The World Health Organization recommends that the ideal rate for caesarean sections should be between 10 and 15%. However, caesarean sections have become increasingly common in both developed and developing countries (WHO, 2015).
A recent survey by Macfarlane et al (2015) found caesarean section rates ranging from 14.8% (Iceland) to 24.6% (England) to 52.2% (Cyprus), with a median rate of 25.2%. By contrast, instrumental vaginal delivery rates ranged from 0.5% (Romania) to 12.6% (England) to 16.4% (Ireland), with a median rate of 7.5%. These variations, the authors conclude, illustrate a lack of consensus about practice and raise questions for further investigation.
Macfarlane et al's (2015) data support the contention of Penna and Arulkumaran (2003: 399) that obstetricians are ‘… more likely to agree to a request for a non-medically indicated caesarean section than in the past’, citing a 1986 study showing that most obstetricians refused to perform unnecessary caesareans; but in 1998 another study found that 69% complied with such requests.
Why do more women favour caesarean section?
Nzewi and Penna (2011: 327) suggest that fear is the reason behind these requests: ‘This includes fear of injury to or death of the baby as a result of labour, a previous traumatic birth experience, [and] … Some women also state worries about pelvic floor damage and perineal trauma …’ The authors describe tokophobia as a morbid fear of labour and delivery, with a complex aetiology, and recommend that tokophobics should be offered a psychiatric assessment, which might ultimately result in a medically-indicated caesarean section.
Ethical views
Bewley and Cockburn (2002) state that doctors should first do no harm and do what is both medically indicated and ethically vindicated on a risk–benefit assessment. In which case, it is worth quoting Nzewi and Penna (2011: 327), who reported: ‘Maternal mortality is estimated to be 2.5 times higher in women having elective caesarean sections compared to vaginal deliveries, though there remains a paucity of safety data regarding caesarean section in healthy women with “high-risk” women excluded.’ They also highlight doctors' obligation to use health resources wisely, stating: ‘A vaginal birth has been estimated to cost approximately £1500 compared to £2700 for uncomplicated elective caesarean delivery.’
Bewley and Cockburn (2002: 593) remind us that a doctor's duty is to respect women's autonomy, and ‘… fulfil an informed choice (paid for privately or by the NHS), even if the operation is not medically indicated and more dangerous.’ But Gass (2006) opposes this point of view. The author contends that there is insufficient evidence to support the claim that elective caesarean section avoids pelvic floor trauma. Gass (2006: 34) also suggests that cost ‘… may be one reason why the National Institute for Health and Care Excellence advised against caesarean section on demand’.
A third ethical standpoint considered by Bewley and Cockburn (2002: 593) is the claim that because information is insufficiently clear to make assessments about competing risks, ‘… choice can be reasonably included in the equation’ and doctors should acquiesce to caesarean section requests rather than risk being perceived as paternalistic. However, they dismiss this argument as indistinct, asserting that the language of ‘choice’ is used as rhetoric to persuade, and that ‘[l]essons from history do not solely concern paternalism, but also fads and unanticipated damage.’ (Bewley and Cockburn, 2002: 594).
Latham and Norwitz (2009) consider the phrase ‘caesarean delivery on maternal demand (CDMD)’ and decide that if every non-medically indicated caesarean is defined as a CDMD ‘… then we lose sight of the need to uncover and curb unhealthy financial, legal, or workplace incentives that might motivate physicians to perform unnecessary procedures.’ (Latham and Norwitz, 2009: 406). This in turn, the authors suggest, raises the topic of where the boundaries of medical authority are placed. They speculate, that what are taken to be patient ‘demands’ and ‘requests’ ‘… are in fact the results of (conscious or unconscious) physician suggestion or persuasion.’ (Latham and Norwitz, 2009: 406). Perhaps it is the case that the notion of patient autonomy is not quite as robust as the vocabulary of CDMD suggests.
Finally, Latham and Norwitz (2009) propose that elective caesarean sections should not be offered as a routine. If, however, the mother raises the topic of CDMD, they recommend that the physician should discuss in a serious and objective manner the risk-benefit arguments with her, resulting in an outcome which ‘… should, in many cases, have the effect of dissuading the patient from its use.’ (Latham and Norwitz, 2009: 408).
But as the data of Macfarlane et al (2015) demonstrate, neither women nor, it seems, their midwives are sufficiently persuaded to disregard CDMD as a preferred option. Midwives will discuss caesarean sections with women and this should be acknowledged.