Should women’s right to maternal request caesarean section be promoted?
Lesley Page – CBE
Birthrights recently published a report on responses by individual hospitals in the UK to women’s requests for caesarean section.
The new Lancet Series has raised once again one of the central challenges of maternity care: how to prevent both the underuse and the overuse of caesarean section, and how to ensure that services ‘enable women and families to be confident of receiving the most appropriate care for their individual circumstances’.
Within this big picture, how should those of us working in, designing, researching, writing about, and using maternity services respond to individual women who request caesarean section when both the woman and her baby are healthy and where there is no obvious physical or psychological indication for surgery?
Given the recent publication of the Lancet series on Optimising Caesarean Section published together with WHO recommendations in this area, and a related Figo position paper are there any ethical, financial or moral grounds for promoting maternal request for caesarean section (MRCS) for healthy women with healthy pregnancies and healthy babies?
The Birthrights report, published in August 2018, was stimulated by a third of enquiries to their advice service (83 enquiries out of 262) being concerned with difficulty in access to MRCS. Of these 16% (13) enquiries gave personal choice as the reason for their request.
The survey examined how many NHS Trusts or NHS Boards had a policy that reflected explicit advice in the relevant NICE Guideline on maternal request for caesarean section. Based on their findings, the Birthrights report authors stated that:
‘the majority of Trusts in the UK make the process of requesting a caesarean lengthy, difficult or inconsistent adding anxiety and distress to women at a vulnerable time. And lawyers acting for the charity are concerned that at least one Trust may be acting unlawfully’.
The reference to acting unlawfully relates to a finding that some parts of the NHS have policies that effectively ban MRCS. This, in the opinion of Birthrights, may be determined to be illegal if tested in court.
Birthrights’ says that women should, based on information provided to them, even if there is no apparent indication, be able to choose caesarean section, and that those wishes should be respected. This is particularly relevant in respect to drivers such as previous traumatic vaginal birth, or disclosed or undisclosed prior trauma, such as sexual assault. However, in Birthrights’ view, such factors do not need to be present to justify a woman’s request, if she simply prefers a surgical birth after support and counselling have been provided, in line with the guidance of NICE.
We should bear in mind that the numbers of women requesting caesarean section is low, and MRCS is not at present a central driver of the increasing caesarean section rate (Bertran et al., 2018).
Note that, contrary to perceived opinion, most women around the world do not prefer a caesarean section, in the absence of current or previous complications. A 2011 systematic review on worldwide preferences reported an overall preference for caesarean section of 15% which decreased to 10 % when women who previously had a caesarean section were excluded.
The number of women who made enquiries about MRCS to Birthrights was small. Given this, is it right to deny the small numbers of women requesting caesarean section their choice?
The counterargument is that the risks of caesarean section are becoming increasingly clear, and the risk/benefit balance for both mothers and babies does not favour caesarean section where there is no indication (Sandall et al., 2018). If we are to be truly respectful to women, they do, at least, need to have access to all the relevant information, about both short- and long-term outcomes across subsequent pregnancies and births and even into the post-childbearing years (Lindquist et al., 2017).
Birthrights emphasise, rightly, that women should always be the primary decision makers in childbirth, whilst also protecting the right of individual doctors and midwives to decline to support an individual who requests a caesarean section on non-medical grounds.
Birthrights also reiterates the importance of healthcare professionals giving woman all the information and support they need to make an informed decision. It will be important then that all the evidence that is examined by Jane Sandall and her co-authors is considered and included when developing information and sharing it with women (Sandall et al., 2018).
Professionals should know of the risks of the underuse and the overuse of caesarean section, if they are to ‘first do no harm’. This is particularly important because, while women clearly have the right to decline medical treatment, for example induction or hospital-based birth, or caesarean section, this right differs from a request for treatment or intervention.
