The study was funded by the Nuffield Foundation, London, United Kingdom.
Are There “Unnecessary” Cesarean Sections? Perceptions of Women and Obstetricians About Cesarean Sections for Nonclinical Indications
Article first published online: 26 FEB 2007
2007, Blackwell Publishing, Inc.
Volume 34, Issue 1, pages 32–41, March 2007
How to Cite
Weaver, J. J., Statham, H. and Richards, M. (2007), Are There “Unnecessary” Cesarean Sections? Perceptions of Women and Obstetricians About Cesarean Sections for Nonclinical Indications. Birth, 34: 32–41. doi: 10.1111/j.1523-536X.2006.00144.x
- Issue published online: 26 FEB 2007
- Article first published online: 26 FEB 2007
- Accepted May 5, 2006
- cesarean section;
- maternal request;
- maternal choice
ABSTRACT: Background: The belief that many women demand cesarean sections in the absence of clinical indications appears to be pervasive. The aim of this study was to examine whether, and in what context, maternal requests for cesarean section are made. Methods: Quantitative and qualitative methods were used. The overall study comprised 4 substudies: 23 multiparous and 41 primiparous pregnant women were asked to complete diaries recording events related to birth planning and expectations; 44 women who had considered, or been asked to consider, cesarean section during pregnancy were interviewed postnatally; 24 consultants and registrars in 3 district hospitals and 1 city hospital were interviewed; 5 consultants with known strong views about cesarean section were also interviewed; and 785 consultants from the United Kingdom and Eire completed postal questionnaires. Results: No woman requested cesarean section in the absence of, what she considered, clinical or psychological indications. Fear for themselves or their baby appeared to be major factors behind women’s requests for cesarean section, coupled with the belief that cesarean section was safest for the baby. Most obstetricians reported few requests for cesarean section, but nevertheless, cited maternal request as the most important factor affecting the national rising cesarean section rate. Several obstetricians discussed the significance of women’s fears and the importance of taking the time to talk to women about these fears. Conclusions: Existing evidence for large numbers of women requesting cesarean sections in the absence of clinical indications is weak. This study supports the thesis that these women comprise a small minority. Psychological issues and maternal perceptions of risk appear to be significant factors in many maternal requests. Despite this finding, maternal request is perceived by obstetricians to be a major factor in driving the cesarean section rate upward. (BIRTH 34:1 March 2007)
The belief that many women are demanding cesarean sections in the absence of clinical indications has been prevalent for many years. In particular, this belief underlies the basis of much media rhetoric about continuing high levels of cesarean section. For example, middle-class women have been labeled “too posh to push” or have been accused of following celebrity trends for birth by cesarean section (1–5). However, the persistent trickle of commentaries, editorials, and correspondence in the medical press on the ethical and medical dilemmas surrounding the issue suggests that it is not just the lay public who are convinced of this trend (6–8). Recently, the National Institute for Clinical Excellence guidelines in the United Kingdom have also discussed women who request cesarean section in the “absence of an identifiable reason”(9).
However, evidence to support the belief that large (or even moderate) numbers of women request the operation for nonclinical reasons is limited. Audit data show that most cesarean sections in the United Kingdom are performed for clinical indications (10,11). When maternal involvement in decisions for the operation has been addressed in audit and research, the resultant findings are often open to question. For example, in the National Sentinel Caesarean Section Audit (NSCSA), carried out in the United Kingdom in 2000–2001 (10), clinician reports gave maternal request as the primary factor in 7.3 percent of the cesarean sections audited. However, the audit report did not make clear which of these cases (<2% of the total births) also involved other clinical factors. The NSCSA also included a survey of obstetric consultants. The audit calculated that half the respondents were being asked for cesarean section, in the absence of clinical indications, by at least 3 percent of the women they saw in clinic. However, this estimate may have been unduly inflated. The clinicians were asked how many requests per week they received. Those receiving fewer than 1 request per week may have experienced difficulty in responding. Estimates per month or per year might have resulted in different findings.
