BJOG Exchange
DOI: 10.1111/1471-0528.13424 www.bjog.org
Re: Caesarean section should be available on request
Debate continues in 2015 – ‘Should caesarean section be available on request?’ – but if 2011 NICE recommendations were followed, it already would be Sir, The 2011 National Institute for Health Care and Excellence (NICE) CG132 evidence-based recommendations are clear: For women requesting a caesarean section, 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, a planned caesarean section should be offered. An obstetrician unwilling to perform a caesarean section should refer the woman to an obstetrician who will carry out the procedure. In fact the final draft in September 2011 read: ‘For all women requesting a caesarean section. . .’, though the word ‘all’ was controversially removed before the November publication, and in October, media reports prompted a rare prepublication statement from the Royal College of Obstetricians and Gynaecologists (RCOG) insisting: ‘There is no proposal in the current NICE guidelines which state that women should have the automatic right to a caesarean section’.1 Yet ‘rights’ aside, in its CG132 Clinical Audit Tool and 2013 QS32, NICE reiterates precisely that—caesarean choice should be supported, with ‘no exceptions’. We are only debating it still
because fundamental opposition to the recommendations has led to blatant misinterpretation and disregard for them. For example, Abigail Easter2 makes the classic mistake: ‘if after discussion and support vaginal delivery remains unacceptable to a woman CS [caesarean section] should be offered’, as did midwifery professionals in the BMJ in 2013: ‘a caesarean section should be offered only if this fails’, and: ‘clinical guidelines hold that surgical interventions, such as caesarean section, are not available on demand unless clinically indicated’.3 These pervasive ideas are simply not true. Only the ‘offer of support’ is recommended, and NICE specifically clarified that it ‘was not the intention of the GDG to suggest women should be talked out of a CS. . . [it] strived to place women at the centre of decisionmaking’.3 My organisation, electivecesarean.com, is aware of numerous cases of costly forced NHS appointments with mental health counsellors and/or psychiatrists, with the sole purpose of persuading against caesarean delivery on maternal request (CDMR), and of Hospital Trusts openly warning women in writing that their policy is not to offer CDMR. Furthermore, Abigail Easter cites threefold maternal ‘fatality rates’ in the context of CDMR, which is at best misinformed and at worse misleading. Economic implications are another myth; CG132 reports just £84 extra for CDMR with urinary incontinence factored in: ‘On balance, this model does not provide strong evidence to refuse a woman’s request for CS on cost effectiveness grounds’.
ª 2015 Royal College of Obstetricians and Gynaecologists
It was inevitable that new CDMR guidance would be unwelcome to many, but the irony given the promotion of homebirth ‘choice’ is palpable. The Royal College of Midwives (RCM) commented that it ‘seems to be simply encouraging CS. Many of our members have commented on this as very unhelpful in their quest to reduce CS rates’.4 And so just 6 months after CG132 was published, and despite it containing no recommendations to reduce caesarean rates, the RCOG, RCM and National Childbirth Trust jointly published highly criticised recommendations for a ‘clear action plan’ to reduce caesarean rates to 20% and increase the vaginal birth rate, ‘which includes delivery by forceps and ventouse’.5 A recent UK Supreme Court landmark ruling on childbirth autonomy and elective caesareans may help challenge this plan, although to date, the push for ‘normal’ birth has been undeterred by the colossal resultant litigation costs.6 The truth is that politics and ideology play an instrumental role in the structure and delivery of maternity care, regardless of what NICE recommends, and CDMR—a legitimate, prophylactic birth choice—strikes fear into the heart of many. Not only does it challenge the perception of how women ‘should’ give birth, but if enough women opt for CDMR, hospital records of infant and maternal health outcomes will provide direct comparative data that has been absent from this debate for so long. And as Australian doctors warned in 2003 when debating a CDMR clinical trial: ‘What a disaster it would be if it was found elective caesarean was safer than vaginal birth’.7
1031
BJOG Exchange
Disclosure of interest
PMH is the co-author of Choosing Cesarean, A Natural Birth Plan (Prometheus Books 2012) and was a stakeholder for the NICE CG132 Caesarean Section Update in 2011. & References 1 RCOG statement on draft NICE caesarean section guidelines. 31 October 2011. [www.rcog.org.uk/en/news/rcog-statementon-draft-nice-caesarean-section-guidelines/]. Accessed 3 February 2015. 2 Easter A. AGAINST: Women need accessible evidence-based information on caesarean section. BJOG 2015;122:359–60. 3 BMJ 2013;347:f4649 Re: NICE says caesarean section is not available on demand unless clinically indicated. 7 August 2013. [www. bmj.com/content/347/bmj.f4649/rr/656733]. Accessed February 3 2015. 4 Caesarean section (update): consultation table with responses, 5 September 2011; Caesarean section (update): pre-publication check comments table, 23 November 2011. [www.nice.org.uk/guidance/cg132/documents]. Accessed February 3 2015. 5 New RCOG guidance urges CCGs to increase births without epidurals and reduce caesarean rates to 20%. 23 August 2012. [www.prlog.org/11953412-new-rcog-guid ance-urges-ccgs-to-increase-births-withoutepidurals-and-reduce-caesarean-rates-to20.html]. Accessed February 3 2015. 6 11 Mar 2015 UKSC 2013/0136 Montgomery (Appellant) v Lanarkshire Health Board (Respondent) (Scotland). 7 Robson S, Ellwood D. Should obstetricians support a ‘term cephalic trial’? Aust N Z J Obstet Gynaecol 2003;43:341–3.
