The emergence of caesarean section by maternal request (CSMR) as a concept is closely related to a shift in the perception of childbirth from a physiological process to a medical one, as has occurred since the early 20th century. Prevailing health-care philosophy over that period has focused on safety and the management of risk—a view that has consequently entered into the thinking of the public (Regan and McElroy, 2013). The outcome of a pathologised approach to childbirth is that it requires technological management in hospital (Clews, 2013). Influential historical publications have emphasised and reinforced the necessity for medical management of childbirth; the Peel report in 1970 recommended that all births should take place in hospital (Peel, 1970). In 1985, a study published in the New England Journal of Medicine advocated prophylactic caesarean section to avoid risk linked to anxiety around anticipation of delivery (Feldman and Freiman, 1985). Around that time, eminent obstetricians openly advocated caesarean sections instead of vaginal births. A 1997 study of female London obstetricians (Al-Mufti et al, 1997) found that 31% would prefer a caesarean section for themselves. Furthermore, a well-known book of the time stated: ‘With a scheduled caesarean section, you and your doctor have agreed to a time at which you will enter the hospital in a fairly calm and leisurely fashion, and he or she will extract your baby through a small slit at the top of your pubic hair. There are a lot of reasons to schedule a caesarean section…’ (Lovine, 1995: 217–8).
In 2012, 25.5% of babies born in the UK were delivered by caesarean section; an increase from 9% in 1980, and 24.8% in 2009-10 (Health and Social Care Information Centre (HSCIC), 2013). The adjusted rate variation among NHS institutions ranges between 22.6% and 28.4% by region, with the lowest unit being 10% (HSCIC, 2013; Parliamentary Office of Science and Technology, 2002). In the private sector, higher figures have been recorded, e.g. 44% at Portland Hospital (Parliamentary Office of Science and Technology, 2002). It is difficult to say how many of these were carried out due to maternal request, although it is noted that differences in the adjusted elective rate are insufficient to explain variance between regions (Bragg et al, 2010). The available figures suggest a variable frequency of between 1.5% and 28% of women who request a caesarean section (Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit, 2001). In 2001, 7% of the total caesarean sections performed were by maternal request (Marx et al, 2001). It is believed CSMR is increasing in the US and some European countries.
Birth normality
The dominance of the obstetric childbirth model devalued the seemingly less-authoritative midwifery profession (Jordan, 1997). Midwives have been referred to as the guardians of birth normality (Royal College of Midwives (RCM), 2004), although what ‘normality’ is in this context lacks a universally-agreed definition (Walsh, 2010). This dominance has been increasingly challenged in recent years, and is now countered by policy (RCM, 2013), but a legacy remains in part due to its embedded nature in birth culture and women's minds. The clash between physiological birth ‘normality’ and caesarean section is a prevailing feature of childbirth today.
CSMR has occupied regular media attention over recent years, and features often in the tabloid and broadsheet newspapers, magazines and websites. ‘Too posh to push’ has become a widely known phrase and is frequently applied to celebrities and linked to care provision in the private, rather than the public, sector (McCourt et al, 2007). However, we must be mindful that because the subject of CSMR is often portrayed in relation to the celebrity culture, it deeply pervades contemporary media and hence societal culture and consciousness (Furedi, 2010).
Current guidance and practice
The current National Institute for Health and Care Excellence (NICE) guidelines (NICE, 2011) potentially facilitate the provision of CSMR, under a remit of informed choice. Clinicians are advised to discuss the risks and benefits of CSMR and vaginal birth, and ensure all the information is given to enable an informed decision. Different team members should be involved. If anxiety about vaginal birth is the reason, then a referral to someone with appropriate experience in its treatment should be made. The guidance states: ‘For women requesting a CS, if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS’ (NICE, 2011: 13). If the consulting obstetrician does not wish to perform the CSMR, then a referral should be made to another who is willing to do it.