Other studies that claim to show the place of maternal choice in decisions have been criticized for a variety of reasons (12), for example, that data have been extracted from case notes or by asking a clinician’s perspective on the woman’s level of involvement, rather than by asking the woman herself. Moreover, few studies have examined why women may be requesting cesarean section. The existing research suggests that women want the operation when they perceive themselves to have complications or are fearful of the outcome (13–16). Thus, rhetoric around women’s beliefs that cesarean section is easier than vaginal birth, or on the influence of celebrity trends, appears to have been based largely on assumption. This problem continues. The recent United States National Institutes of Health conference, although stating that no reliable evidence was available about the numbers or about any underlying reasons, seemed to accept high rates of cesarean section at maternal request as a given (17,18).
Therefore, considering the whole debate around women’s requests, 2 important questions remain unanswered by the key protagonists, women and obstetricians. The questions are: do many women demand cesarean section and, if so, what are their reasons? The aim of this study is to explore the perceptions of both women and obstetricians about whether women are making nonclinical requests for cesarean section.
This study used quantitative and qualitative methods to obtain current and retrospective data from pregnant women, new mothers, and obstetricians and formed part of a larger study into choice and decision making in cesarean section (19). The study had approval from the local research ethics committees in the study hospitals and the University of Cambridge Psychology Research Ethics Committee. Copies of all research instruments are available from the authors.
Data collection from women
Pregnant women were recruited from the antenatal clinics at 2 district hospital maternity units between September 1999 and March 2001 to provide prospective data. All primiparous women were invited to take part. Multiparous women were invited if their previous birth experiences made it likely that cesarean section would be discussed, or if the women, when asked about their desires for the birth of their baby, expressed an interest in discussing it. Those who agreed to take part were given a questionnaire that asked for details of previous pregnancies and births and their wishes for the birth of this baby. They were then asked to keep diaries, making an entry whenever an event arose that made them think about the type of birth they wanted. The diary asked for details of each event, and any effect it had on the woman’s thoughts. A final page asked for details of the birth.
Women who had recently given birth, who had either discussed cesarean section in pregnancy or considered it an issue, were identified from the new mothers discharged from the postnatal ward of the same 2 district hospitals between September 1999 and March 2001. An information sheet was placed in the discharge pack of all English-speaking women with a healthy baby, explaining the study and giving a series of questions for women to answer if they wished to take part. These questions asked whether they had wanted, or been advised to have, a cesarean section before the onset of labor, and if so, whether they were happy with the advice they had been given. They were also asked how their baby had been born, how satisfied they had been with the experience, and if they were willing to be contacted at a later date to discuss these issues further. Semistructured interviews were conducted approximately 6 weeks after birth in a place of the woman’s choice and explored the woman’s birth experience, her wishes and choices, and her feelings about what had actually happened.
Data collection from obstetricians
Data from obstetricians were collected through interviews and questionnaires between March 2000 and December 2001. Semistructured interviews took place with obstetricians from 4 hospitals: the 2 hospitals from which women were recruited, a third district hospital, and a large city hospital. Obstetricians were contacted by letter and by means of their secretaries. Because we were keen to gain an insight into both strong and moderate views about the issues, some further purposive sampling was considered appropriate and 5 additional consultants from other hospitals were also interviewed; these individuals were known, through publications, to hold strong but diverse views on reasons for cesarean section. Interviews focused on obstetricians’ views and opinions of cesarean section and the significance of maternal request.
A questionnaire that was designed for the study based on data collected during the interview phases and incorporating current issues in cesarean section was sent to all consultants on the Royal College of Obstetricians and Gynaecologists’ register for the United Kingdom and Eire with a prepaid return envelope. The questionnaire explored respondents’ views on the current cesarean section rate; opinions and experiences of women who made requests; perception of the risks and benefits of cesarean section and vaginal birth; concerns and experiences of litigation; and demographic information.