This extremism makes three mistakes. First, it assumes that maternal rights are the only relevant ethical consideration in obstetric practice. Maternal rights are indeed an ethically important consideration but not exclusively so in professional obstetric ethics.2,3 Second, the obstetrician must, as required by professional integrity, identify and balance three ethical obligations: autonomybased (or rights-based) obligations to the pregnant woman as well as beneficence-based obligations to the pregnant woman and soon-to-be-born fetal patient.2,3 Third, given the lack of evidence of net clinical benefit and growing concern about maternal risks for current and future pregnancies and about paediatric risks, professional integrity rules out the neutral stance proposed by Ms Hull in favour of the professional responsibility to recommend against caesarean delivery that is not indicated.4,5 One-sided accounts such as the extreme version of maternal rightsbased reductionism put forth by Ms Hull distort not only the science and clinical practice of obstetrics but also its professionalism. Disclosure of interest
The authors have no conflicts of interest. Both authors wrote the letter and approve the submitted, final version. & References
Pauline M Hull Calgary, Canada Accepted 19 February 2015. DOI: 10.1111/1471-0528.13424
Authors’ reply Sir, We thank Ms Hull for her letter.1 She appears to be committed to an extreme version of maternal rights-based reductionism in obstetric ethics,2,3 in which the requests of pregnant women for caesarean delivery are in all cases final and controlling ethical considerations.
1032
1 Hull P. Re: Caesarean section should be available on request:Debate continues in 2015 – ‘Should caesarean section be available on request?’ – but if 2011 NICE recommendations were followed, it already would be. BJOG 2015;122:1031– 1032. 2 Chervenak FA, McCullough LB, Brent RL. The professional responsibility model of obstetric ethics: avoiding the perils of clashing rights. Am J Obstet Gynecol 2011;205:315.e1–5. 3 Chervenak FA, McCullough LB, Brent RL. The professional responsibility model of physician leadership. Am J Obstet Gynecol 2013; 208:97–101. 4 Chervenak FA, McCullough LB, Brent RL, Levine MI, Arabin B. Planned home birth: the professional responsibility response. Am J Obstet Gynecol 2013;208:31–8.
5 Chervenak FA, McCullough LB. Preventive ethics for cesarean delivery: the time has come. Am J Obstet Gynecol 2013;209:166–7.
Frank A Chervenaka & Laurence B McCulloughb a
Weill Medical College of Cornell University, New York, NY, USA bBaylor College of Medicine, Houston, TX, USA Accepted 3 March 2015. DOI: 10.1111/1471-0528.13425
Author’s reply Sir, I would like to thank Ms Hull for her interest and response to our article— Women need accessible evidence-based information on caesarean.1,2 As stated, we believe it is fundamental that discussions with women requesting a caesarean section (CS) should be both supportive and informed by a range of relevant evidence. Women requesting CS will require differing levels of support and input from multidisciplinary teams, based on their needs and circumstances. Rather than the ‘forced NHS appointments’ described in Ms Hull’s letter, clearly a more individualised womencentred approach to care is what is needed. When a woman has a chance to discuss what she cares about, what worries her and what she wants to avoid with an experienced, woman-centred midwife, it is often possible for the midwife to address all of the woman’s concerns and aims. Working with obstetric colleagues, anaesthetists, and sometimes with perinatal mental health services, can be helpful during these discussions. As the National Institute of Health Care and Excellence guidance states, ‘if after discussion and support vaginal delivery remains unacceptable to a woman, CS should be offered’. NCT supports this approach. Ensuring that discussions are evidence-based is also essential. As highlighted in all four of the debate
ª 2015 Royal College of Obstetricians and Gynaecologists
Copyright of BJOG: An International Journal of Obstetrics & Gynaecology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
DOI: 10.1111/1471-0528.13424 www.bjog.org
Re: Caesarean section should be available on request
Debate continues in 2015 – ‘Should caesarean section be available on request?’ – but if 2011 NICE recommendations were followed, it already would be Sir, The 2011 National Institute for Health Care and Excellence (NICE) CG132 evidence-based recommendations are clear: For women requesting a caesarean section, 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, a planned caesarean section should be offered. An obstetrician unwilling to perform a caesarean section should refer the woman to an obstetrician who will carry out the procedure. In fact the final draft in September 2011 read: ‘For all women requesting a caesarean section. . .’, though the word ‘all’ was controversially removed before the November publication, and in October, media reports prompted a rare prepublication statement from the Royal College of Obstetricians and Gynaecologists (RCOG) insisting: ‘There is no proposal in the current NICE guidelines which state that women should have the automatic right to a caesarean section’.1 Yet ‘rights’ aside, in its CG132 Clinical Audit Tool and 2013 QS32, NICE reiterates precisely that—caesarean choice should be supported, with ‘no exceptions’. We are only debating it still