It is unclear how many obstetricians actually perform CSMR in the UK at present. The most recent Government data suggest around half of requests in the UK are accepted (Parliamentary Office of Science and Technology, 2002). In the 2006 EUROBS study, 79% of obstetricians questioned would perform CSMR. Of these, 97% cited their reason as protecting the mother's autonomy, 33% to avoid non-compliance during vaginal birth and 52% for medico-legal reasons (Habiba et al, 2006). Lavender et al (2005) reported 49% of UK consultant obstetricians and 27% of heads of midwifery departments supported the right of a woman to choose CSMR if she desired. It is known that the offering of CSMR can be controversial and provoke polarised opinions among those involved in maternity care.
Why might women choose a caesarean section?
Many reasons have been suggested to explain why women may choose a caesarean section over a vaginal birth. Fear of giving birth, the severe form of which is known as tokophobia, is commonly cited as a reason for CSMR. Fear of birth may present major psychological difficulties for the mother-to-be (Hofberg and Ward, 2003). In multiparous women, these feelings may be compounded, or caused, by previous problematic vaginal births (Elmir et al, 2010). The NICE (2011) guidelines state that appropriate counselling should be offered to such mothers before agreement to perform a caesarean section. In line with an increasingly common societal thought process, childbirth may be viewed in the context of risk. Perception of risk varies according to individual experiences and influences—some women may view caesarean sections as a safer option, either for themselves or the baby (Robson et al, 2008; Fenwick et al, 2010). The dominance of medical obstetrics, seen as authoritative and progressive (Clews, 2013), serves to reinforce this view, such that choosing a caesarean section may be seen as a safer and more responsible choice (Fenwick et al, 2010). Robson et al (2008) reported that of 78 questionnaire responses from mothers choosing CSMR, 46% said their choice was due to concerns for the safety of the baby (although this still leaves 54% who did not cite reasons of baby safety/risk). Tied in with safety is the suggestion that the view of the female body has been eroded and devalued, to the extent that the normal female form may be seen as abnormal and incapable of vaginal birth (Clews, 2013). The idea of ‘normal’ among the wider public is open to distortion by digital and printed media. Media content may not always be accurate and representative, and is prone to sensationalising extremes, which can warp perceptions of what is real and normal (Bick, 2010).
Women may request a caesarean section to exert autonomy and possibly in defiance of the male-dominated obstetric model (Wagner, 2000) or due to degradation of the woman's role in childbirth as illustrated by terms such as ‘incompetent’ cervix and ‘failure to progress’ (Clews, 2013). Choosing to have a caesarean section is a means of regaining control over the birth process, which tends to turn women into patients under the direction and ‘active management’ of maternity/medical staff. This directly parallels the control women have over other female reproductive matters such as contraception and fertility. Namey and Lyerly (2010) argued that the actual meaning of the term ‘control’ in this context is not well-defined, and suggested it comprises five domains: self-determination, respect, personal security, attachment and knowledge. Each of these domains could be important in an individual's decision-making. A less than perfect birth may be ‘blamed’ on the birthing woman, which could pressurise some towards CSMR in the future.
It has been suggested that caesarean section is now viewed as a ‘consumerist discourse’ (Clews, 2013), and chosen as a means of birth convenience. The time, place and person can be chosen (certainly in the private sector) to facilitate the woman's employment and social engagements, although little evidence exists to prove such thinking is widespread. Some celebrities, however, have been widely reported in the popular press as subscribing to, and enacting, such philosophies.
Why should CSMR be allowed?
A major argument to support CSMR is one of choice. The ability of women to choose a CS may be seen as empowering, especially in a maternity environment that can actually be disempowering (Kitzinger, 2006). Childbirth is a very personal and individual process, with a different meaning and identity for each woman (Clews, 2013). Caesarean section is a well-known entity (although its detailed risks may not be) and arguably may be viewed as an accepted mainstream option and reasonable alternative to vaginal birth among the contemporary UK population, reinforced by the media and the highlighting of celebrity choices.