All interviews were tape-recorded, with consent, and transcribed verbatim. Transcripts were checked and corrected against the tapes. All respondents were offered copies of their transcripts and the opportunity to make changes where they thought the text did not reflect their meaning, although only 1 participant asked for any changes to be made. The main researcher (J.J.W.) was responsible for overall coding and analysis. An initial coding frame was developed from issues arising in the appropriate research literature and from repeated readings and rereadings of these final transcripts. The Atlas-ti package was used to aid analysis (20). As complex descriptions and images were explored, new codes were developed, whereas others were subdivided. Already-coded text was then recoded. When this iterative process resulted in no more new codes and when all the transcripts had been processed, the text within each code was explored, and examined against others, both within and across interviews, to identify themes. To improve reliability, a second researcher (H.S.) coded a selection of transcripts independently and findings were compared. The research team also read transcripts and thematic descriptions and met regularly to discuss the entire analytical process.
Quantitative data from the questionnaires were analyzed using the Statistical Package for Social Sciences (21). Comments to open-ended questions were both coded and analyzed thematically.
Recruitment of women
Of 105 women who agreed to complete antenatal diaries, 95 returned the recruitment questionnaire and 64 (61%) returned a completed diary (23 multiparas, 41 primiparas). Women who did not return a diary were significantly younger but did not differ in either sociodemographic terms (study hospital, age at leaving school, parity, previous pregnancy experiences) or pregnancy-related attitudes (having positive or negative feelings about being pregnant, perception of pregnancy and childbirth as natural or difficult, and in wanting or not wanting a cesarean section). Among participants, primiparous and multiparous women did not differ with respect to age, level of education, and pregnancy-related variables.
Four hundred and eight postnatal women returned forms indicating any discussions they had about cesarean section and how their baby was born. Two hundred and ninety-eight women were not contacted because they either did not have, or did not consider having, a cesarean section or identified obstetrically defined clinical indications for their cesarean section. Of the remaining 110 women who answered in their questionnaires that they had taken part in decisions about cesarean section, 66 were found, on the basis of a telephone call, to be describing cesarean section as the only safe option for the birth of their baby and most of these were emergency procedures. These women were not invited to be interviewed. Forty-four women were invited and agreed to be interviewed.
What type of birth do women want?
Most (42/61, 69%) women in the prospective antenatal diary study gave the answer “vaginal birth” to the question in the recruitment questionnaire “At this early stage, what do you think you would like for the birth of this baby” (Table 1). However, 5 primiparas added that a safe outcome would override their preference for a vaginal birth. Only 1 (3%) primipara answered “cesarean section” as (surprisingly, given the recruitment strategy) did only 6 (26%) multiparas. Nine primiparas (24%) and 3 multiparas (13%) were unsure about their preferred mode of giving birth but stated that safety was paramount.
|What Women Said They Wanted||Primiparas No. (%)||Multiparas No. (%)||Total No. (%)|
|Vaginal birth||28 (73.7)||14 (60.9)||42 (68.9)|
|Cesarean section||1 (2.6)||6 (26.1)||7 (11.5)|
|Unsure/what is safe||9 (23.7)||3 (13.0)||12 (19.7)|
At the postnatal interview, 26 women reported that they had wanted a cesarean section and 18 reported that they had not—their wishes and outcomes are shown in Table 2. Of the women who wanted cesarean section and who had an emergency operation, 3 had been offered elective cesarean section and the other 2 had not.
|Wishes||No.||Had Elective Cesarean Section||Had Emergency Cesarean Section||Did Not Have Cesarean Section|
|Had wanted cesarean section||26||8||5||13|
|Had not wanted cesarean section (or accepted reluctantly)||18||8||2||8|
Women’s views about cesarean section
All the women in both phases of this study expressed an overriding concern for the baby to be born safe and well. In the quotations, postnatal interview participants are denoted by “P” and diary entries by “D”. All interview participants are numbered consecutively according to date of interview. Diary participants are similarly numbered but with 2 prefix numbers, a 1 or 2 indicating the hospital from which they were recruited followed by 1 (primipara) or 2 (multipara).