It might help understand this if you think about the response to a hypothetical request for induction of labour at 34 weeks. Would respecting the woman’s autonomy require that we grant this request? There is no other field of health care in which a health care professional is required to intervene without indication. In her interview in a Sprogcast (episode 34),
Professor Bewley clarifies the duty of the doctor to serve the best interests of the patient (woman), working on this fundamental principle of ‘first do no harm’. Thus, she makes it clear it is the duty of the doctor, (and I would add the midwife), not simply to offer a menu of consumer choices, some of which may harm. It is rather, a more complex process, sometimes requiring complicated conversations. Bewley also reminds that caesarean section is major surgery, and that while complications may be rare, they are not benign.
Birthrights has rightly emphasised the need for and importance of individualised and compassionate care. Prof Bewley gives a helpful, detailed, and nuanced description of the conversations that are important when there is a request for non-medically indicated caesarean section. What she describes is a dialogue in which the conversation starts with understanding where the request is coming from, to understand where the woman is. She emphasises the importance of not starting with a no but beginning a dialogue. She describes beautifully her approach, that emphasises making it clear to individual women the importance of her ‘first doing no harm’. She describes how she explains to women that it may be best to leave well alone. In her view, expressing a reluctance to use intervention that is not indicated and that may harm is a central part of the professional relationship. Prof Bewley is clear that her role is to serve the woman’s best interests. The dialogue around a request for non-indicated intervention, she says, may need a complicated conversation and sometimes a complicated plan to follow depending on the result of the meeting.
Birthrights also give examples of good practice by midwives supporting women who have expressed a wish for caesarean section without indication. This approach involves an initial and non-judgemental acceptance of the maternal request while listening and offering support. In this case, women will often subsequently elect to avoid caesarean section.
While the numbers of woman requesting, and preferring caesarean section are small at present, this could change if we do not improve the overall quality of care being offered. In a recent article Prof Soo Downe makes clear the need to improve the quality of care to minimise such requests:
Developing services where those women who need caesarean section get one, but where unnecessary caesarean section is prevented, requires overall improvement in quality with compassionate care to individual women (and their partners). Birthrights described human rights as an essential foundation to maternity care and critical to safety in a letter to the National Maternity Review (England).
The problem of a steadily increasing caesarean section rate, and reducing unnecessary caesarean section, will not be resolved unless we are able to ensure high quality, compassionate care to all. This will require systems change and culture change. The WHO Guidelines have proposed a number of non-clinical interventions that include a response to the increase in levels of fear around birth in both women using the service, and in those providing it.
The editorial in the Lancet Series on reducing unnecessary caesarean section is titled: ‘Stemming the global caesarean section epidemic’. The authors reserve the final paragraph to the tension between reducing unnecessary caesarean section and respecting women’s agency and the rights to choose the circumstances of her birth, as follows:
‘What is left unresolved are the tensions generated when women’s agency in choosing a caesarean section go against medical directives to intervene against them. Although the Lancet Series says that women’s demand is not a substantial driver of the current problem of overuse, efforts to reduce caesareans must, nevertheless, strongly respect women’s rights to choose the circumstances of birth. NICE guidance in the UK, for example, states that a woman should be offered a planned caesarean section if she so wishes. But it also says that practitioners can decline to provide one, and the new WHO guidance urges avoidance when a caesarean is not indicated. What then? With this new Series we hope to spark more debate and research about implementing recommendations to reduce caesarean section use’.
I suggest that while we need to respond sensitively to women’s needs and requests, we should not be actively promoting MRCS for healthy woman and babies. If we improve the quality and compassion of care and manage the fear that is escalating there will be fewer maternal requests for unnecessary surgery. Any strategy must include determined actions to improve the quality of care for all.
Meantime it will be important to ensure that all professionals providing maternity care are able to listen to women, hear their concerns, and engage in the compassionate but sometimes complex conversations that are needed when we are supporting women who are making decisions about their own care. Then whatever decision is made, women require the skilled knowledgeable and compassionate support of midwives and other professionals who can get to know them over time, who are themselves respected and adequately resourced, who work in safe systems of care, responding to their individual needs.
We need to change the conversation around birth on many levels and improve the quality of care for all.
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