997). Sultan and Stanton point out that: “unfortunately, maternal freedom of choice does not always equate with a logical decision in terms of neonatal outcome or maternal well-being.” It is illogical to allow some women to choose surgical delivery at increased risk to themselves and their babies while forcing others to have caesarean sections against their wishes, sometimes by court injunction. Ryding (1991) comments that: “a serious complication or a young mother’s death is felt to be an even greater tragedy if the indications for surgery were not indisputable” and maternal choice cannot be regarded as an indisputable indication.
Losing the ability to give birth vaginally
Savage (1992) has stated that: “as the developed world becomes more and more dependent on technology, there is a danger that people will cease to believe that women can give birth naturally,” and comments that she believes that a reduction in the caesarean section rate can only be achieved by making midwives independent practitioners, mostly based outside hospitals, and allowing them to become the guardians of normal birth again. This view is echoed by Treffers and Pel (1993) who argue that midwives, `dedicated to protecting physiology,’ working in teams with their own caseloads of women, can reduce unnecessarily high levels of intervention. While it is indisputable that lack of intervention in childbirth can have disastrous consequences for women, midwives must seek ways of supporting labouring women and auditing our work so that complications can be reduced without recourse to surgical intervention (Magill-Cuerden) and must believe in women’s ability to give birth and promote that belief, so that our society does not develop such a fear of normal birth that surgery is seen to be preferable.
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AH updated 22 July 2001
This article was originally published in MIDWIFERY MATTERS, Spring 2000, Issue No. 84 and was obtained online from Radical Midwives’ Homepage – www.midwifery.org.uk