I wanted the baby more than giving birth to it, if that makes sense. (Primipara P13)
It doesn’t matter how your baby’s born really. As long as they’re safe and well. (Primipara P14)
But my sister was very good because she summed it up as “well, we’re both very good at having nice healthy babies, we just can’t give birth.” And I said “at the end of the day, if that’s the way it is, I’d rather have it that way round that I’ve got two nice healthy children that I have had to have by caesareans than the other way round, you know, giving birth and then having two very poorly children.” (Multipara P24)
At present my overriding thought is that I just want a live baby at the end of the process. I don’t see the process of birth as some kind of big payoff for me. I’ll do anything, c-section or whatever, in order to get a healthy baby. (Primipara D1105)
Two interview participants described wanting to ask for cesarean section to have some control over the timing of the birth, but neither voiced her request to hospital staff. In the prospective diaries, only 1 woman described wanting a cesarean section because at 16 weeks she described herself as
Extremely anxious—do not want a long labour followed by emergency caesarean (Primipara D1111)
But she was talked out of it by family and friends:
Talked to two friends who had both had caesarean and vaginal births. Both said the recovery from a vaginal birth was far quicker and both said they would definitely opt for vaginal births again. Interested and reassured that giving birth vaginally may not be so bad. Thought about it for a considerable time and am now wondering if I do want caesarean. (Primipara D1111)
The 8 women who asked for and underwent cesarean section believed that they had clinical justifications for the operation. However, it was clear from some of their comments about the reactions of health care professionals that the doctors and midwives caring for them did not always share their interpretation that their fear of vaginal birth was clinically justified:
Apart from being absolutely paranoid that there was something wrong with him because of having lost one already, I was very concerned that I’m going to end up going through 10 hours of labour and then find that I need a caesarean anyway. Because my sister’s had 3 caesareans, we’re both 5ft nothing …. But there was very much, again they treated me a little bit like a clucking mother, “yes, you’ve had a miscarriage but it’s not so disastrous.” (Primipara P57)
Fear could arise during a pregnancy because of a woman’s previous experiences:
It was a horrendous delivery … in the end it was forceps delivery, and it was very traumatic …. In less than a year after that I discovered I had a prolapse, and I went to see the doctor and he said it was a bladder prolapse. He assured me it was nothing at all to do with giving birth, but … I can only think that all that squeezing and pushing must have done it … and then when I became pregnant with the second one, all I could think of was going through all that again, I was just going to lose everything. I thought it would be awful, so I thought about having a caesarean straight away. One of the first things that crossed my mind, sort of arranging it. (Multipara P34)
Fear could also be induced in women through comments made by health professionals, friends and family, or others’ previous experiences:
On a routine visit to the midwife, she said the baby felt like it was going to be another big one, she didn’t think it was going to be anything below what [previous baby] weighed and she said I might want to think about having a caesarean. Then that started me worrying a bit … I didn’t think I’d be able to push the baby out myself as I couldn’t with [previous baby]. I thought I was going to need forceps and a ventouse or something again. That’s what worried me the most, and damaging my pelvis, if it was a big baby. (Multipara P41).
How I formed the opinion of giving birth was really through my sister and my mother, talking to them, and I remember particularly my mother saying how painful it was and if I was given the option to have a caesarean to go for it, and she said it on more than one occasion, and the first time I didn’t really think an awful lot about it, I just thought, “Oh she’s just being protective of me,” but when she said it several times, I thought “Oh, there must be something to this and she’s not telling me the whole story about the horrors of childbirth.” (Primipara P53)
Cesarean section was widely perceived as safe and safer than vaginal birth for babies. Any risks associated with cesarean section were usually minimized and described as risks to the mother:
I just felt the caesarean was safer for the baby … although the risks to me were it was a major operation, it was going to take longer to get over and all the rest of it, the risk of infection and stuff like that. I still felt, well at least the baby, I knew I could recover all that, because I was quite fit and a healthy person, I just wanted to make sure that she was OK really. (Primipara P13)
I’ve read things where I’ve heard it’s better for the baby, to have a caesarean; they’re not getting squashed all the way along the birth canal. (Primipara P57)
I understand it’s relatively easy surgery in that respect on the baby. (Multipara P16)
If there’s anything that you feel could damage the baby at those last few days, then they should ask you then if you want a caesarean. (Multipara P20)
Interviews took place with all 29 obstetricians who were asked: 9 registrars and 15 consultants from the 4 hospitals (labeled 1–4) plus the 5 additional consultants (labeled 5) known to hold strong views.
