C-Section on Maternal Request, Cont.

BMJ has a "Head to head" feature on whether women should be given the chance to request c-sections if they aren't medically indicated. Have a look, pro here, con here. My own view is that maternal request for c-section is sometimes reasonable, particularly with regard to the woman's desires to avoid sequelae that are more associated with one form of birth than the other; but that I'm also worried that "maternal request" can be manipulated by physicians who are concerned with scheduling, cost, or other variables, and can manipulate women into requesting the surgery.

More on NHS and C-Sections

Over at BMJ Journal of Medical Ethics Blog, Iain Brassington wonders why, in my earlier post on the new NHS policy permitting c-section on maternal request, I said I was worried about the policy opening the door to c-sections being scheduled for reasons other than maternal request. "It's a heck of a leap from 'maternally requested' to 'requested by someone else," he says.

Well, maybe not such a leap. Allow me to quote myself (and co-author Errol Norwitz) (notes omitted):

"There is extensive support for the idea that some cesareans are performed at the instigation of physicians for reasons unrelated to medical indication. A by-now venerable body of published data demonstrates that the overall cesarean rate is responsive to method of reimbursement, to physician time demands, and to physicians’ fear of medical malpractice lawsuits. This medical literature is supported by the results of a 2006 survey of recent mothers. The survey showed that mothers with primary cesareans indicated that not they, but their physicians, were the predominant decision-makers in choosing the cesarean procedure. A total of 26% of women with primary cesareans reported having felt pressured by their providers to get the procedure. In contrast, only 1 of 252 survey respondents with primary cesareans reported making the choice to schedule a cesarean in advance for no medical reason. Two others who reported having had cesareans for no medical reason reported that the decision to have the cesarean was made by their provider and not by themselves. These data are similar to findings in Brazil, which has a cesarean rate of 36%. Repeated studies there have shown that a majority of primiparous women in Brazil want to delivery vaginally, but end up delivering surgically, particularly in private hospital settings.Their decisions to undergo surgery emerge only after discussions with their physicians; yet the public rhetoric around cesarean section in Brazil is that women are “demanding” the procedure. Finally, consider the striking results of a 2004 paper on intrapartum elective cesarean delivery. Researchers surveyed obstetricians after all intrapartum cesarean deliveries in their facility, asking whether cesarean delivery was offered by the obstetrician or requested by the patient before being medically indicated. Of a sample of 422 cases, cesarean was offered in 13% of cases before any clear medical indication emerged, and requested in only 8.8%. Thus, among intrapartum cesareans without medical indication, more were offered by physicians than were “requested” or “demanded” by patients. Physician characteristics, and not patient characteristics, were a significant factor in determining whether elective cesareans were offered."

In sum: in the US and in Brazil, a lot of what gets talked about as c-section on maternal request is physician-driven. Will the new NHS policy open the door to this phenomenon?

Finally, I don't think I said anything inaccurate about the new NHS policy, as Iain gently suggests. I gave a summary account of the steps to be taken under the policy by the physician before the woman's request for c-section is agreed to, and Iain helpfully spells those out. But in the end, if the requesting persists, the c-section is given, even if that requires transfer to another physician's care. My concern is that the initiation of requests, and their persistence, is subject to influence by physicians. At least in the States (where, admittedly, the financial incentives are different), the occasional doc has been known to prefer higher reimbursement to lower, Friday afternoon c-sections to vaginal births on Saturday at 2am, and so on.

NHS Permits "Caesarian on Maternal Demand"

An update of a new guidance document being developed by the UK's National Institute for Health and Clinical Excellenct ("NICE") would permit caesarian section on maternal request, even when there are no medical indications for the procedure. In the US context, I'm skeptical even of the language of "maternal request" or "maternal demand," since I believe that there is significant evidence that physician preferences and reimbursement drive our sky-high c-section rates here in the US, and elsewhere (such as Brazil); and also that physician preferences and conversations can end up driving what is later called "maternal demand". The new guidelines make me worry that the official availability of c-section on maternal request in the UK will lead to some non-medically-indicated c-sections being performed for reasons other than "maternal request," like physician scheduling convenience. But it may work differently in the NHS; and anyway, the NICE guidelines include a number of steps to be taken before acquiescing in mom's request for CS, like counseling on fear of childbirth, and proper discussion of the comparative risks of CS and vaginal birth. Let's see what happens to the overall CS rate, and how many maternal requests for CS crop up, after the new guidelines are finalized.