The right to a caesarean. Should every woman have it?

Leslie Cannold Tuesday 15 March 2011 8:44am

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Australian women giving birth in private hospitals have a caesaerean rate of 41 percent. Public hospitals: 28 percent. Could this be where the expression ‘too posh to push’ came from? And is it a legitimate label for women who choose to have a caesarean for non-medical reasons?

Leslie Cannold, author, researcher and medical ethicist recently argued in The Age that  the right to an elective casaerean should apply to every woman. She writes…..

“Mention Australia’s caesarean section rate and collective tongues start wagging. It’s too high, the experts say.

In 1997, 20 per cent of women gave birth by caesarean. By 2007, the rate had climbed to 31 per cent, where it has remained since. This is at least double the 10 to 15 per cent rate recommended by the World Health Organisation.

But the WHO ideal is 25 years out of date. Britain’s Parliamentary Office of Science and Technology says that if the organisation repeated the exercise used to arrive at the initial figures, it would come up with a “rather higher range”.

This is because the recommendation was derived from figures in countries that had the lowest mortality rates at the time and today, few countries have c-section rates below 15 per cent.

Caesarean rates follow the money. Australian women giving birth in private hospitals had a c-section rate of 41 per cent, compared with 28 per cent for those in the public system.

Staff and institutional attitudes also play a part. A comparison of two British hospitals found that caesarean rates were lower in the institution where women lacked the “freedom” to “express a preference for caesarean section” and higher where women were “given information about the known relative risks of [caesarean and vaginal birth" and allowed to "make . . . the final choice"."]

Such findings should sound alarm bells to those concerned with the right of women to make autonomous choices about their medical care. Several studies suggest that most women want to have their babies the old-fashioned way. Guesstimates of those who have no medical indicators but want a caesarean anyway are between 3 and 15 per cent. Such figures fit with the observation of the International Federation of Gynecology and Obstetrics (FIGO) that most women will act to improve their chance of having a normal birth and healthy baby if they have access to the necessary information and support. In other words, most pregnant women will choose the option medical staff tell them is in their, and their foetus’s, best interest.

But what if they don’t? What if women have no risk factors for a c-section, and are not being told by their doctors that they should have one (the scenario for most lumped in the confusingly named “elective cesarean” category), but want to have one anyway. They want to schedule a caesarian because they are scared of labor, or because they want to lower their risk of pelvic floor damage and incontinence or because they had one last time and despite being told could safely attempt a VBAC (Vaginal Birth After Cesarean) they feared rupture or because they tore so badly last time the preferred the costs of c-section to risking that again or because it had taken them years to fall pregnant and the believed, rightly or wrongly, a c-section was the safest for the baby or just because they do, and that’s all they have to say about that.

As it happens, there is according to a 2009 Report by the FIGO Committee for the Study of Ethical Aspects of Human Reproduction and Women’s Health, there is “no hard evidence on the relative risks and benefits of term caesarean delivery for non-medical reasons, as compared with vaginal delivery.” Please, read that quote again carefully, It does not say there is no hard evidence on the relative risk and benefits of c-section for all reasons versus vaginal birth, but no hard evidence on the relative risks and benefits of caesarean delivery for non-medical reasons compared with vaginal delivery. This makes emphatic assertions by health experts that vaginal birth is safer than elective caesarean for women with no medical indications for c-section worth less than a hill of beans.

But even if medicos had the evidence on which to base an agreed recommendation about non-medically indicated caesareans, women would still have the right to pick the medically less-preferred option. Indeed, the freedom to review and evaluate the risk-benefit profile of all available medical options and to make a decision based on one’s own needs and values is what informed choice is all about.

If every time a medical professional thought one medical option was superior (on the basis of some, none or good evidence) he was empowered to simply chose it on the patient’s behalf, we would no longer be operating in an environment of informed consent, but one dominated by the medical paternalism of yesteryear.

The bottom line is that – short of engaging in self- or child abuse – women don’t have to prove to health professionals that their healthcare choices are good or worthy ones to be entitled to make them. Nor, and sadly much like their doctors, must they prove they are evidence-based.

Pregnant women can choose a glass of wine with dinner, to have their baby by caesarean and to give it a bottle instead of the breast.

As long as women are making their decisions freely and on the basis of a substantial understanding of the medical and other matters relevant to them, that is an informed and voluntary choice, and that choice belongs to them.

Did you have an elective caesarean? Did you deliver vaginally against your will? Do you think women should make this decision or should it be in the hands of the medical professionals?