Of the doctors interviewed, only 1 (from the large city hospital) reported performing many cesarean sections purely because women asked for them:
Now we have a population at this hospital which is very different to most other hospitals. It is a much older population and a population of women who are very well educated, very professional women … who seek us out … they have access to information which informs them about whether they should have a caesarean section as an elective procedure or not. (Consultant 4:97)
More often obstetricians described 1 or 2 specific cases in which a cesarean section had been requested in the absence of any indication. It may have been that they remembered the details clearly because the cases were different from their usual ones and the doctors had taken considerable time to discuss with these women their reasons. Examples given included a woman with a poor body image, a woman whose husband had found the previous partner’s birth experiences traumatic, and a misinformed teenager. Overall, doctors in all 4 of the hospitals were more likely to say that cesarean section for maternal request in the absence of clinical or significant psychological issues was a relatively rare occurrence:
We’re not talking about many, it might be 1 a month, if that actually. There are about 5 or 6 a year. (Consultant 2:76)
The numbers I’m talking about in terms of maternal requests for caesarean are actually very small. It’s just that you remember them because you have to justify them afterwards, as to why you said yes, in a way that you don’t with people with good obstetric implications. (Consultant 3:83)
Although the press talk about people electively asking for caesarean section for maternal reasons, I don’t see that much. (Registrar 1:88)
This is the one that always attracts the press, too posh to push, that sort of thing. That is … I don’t think that’s a big issue at the moment. (Registrar 4:106)
Several doctors reported that these requests were more likely to be made by pregnant members of the medical, nursing, and midwifery professions:
But a number of them, particularly the ones who are requesting it, are either medical or nursing. Not infrequently. (Consultant 2:60)
I know of several midwives who have had elective caesarean section for no indication whatsoever, and I think the numbers for that group may well increase. (Consultant 3:78)
Like the women, doctors identified fear as an issue, and positioned it as an important factor in women’s requests:
I think the professional woman who needs to get back to driving her company as soon as possible is probably the exception. I think the majority that come along are either scared and it’s their first baby and they’re scared, or they’ve had a caesarean section before for a reason which isn’t likely to recur but feel that they don’t want to go through labour at all and would rather have a caesarean section in the future. (Consultant 2:68)
Most people in my experience who want an elective caesarean section want it because they have some nonspecific fear about vaginal delivery. (Consultant 4:101)
They recognized that this fear might be because of a previous traumatic birth experience or other experiences, for example, previous miscarriages or having conceived after several attempts at in vitro fertilization, and a consequent high level of anxiety for the safety of the baby. Some obstetricians thought that many of these women did not truly want a cesarean section but saw this as the only way to guarantee the safety of the baby or to avoid a repeat of their previous frightening experience:
I have come across women who are actually requesting a caesarean section, mostly because they’re not very sure what to do, whether to have a vaginal delivery or a caesarean section, especially this comes with the woman who had [an emergency] caesarean section before … obviously emergency caesarean sections are not very pleasant, they’re a little bit stressful. (Registrar 1:90)
Yes, there are changes both from obstetricians’ point of view and from the mothers’ point of view because what we have seen, more mothers are coming requesting for caesarean section. For different reasons. Some of them have difficult delivery before or difficult experience, or they have heard something from their friends who had a caesarean section and they are concerned about the delivery or frightened about the delivery and they’re requesting caesarean section. (Registrar 3:99)
There are some people who are worried about sex afterwards and their perineum and things like that, so I think that does come into some people’s decisions, but no, the impression I get is much more it’s people who either had a bad experience in labour or who are nervous about labour. (Registrar 4:105)
Although doctors recognized women’s fears, some did not see these as constituting a clinical indication:
There’s no doubt there’s also been an increase in patient requests for elective caesarean section because of concerns over the perineum and urinary and bowel issues. These are more difficult, obviously, because there’s no strong medical indication for caesarean section with these cases. (Consultant 1:76)