Choice is a central theme of the NHS, and is promoted and protected by the Health and Social Care Act 2012. Various publications, e.g. National service framework: children, young people and maternity services (Department of Health (DH), 2004), Maternity Matters (DH, 2007) and Midwifery services for improved health and wellbeing (DH, 2013) also emphasise the integral right of the woman to choose her birth. Such a right was formally instated as part of the NICE (2011) guidelines. If women are able to choose to have an abortion, why not choose a caesarean section? Bost (2003) argues that if their choice is related to psychosocial difficulties or childbirth anxieties which cannot be ameliorated, then providing a caesarean section is more beneficial than subjecting a woman to a vaginal birth against her will. Whether consent in such situations is truly informed, however, is debatable (McFarlin, 2004), and requires weighing up of the relative risks of the procedures.
Numerous risks to the mother and baby are known and have been studied for both caesarean section and vaginal birth, although a direct comparison between the two is more difficult. Three systematic reviews have attempted such a comparison (Visco et al, 2006; Viswanathan et al, 2006; Lavender et al, 2012). They found inadequate evidence to make any firm conclusions. Part of this inadequacy is because the studies have not looked at a specific CSMR cohort, tending instead to be elective caesarean section (comprising both medical caesarean section and CSMR). The existence of any significant difference in morbidity or mortality between caesarean section and vaginal birth, either for the mother or the baby, is questioned (Lewis et al, 2004). Caesarean section is a generally safe and effective surgical procedure and may possess some perceived benefits over vaginal birth to some women. These benefits include reduced postpartum pain and incidence of vaginal injuries (NICE, 2011). Overall, for some women, having a caesarean section may be less unpredictable and give more certainty, in at least some respects, than vaginal birth. Since this option does exist, and is close to or as safe as vaginal birth, should it not be open and available to women?
Why should CSMR not be allowed?
A common view with CSMR is that it medicalises a physiological process, at a time when a strong international movement exists to do precisely the opposite (International Confederation of Midwives, 2011; RCM, 2013). Caesarean section is an invasive surgical procedure with potentially serious complications, and one which many would argue should not be undertaken unless clinically necessary. It is a central tenet of the medical profession to act with beneficence and non-maleficence: that is to benefit the patient, and to do no harm. It may be difficult to reconcile these tenets with the provision of CSMR (Bost, 2003), as traditional medical teaching doctrine states that requests for treatment that is felt to be unnecessary or harmful should be refused.
It has been claimed that caesarean section has a higher cost compared to vaginal birth (Druzin and El-Sayed, 2006). At a time of increased pressure on health-care budgets, it may be reasonable that procedures with no tangible benefit over an equally safe or safer alternative, should not be provided by a state-funded health-care system such as the NHS. To do so would raise questions of justice for the wider population in terms of fair and equitable use of resources (Ludwig and Loeffer, 2001).
Health professionals could also have an influence. Wagner (1998) suggests medico-legal concerns may encourage caesarean sections, as there is a lower perceived threat of litigation, as well as various other potential benefits to the doctor, such as financial gain and better work patterns. Such views may expose women to bias in the presentation of their options, thus influencing their decision-making, and could be an affront to their autonomy (Bost, 2003). Informed consent is essential to proceed with any intervention, and the existence of such influences could have an impact on the voluntariness of such consent. For CSMR to proceed, the clinician must be satisfied that the woman has been given all the necessary information—it may not always be straightforward to ensure full understanding and capacity in this regard. Maternal choice is only one factor to be considered in deciding which birth option to pursue; therefore, genuinely informed consent may be difficult to achieve in reality.
It has been suggested that a caesarean section may bring about an emotional disconnect from labour, and that allowing CSMR does women a disservice and constitutes a lack of responsibility (Amu et al, 1998). Whereas previously home birth against medical advice was seen as a deviant choice, CSMR could now be perceived as the deviant choice.
