Caesarean section should be available on request: AGAINST: Women need accessible evidence‐based information on caesarean section

Abstract

Since the 1960s, worldwide trends have shown a dramatic rise in caesarean section (CS) rates, but with considerable variation between countries (0.4–46%) and healthcare settings (WHO Background Paper, 30). The contribution of CS on maternal request (CSMR) to overall CS rates ranges from 1–48% in public sector, and 60% in private sector healthcare systems, but diffferences in how CSMR is recorded limit reliability [Lavender et al., Cochrane Database Syst Rev 2012;(3):CD004660]. CSMR that are not medically indicated can do more harm than good, and should not be available ‘on demand’. A more woman-centred and evidence-based approach to maternity care is needed. FIGO has stated that CS without medical indication is ‘ethically unjustified’. Updated NICE clinical guidelines (CG132) have given more weight to CSMR: ‘if after discussion and support vaginal delivery remains unacceptable to a woman CS should be offered’. However, the RCOG emphasises that this is not a reason for CS being available ‘on demand’. Three primary reasons for CSMR exist (D'Souza, Best Pract Res Clin Obstet Gynaecol 2013;27:165–77): However, maternal case–fatality rates are estimated to be three times higher for CS than VB (Hall and Bewley, Lancet 1999;354:776). Moreover there are considerable short and long-term risks for mothers (increased anaesthetic risks, surgical complications, blood loss and pulmonary embolisms) and babies (increased neonatal admission, respiratory problems and stillbirth in the next pregnancy) [Lavender et al. Cochrane Database Syst Rev 2012;(3):CD004660]. Although we cannot accurately quantify the clinical impact of CSMR, these risks must not be overlooked. Clinical guidelines emphasise the importance of assessing the risk and benefits to mother and baby when considering CSMR. Given the balance of risks and benefits ACOG proposes that in the absence of maternal or fetal indications, a planned VB is the safest and most appropriate recommendation. We need to ask: ‘is the most appropriate response to psychological distress to offer surgery that carries risks for mother and baby?’ Tocophobia can be effectively treated with psychological therapies (up to 86% of women receiving therapy choose to have a VB (Nerum et al., Birth 2006;33:221–8). Therefore, an interprofessional approach to supporting women with tocophobia is needed, rather than simply offering CSMR. In some cases, psychological support will be insufficient to allay fears and a CS may be indicated. A woman's preference for a VB after a previous CS (VBAC) is greatly reduced (Mazzoni et al., BJOG 2011;118:391-9). However, previous CS should not dissuade women from choosing VBAC, or healthcare providers from offering it. VBAC is considered a safe option for the majority of women; 60–80% of women pursuing a VBAC will be successful (Obstet Gynecol 2010;115:1279–95). Planning a VBAC can be a difficult decision for women and additional support and information on associated risks and benefits should be provided. Health system factors are often neglected in this debate. A recent WHO World Report (Background Paper 29) implied that a demand-driven model exists, as regardless of medical need, the greater the capacity is to deliver surgical obstetric procedures, the more procedures will be delivered. Rising rates of CS have considerable cost implications; in the UK it has been estimated that every 1% reduction in CS could save the NHS ~£5 million (NICE; D'Souza, Best Pract Res Clin Obstet Gynaecol 2013;27:165–77). Healthcare provision should not be withheld on the basis of cost alone but it is impossible not to consider the economic implications of rising CS rates. In sum, rather than offering ‘CS on demand’, women should be offered accessible evidence-based information on CS risks, continuity of obstetric care and interprofessional support. Although we argue against CS on demand, we argue for tailored support and evidence-based information for women requesting a CS. In these circumstances we predict that the proportion of women favouring CS in the absence of medical reasons will decrease. I am grateful to Mary Newburn (Head of Research and Quality, NCT) and Elizabeth Duff (Senior Policy Advisor, NCT) for their helpful comments and feedback on drafts of this article. None declared. ■