Often there’s a slight medical reason in it, such as some people have had a difficult or been unhappy with a vaginal delivery last time round and may ask for one this time, it may have just been an awful experience, or they may have had a tear and had problems. It’s often difficult to separate them completely. (Registrar 2:88)
Many of the doctors stressed the importance of taking time with women to find out what was behind the request, and where appropriate, exploring safe and acceptable alternatives:
So I think if people are just saying “Oh I just want a caesarean” because they’re worried … sort of superficially worried about labour or they just can’t be bothered or they want it more planned and things like that, I think often you’ve got a duty to kind of not talk them out of that, but sort of put the pros and cons of it to them. So I wouldn’t just say “yes” to everybody who wanted an elective section. (Registrar 4:105)
However, some doctors pointed out that finding the time to give to such women in their busy schedule could be extremely difficult:
We explored all the reasons for the request for the section … after several consultations she actually said at the end of it, “well, I actually didn’t want a section anyway, but it was just because of X, Y and Z, and now that we’ve got a plan, we’re going to do this, this, and this I feel a bit more comfortable.” But it is ever so time consuming I think to do that. (Consultant 2:59)
Fear of labour, fear of problems in labour, bad labours last time; those are the sorts of things. … it’s not a large number, but it’s a significant proportion of the workload, because they take so much time. (Consultant 3:94)
Of 1,525 questionnaires posted, 972 were returned. Six obstetricians refused to participate and 181 returns were invalid (mostly from doctors not practicing obstetrics). The valid response rate was 58 percent (785/1,344).
The most cited response in answer to the question “What, in your opinion, are the three main reasons for the rising national caesarean section rate?” was “maternal request” (77% of obstetricians), with litigation and defensive practice cited by 67 percent (Table 3). Although stating that maternal request was a significant contributory factor to the rising cesarean section rate, most obstetricians who returned questionnaires reported few requests themselves. Of 725 obstetricians who answered the question “In your personal practice, approximately how many requests for elective caesarean section have you had in the past 12 months from women who, in your opinion, had NO clinical indication for the operation?”, 29 (4%) reported they had none. Three hundred and seventy-two (51.3%) reported requests for 6 or fewer cesarean sections each (i.e., 1 request every 2 months at most), whereas only 62 (8.6%) had more than 20 requests. Less than one third of obstetricians (28%) reported receiving two thirds of the total requests.
|“What, in Your Opinion, Are the Three Main Reasons for the Rising National Caesarean Section Rate?”*||Obstetricians Giving Response No. (%)|
|Maternal requests||603 (76.8)|
|Litigation/defensive practice||527 (67.1)|
|Issues around doctors’ training||294 (37.5)|
|Previous cesarean section||191 (24.3)|
|Breech births||162 (20.6)|
|How pregnancy/birth is now managed||103 (13.1)|
|Evidence/changes in obstetric practice||88 (11.2)|
Six obstetricians who reported “lots/many” and 26 who reported “several/a few” were excluded from the above calculations because it was not possible to estimate what they meant by these numbers. The potential for different interpretations of terminology, such as a few or lots, is illustrated by part of an interview carried out before developing these questionnaires:
Interviewer: You mentioned earlier that you’d had three women who requested caesarean sections last year … Do you think that that low number was because …?
Doctor: Low! I thought that was high! I mean before … I was at [hospital] for 25 years, and the first 20 of those years I would say that only about one woman every 2 or 3 years would ask for a caesarean section. (Consultant 5:104)
The aim of this study was to explore the perceptions of both women and obstetricians about whether or not women are making nonclinical requests for cesarean section. The data, derived from both women and obstetricians, did not provide evidence to support this widespread belief. We did not find women making requests for cesarean section in the absence of what they perceived to be clinical indications, but the perceptions of women and doctors as to what constituted a clinical indication were not always similar. The only women in this study who made requests for cesarean section did so in the light of anxiety or fear about the safety and well-being of themselves or their baby. Similarly, most obstetricians who took part in interviews or returned questionnaires reported few requests from women in their personal practice. However, in contrast to these accounts of their own experiences, many obstetricians also reported in the questionnaire that maternal request was an important contributor to rising cesarean section rates in the United Kingdom.