The increased control that some may feel CSMR imparts to the birth process has been questioned: for some women the feeling of ‘control’ may impose an ideal that is unreachable, and thus predisposes to guilt or shame when it is not achieved (Namey and Lyerly, 2010). The emphasis on self-determination in women's approach to reproduction may result in the unintended consequence of producing an assumption that women are responsible for their adverse events (Layne, 2003).
Some of the cited potential benefits of caesarean section over vaginal birth have been questioned. Reduced postpartum pain can be a false promise (Wagner, 2000). The maintenance of ‘the vaginal tone of a teenager’ may be more of a benefit to the woman's sexual partner than the woman herself (Wagner, 2000: 1678), and may represent potential for negative and concerning influences on a woman's decision-making. This potential for negative outside influence could potentially pressurise some women into making this choice.
Discussion
There is a fundamental dichotomy between CSMR and the mainstream philosophy in midwifery of promoting natural birth. Over recent years the RCM has promoted its Campaign for Normal Birth (RCM, 2013). This encourages a more physiological birth process with minimal intervention, moving away from the medicalised obstetric model. This seems at direct odds with the idea of choosing a medical, surgical method of childbirth. Decisions around birth are incredibly personal, depending on individual beliefs and experiences around what is a deeply intimate and emotional experience.
The existence of a true choice for women has been argued as an elusive and illusionary concept (Jomeen, 2012), meaning women may not be the active decision-makers we may assume them to be. Barriers to the concept of choice have been consistently described over recent years (Hollins Martin, 2007; Jomeen, 2007), including practitioner gatekeeping, imposition of hospital protocols, difficulties in challenging senior health-care staff and the woman's desire to conform.
Current RCM literature (2011) states ‘…if midwives are able to help women to understand what their choices mean for them and their baby and feel they will be supported in labour then very few women will want an elective caesarean section’. Furthermore, the RCM (2013) states: ‘Interventions and caesarean should not be the first choice—they should be the last.’ Such a view is unsurprising given the vested interest of the midwifery profession in occupying a central role in the birth process. However, the RCOG states ‘the decision to perform a caesarean section should be based on sound clinical indications and doctors are duty-bound to ensure that women are aware of the risks and benefits of the operation’ (RCOG, 2011). NICE is also clear that its guideline is not intended to legitimise surgery for all women (NICE, 2011).
‘There is a fundamental dichotomy between caesarean section by maternal request and the mainstream philosophy in midwifery of promoting natural birth’
So while the professional position is relatively consistent and of one voice, a strong pro-CSMR lobby exists, with vast amounts of material readily accessible online. Many different opinions exist, but it is clear that CSMR is open to women as a choice in the UK today.
Conclusions
CSMR is a controversial subject, with polarised views among both professional and lay groups. It is available as an option for women in the UK today, provided certain caveats have been fulfilled (NICE, 2011), although it is not a very common procedure. There are numerous reasons why women may request a caesarean section, and these reasons need to be viewed in the context of wider social and societal factors in order to be fully appreciated. A large number of health, financial, philosophical and ethical arguments can be put forward to either support or dissuade the provision of CSMR, reflecting the complexity of this subject and the very individual and personal nature of childbirth.
There are clear gaps in the knowledge of how often CSMR is undertaken, and strong evidence comparing outcomes of elective caesarean section and vaginal birth is still lacking. Evidence specifically for CSMR outcomes is even more scarce. Such research would give a stronger base from which to discuss these issues with women.
It is clear that CSMR continues to be a pertinent issue to practising clinicians. With recent prominent discourse to step back from the medicalisation of childbirth, further evolution of public and professional opinion regarding CSMR is certain.
Key Points
- Caesarean section by maternal request (CSMR) is a relatively uncommon procedure undertaken in the UK today, although the data are incomplete
- The 2011 National Institute for Health and Care Excellence guidelines confirm CSMR as an option under certain specific circumstances
- There are numerous reasons why women may choose a caesarean section, involving social and societal factors
- CSMR remains a contentious subject, with polarised views on both sides