Caesarean sections are women doing the choosing?

Caesarean sections are women doing the choosing?

September 1998 Women's Health Watch

The number of women giving birth by caesarian section at National Women's Hospital continues to rise with suggestions some of the increase is due to women seeking elective caesareans. The caesarean rate now stands at just over 22%, a rise of about five percent since 1992.

In its annual report, National Women's notes rates are much higher among women over the age of 41 (35.7%), Asians (up to 28.7%) and Fijian women (35.7%). O&G specialist Rob Buist says National Women's is trying to reduce the caesarean section rate by developing guidelines, antenatal education, as well as a comprehensive audit, examining issues such as caesareans in the second stage of labour, complications and diagnostic criteria for foetal distress.

Although National Women's doesn't yet have figures on elective caesareans, Lynda Williams, the co-ordinator of Auckland Maternity Services Consumer Council says an important factor is women requesting caesarean sections.

'There's a consistent message coming through that women are choosing to have elective caesarean sections. It appears some career women are trying to fit a birth into their busy schedule.'

However Ms Williams doesn't see elective caesareans as a positive move towards consumer choice and says the council believes women should be empowered to make the best choices for themselves and their babies.

'It's a bit like women having a baby in the paddy fields and then returning straight to work. I have heard stories of women downloading their email while in labour, giving birth and then returning to work on their laptops.'

Ms Williams need to consider the possible health effects both for themselves and their baby when they push for elective caesareans.

She says public hospitals and doctors are also concerned about elective caesareans because they have a capped maternity budget and the Health Funding Authority is unlikely to pay for high levels of technological intervention.

'However I know there are obstetricians who will accede to a woman's request for an elective caesarean.'

New Zealand isn't the only country debating the value of elective caesareans with British health professionals discussing whether this form of birth represents an important choice or a foolish health risk.

Writing in the British Medical Journal, obstetric consultant Sarah Paterson-Brown argues most caesareans sections are carried out in emergency situations so a lot of the figures on death rates may be misleading. She says normal vaginal deliveries can cause damage to the pelvic floor and cause incontinence, as well as resulting in foetal brain damage during labour. '31% of female obstetricians with an uncomplicated pregnancy would choose an elective caesarean section for themselves.' Dr Paterson-Brown believes women's views on birth should be respected as long as that choice is fully informed.

However other consultant obstetricians are unhappy about the trend. Obstetrician Ibrahim Bolaji from Grimsby Hospital points out a huge range of maternal risks, including increased death and hysterectomy rates as well as decreased fertility and pelvic infections. Mr Bolaji accepts a patient's right to autonomy but suggests health professionals give full and honest advice based on the available information.

Writing about 'The Caesarean Epidemic in Great Britain', author Sheila Kitzinger accuses some obstetricians of promoting elective caesareans 'with enthusiasm'. She also suggests the increasing caesarean rate is the result of the 'de-skilling' of obstetricians with younger doctors preferring caesareans for breach births, while older obstetricians will opt for vaginal delivery.

Dr Kitzinger doesn't believe women seek caesareans because they want to keep their vaginas 'honeymoon fresh' (a term introduced from the United States) but because caesareans are promoted as the safe option.

Ref: BIRTH 25:1 March 1998; BMJ, 1998;317:462