because fundamental opposition to the recommendations has led to blatant misinterpretation and disregard for them. For example, Abigail Easter2 makes the classic mistake: ‘if after discussion and support vaginal delivery remains unacceptable to a woman CS [caesarean section] should be offered’, as did midwifery professionals in the BMJ in 2013: ‘a caesarean section should be offered only if this fails’, and: ‘clinical guidelines hold that surgical interventions, such as caesarean section, are not available on demand unless clinically indicated’.3 These pervasive ideas are simply not true. Only the ‘offer of support’ is recommended, and NICE specifically clarified that it ‘was not the intention of the GDG to suggest women should be talked out of a CS. . . [it] strived to place women at the centre of decisionmaking’.3 My organisation, electivecesarean.com, is aware of numerous cases of costly forced NHS appointments with mental health counsellors and/or psychiatrists, with the sole purpose of persuading against caesarean delivery on maternal request (CDMR), and of Hospital Trusts openly warning women in writing that their policy is not to offer CDMR. Furthermore, Abigail Easter cites threefold maternal ‘fatality rates’ in the context of CDMR, which is at best misinformed and at worse misleading. Economic implications are another myth; CG132 reports just £84 extra for CDMR with urinary incontinence factored in: ‘On balance, this model does not provide strong evidence to refuse a woman’s request for CS on cost effectiveness grounds’.
ª 2015 Royal College of Obstetricians and Gynaecologists
It was inevitable that new CDMR guidance would be unwelcome to many, but the irony given the promotion of homebirth ‘choice’ is palpable. The Royal College of Midwives (RCM) commented that it ‘seems to be simply encouraging CS. Many of our members have commented on this as very unhelpful in their quest to reduce CS rates’.4 And so just 6 months after CG132 was published, and despite it containing no recommendations to reduce caesarean rates, the RCOG, RCM and National Childbirth Trust jointly published highly criticised recommendations for a ‘clear action plan’ to reduce caesarean rates to 20% and increase the vaginal birth rate, ‘which includes delivery by forceps and ventouse’.5 A recent UK Supreme Court landmark ruling on childbirth autonomy and elective caesareans may help challenge this plan, although to date, the push for ‘normal’ birth has been undeterred by the colossal resultant litigation costs.6 The truth is that politics and ideology play an instrumental role in the structure and delivery of maternity care, regardless of what NICE recommends, and CDMR—a legitimate, prophylactic birth choice—strikes fear into the heart of many. Not only does it challenge the perception of how women ‘should’ give birth, but if enough women opt for CDMR, hospital records of infant and maternal health outcomes will provide direct comparative data that has been absent from this debate for so long. And as Australian doctors warned in 2003 when debating a CDMR clinical trial: ‘What a disaster it would be if it was found elective caesarean was safer than vaginal birth’.7
1031
BJOG Exchange
Disclosure of interest
PMH is the co-author of Choosing Cesarean, A Natural Birth Plan (Prometheus Books 2012) and was a stakeholder for the NICE CG132 Caesarean Section Update in 2011. & References 1 RCOG statement on draft NICE caesarean section guidelines. 31 October 2011. [www.rcog.org.uk/en/news/rcog-statementon-draft-nice-caesarean-section-guidelines/]. Accessed 3 February 2015. 2 Easter A. AGAINST: Women need accessible evidence-based information on caesarean section. BJOG 2015;122:359–60. 3 BMJ 2013;347:f4649 Re: NICE says caesarean section is not available on demand unless clinically indicated. 7 August 2013. [www. bmj.com/content/347/bmj.f4649/rr/656733]. Accessed February 3 2015. 4 Caesarean section (update): consultation table with responses, 5 September 2011; Caesarean section (update): pre-publication check comments table, 23 November 2011. [www.nice.org.uk/guidance/cg132/documents]. Accessed February 3 2015. 5 New RCOG guidance urges CCGs to increase births without epidurals and reduce caesarean rates to 20%. 23 August 2012. [www.prlog.org/11953412-new-rcog-guid ance-urges-ccgs-to-increase-births-withoutepidurals-and-reduce-caesarean-rates-to20.html]. Accessed February 3 2015. 6 11 Mar 2015 UKSC 2013/0136 Montgomery (Appellant) v Lanarkshire Health Board (Respondent) (Scotland). 7 Robson S, Ellwood D. Should obstetricians support a ‘term cephalic trial’? Aust N Z J Obstet Gynaecol 2003;43:341–3.
