CS - WOMAN'S OR DOCTOR'S CHOICE? : Abstract.

Presentation by Wendy Savage, Senior Lecturer in Obstetrics and Gynaecology, St Bartholomew's and the Royal London School of Medicine, and Honorary Professor, Department of Social Science, Middlesex University.

The rate of Caesarean Section (CS) has risen globally from about 1% in developed countries 50 years ago to rates of under 10% in the Netherlands, over 16% in the UK, 20% in Canada and Australia , a peak of 24% in the USA in 1992 and 37% in Chile last year. It is hard to justify a rate of more than 10% on medical grounds and research, mainly from the US, has shown that 'physician style' is the main reason for the widely differing rates found even within the same hospital. Colin Francome's first survey of obstetricians showed that changing attitudes to breech and forceps delivery were cited by obstetricians as the reason for the rise; in 1989 litigation and improved prognosis for prematures was given.

Women who go into labour naturally at term without any medical problems still have a rate of CS about 5% for a first and 2% for later pregnancies although after 4 the rate begins to rise again. Younger women have a lower rate than older women, tall women lower than short women and paradoxically, rich women have a higher rate than poor women. Those who advocate CS on 'request' cite the reduced risk of damage to the pelvic floor, the fact that about 1 baby in 1000 dies round the time of birth, the convenience of planned birth and the avoidance of the pain and uncertainty of the progress of labour. Those who argue against this approach cite the hazards of surgery, the unknown long-term outcome of CS, the known increased risk of placenta praevia, placenta praevia accreta and hysterectomy in subsequent pregnancies, and the higher maternal mortality.

The recent rise is being justified on the basis of women's choice, but can a woman make an informed choice when the information given about long term side-effects is incomplete or absent?

Recently the FIGO Committee for the Ethical Aspects of Human reproduction and Women's Health issued the following statement:

(1999 International Journal of O&G vol 64 317-222)

Ethical aspects regarding caesarian delivery for non-medical reasons.

1. The medical profession throughout the world has been concerned for many years at the increasing rate of caesarian delivery. Many factors, medical, legal, psychological, social and financial have contributed to this increase. Efforts to reduce the excessive use of this procedure have been disappointing.

2. Caesarian section is a surgical intervention with potential hazards for both mother and child. It also uses more health care resources than normal vaginal delivery.

3. Physicians have a professional duty to do nothing that may harm their patients. They also have an ethical duty to society to allocate health care resources wisely to procedures and treatments for which there is clear evidence of a net benefit to health. Physicians are not obligated to perform an intervention for which there is no medical advantage.

4. Recently in some societies obstetricians have had increasing requests from women to be delivered by CS for personal rather than for medical reasons.

5. At present there is no hard evidence on the relative risks and benefits of term CS delivery for non-medical reasons, as compared with vaginal delivery. However, available evidence suggests that normal vaginal delivery is safer in the short-term and the long-term for both mother and child. Surgery on the uterus also has implications for later pregnancies and deliveries. In addition there is also a natural concern at introducing an artificial method of delivery in place of the natural process without medical justification.

6. Physicians have the responsibility to inform and counsel women in this matter. At present, because hard evidence of net benefit does not exist, performing CS for non-medical reasons is ethically not justified.

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