It would be inappropriate to argue from the above findings that women never demand cesarean section without a clinically significant reason since this study has clear limitations. In particular, the data were mainly collected in 2000–2001, and women’s attitudes may have changed since that time. However, this time was when there was already a widespread belief that large numbers of women were demanding cesarean section merely because they wanted one, a belief that was promoted by the media. Cesarean section rates in the United Kingdom were already high by then, at 21.5 percent of births (10), with maternal requests being blamed for some of the recent increases, as shown in the data from obstetricians presented here. Although it is possible that the continuing media rhetoric itself may have resulted in the issue gaining a higher profile, and more women thus seeing a request for the operation as a feasible option, no current evidence shows that this is the case. The conference statement from the recent National Institutes of Health’s meeting says “CDMR (cesarean delivery on maternal request) is not readily identifiable in any existing studies or US national databases either currently or historically”(17). It can be argued that since the same rhetoric and assumptions are being made now which were current at the time these data were collected, the same conclusions should follow. However, this factor does not negate the need for further research and the collection of more contemporaneous data.
Further limitations include the fact that numbers of women participants in both phases were small, and we can say nothing about those women who did not agree to take part or about different populations of women. Women were also only asked to join the study when they were booked at 1 of 2 district hospitals in the East Midlands, so the results may not be applicable in other areas. An attempt to specifically recruit women wanting cesarean section in the absence of clinical indications in a third hospital resulted in no respondents. Although we cannot be certain that our study populations are not systematically biased, this possibility seems unlikely when the findings of both the qualitative and the quantitative parts of this study involving obstetricians from across the United Kingdom and Eire, and both the prospective and the retrospective phases with women, concur in many respects, and in particular that maternal demands for cesarean section, in the absence of any clinical or psychological concerns, are rare. A small number of obstetricians did report many requests for cesarean section and further investigation is needed into possible explanations: the extent of their private practice, differences in how doctors define maternal request, or, as one of our respondents commented, whether women in particular localities approach particular clinicians because their attitudes become well known.
Given these limitations, the findings still raise several questions about “nonclinical” requests. The question we posed to obstetricians about numbers of nonclinical requests for cesarean section was extremely similar to that posed by the National Sentinel Caesarean Section Audit (10). Their survey asked about the number of requests per week and reported a maternal request rate of 3 percent for half of their respondents. We asked about number per year. The great majority of obstetricians in our study (713/725, 98.3%) reported fewer than 1 request a week; thus, practitioners would have found it difficult to express their experience in terms of requests per week, and 570 (78.6%) reported fewer than 1 request per month. Our findings are in keeping with at least 1 United Kingdom single-hospital audit where Chaffer and Royle (22) concluded that maternal request in the absence of clinical indications was not a significant contributor to the cesarean section rate. Similarly, in an Australian study, only 1 woman in 310 preferred a cesarean section in the absence of any known current or previous complication (23), and a recent United States survey (24) reported that less than 1 percent of mothers (only 1 of 1,300 women surveyed) who had a first cesarean section actually requested one. Critiques of the literature on this issue published since 2001 (25,26) have confirmed the findings of an earlier review (12) that research claiming to demonstrate women’s birth preferences has seldom addressed the issue with women themselves and has almost universally failed to explore the information women are given before making birth choices. When these flaws are taken into account, evidence is available of only small numbers of women requesting birth by cesarean section for a nonclinical reason and of a range of personal and societal reasons, including fear of birth and perceived inequality and inadequacy of care, underpinning the requests.
It is therefore particularly striking that so many (78%) obstetricians perceived maternal request to be the most important factor in the rising cesarean section rate. Several possible explanations for this finding can be given, including the influence of media rhetoric around the causes for the current high cesarean section rate. An alternative explanation centers on the definition of “maternal request.” The data derive from within a culture in which more women, although not too posh to push, are expressing fears about vaginal birth and seeking advice about cesarean section, at the same time as cesarean section has undoubtedly become safer. It is possible that obstetricians prefer to “blame” women than examine their own role in the rising cesarean section rate through such means as their own reduced thresholds for considering the operation appropriate and increasing fear of litigation (27).