This extremism makes three mistakes. First, it assumes that maternal rights are the only relevant ethical consideration in obstetric practice. Maternal rights are indeed an ethically important consideration but not exclusively so in professional obstetric ethics.2,3 Second, the obstetrician must, as required by professional integrity, identify and balance three ethical obligations: autonomybased (or rights-based) obligations to the pregnant woman as well as beneficence-based obligations to the pregnant woman and soon-to-be-born fetal patient.2,3 Third, given the lack of evidence of net clinical benefit and growing concern about maternal risks for current and future pregnancies and about paediatric risks, professional integrity rules out the neutral stance proposed by Ms Hull in favour of the professional responsibility to recommend against caesarean delivery that is not indicated.4,5 One-sided accounts such as the extreme version of maternal rightsbased reductionism put forth by Ms Hull distort not only the science and clinical practice of obstetrics but also its professionalism. Disclosure of interest
The authors have no conflicts of interest. Both authors wrote the letter and approve the submitted, final version. & References
Pauline M Hull Calgary, Canada Accepted 19 February 2015. DOI: 10.1111/1471-0528.13424
Authors’ reply Sir, We thank Ms Hull for her letter.1 She appears to be committed to an extreme version of maternal rights-based reductionism in obstetric ethics,2,3 in which the requests of pregnant women for caesarean delivery are in all cases final and controlling ethical considerations.
1032
1 Hull P. Re: Caesarean section should be available on request:Debate continues in 2015 – ‘Should caesarean section be available on request?’ – but if 2011 NICE recommendations were followed, it already would be. BJOG 2015;122:1031– 1032. 2 Chervenak FA, McCullough LB, Brent RL. The professional responsibility model of obstetric ethics: avoiding the perils of clashing rights. Am J Obstet Gynecol 2011;205:315.e1–5. 3 Chervenak FA, McCullough LB, Brent RL. The professional responsibility model of physician leadership. Am J Obstet Gynecol 2013; 208:97–101. 4 Chervenak FA, McCullough LB, Brent RL, Levine MI, Arabin B. Planned home birth: the professional responsibility response. Am J Obstet Gynecol 2013;208:31–8.
5 Chervenak FA, McCullough LB. Preventive ethics for cesarean delivery: the time has come. Am J Obstet Gynecol 2013;209:166–7.
Frank A Chervenaka & Laurence B McCulloughb a
Weill Medical College of Cornell University, New York, NY, USA bBaylor College of Medicine, Houston, TX, USA Accepted 3 March 2015. DOI: 10.1111/1471-0528.13425
Author’s reply Sir, I would like to thank Ms Hull for her interest and response to our article— Women need accessible evidence-based information on caesarean.1,2 As stated, we believe it is fundamental that discussions with women requesting a caesarean section (CS) should be both supportive and informed by a range of relevant evidence. Women requesting CS will require differing levels of support and input from multidisciplinary teams, based on their needs and circumstances. Rather than the ‘forced NHS appointments’ described in Ms Hull’s letter, clearly a more individualised womencentred approach to care is what is needed. When a woman has a chance to discuss what she cares about, what worries her and what she wants to avoid with an experienced, woman-centred midwife, it is often possible for the midwife to address all of the woman’s concerns and aims. Working with obstetric colleagues, anaesthetists, and sometimes with perinatal mental health services, can be helpful during these discussions. As the National Institute of Health Care and Excellence guidance states, ‘if after discussion and support vaginal delivery remains unacceptable to a woman, CS should be offered’. NCT supports this approach. Ensuring that discussions are evidence-based is also essential. As highlighted in all four of the debate
ª 2015 Royal College of Obstetricians and Gynaecologists
Copyright of BJOG: An International Journal of Obstetrics & Gynaecology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