This study shows that, in the context of cesarean section, women’s fears and needs can play a major part in the decision-making process. Safety of the baby is paramount for women. If they fear for their baby, maybe because of size or previous negative experience, and they also perceive a cesarean section as safer for the baby they may express preferences for the operation. Although the increased safety of cesarean section and growing discussion around the risks of vaginal birth may influence a woman’s decision, little is still known about what information on risks and benefits is given by health professionals, or how it is introduced and discussed. The National Institute for Clinical Excellence guidelines (9) have helped clarify the available evidence, but obstetricians are still faced with a dilemma. They must not only help women make decisions in cases of clinical necessity but also take women’s fears into account sometimes in the presence of clinical ambiguity about the best way to achieve a good outcome, and decide the optimum course of action where no obstetric clinical indication is present but women’s fears are overwhelming.
A study from Finland showed that anxious women who receive appropriate psychological therapy and obstetric and midwifery support in pregnancy are likely to experience shorter labors, and to have fewer birth concerns than anxious women who do not receive such support (28). A recent Norwegian study reported a marked effect of a counseling intervention on the numbers of extremely anxious women who, before the intervention, had expressed a wish for a birth by cesarean section (29). Consequently, it has been argued that when a request for cesarean section arises out of maternal anxiety, it is actually unethical for practitioners to offer the operation without providing psychological and midwifery intervention (30).
A further question raised by the study is whether female health professionals really request cesarean section in disproportionate numbers, as suggested by some obstetricians, or whether this suggestion is a matter of perception? Are health professionals remembered because of the much publicized postal survey among London obstetricians, which asked respondents how they would choose to give birth were they, or their partners, pregnant for the first time, with an uncomplicated singleton pregnancy at term? Seventeen percent of the doctors in total, and 31 percent of the female obstetricians, said that they would choose an elective cesarean section (31). However, heavy criticism of this work has been made on methodological, interpretative, and ethical grounds (32). This study has been succeeded by further research, which shows that other practitioners, such as midwives (33) and obstetricians from other parts of the United Kingdom and from other countries (34), are less inclined to prefer cesarean section; nevertheless, it is still the original study that tends to be remembered.
The perception that there is a high rate of maternal request for cesarean section has fueled calls for a randomized trial of vaginal versus operative birth, as reinforced by the recent National Institutes of Health conference statement (17). Regardless of issues of morbidity and mortality, if maternal request rates are much lower than perception and rhetoric would have us believe, the “need” for such a trial would be significantly reduced.
It is interesting to note that women in this study did not talk about a right to choose cesarean section, even though this is often mooted as an important underlying issue in maternal request (35). When women in this study discussed fears that contributed to their wish for cesarean section, their right to make choices, as propounded by Changing Childbirth (36), was seldom raised.
This study suggests that maternal fears and perceptions of risk are important in requests for cesarean section. These perceptions may relate to the ways in which the risks and benefits of cesarean section are presented by health care professionals and in the birth stories and experiences of their friends and family and also in the media (37). The National Institute for Clinical Excellence guidelines suggest that women who request the operation because they are afraid should be offered counseling (9). However, if fear is a major factor, it must first be acknowledged by both women and health care professionals and time and resources allocated to deal with it.
We would like to thank the Nuffield Foundation, London, United Kingdom, which funded this research. We are grateful to Sarah Clement on whose original suggestion this study is based, and the advisory panel who supported us: Susan Bewley (Consultant Obstetrician), Jo Garcia (Senior Research Officer), Mary Newburn (National Childbirth Trust), and Kirsty Keywood (Senior Lecturer in Law). Particular thanks go to Mary Newburn and Susan Bewley who commented on earlier drafts of this article. We are also grateful to all the women and obstetricians who made this study possible by taking time to talk to us and to complete questionnaires and diaries.
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