[A printable version of this Headline Bioethics Commentary is available via this link]
Author: Matthew Taylor
Date of story: 23rd November 2011
Summary of story: In November 2011, The National Institute of Health and Clinical Excellence (NICE) updated its clinical guidance to health care professionals regarding caesarean sections. This update helps ensure “every mum-to-be in England and Wales can request [a caesarean birth].” The story examines the case of Leigh East, who had concerns over a vaginal birth due to a pre-existing back injury. She was initially refused a caesarean section (CS), but was allowed the treatment after her own research persuaded her midwife to allow it. East said, “There was a great deal of pressure initially to not plan a caesarean”.
The report continues by covering how women who have had a traumatic experience with natural childbirth in the past should be treated. This includes offering counselling and, ultimately, the option for a caesarean birth if the woman is not reassured. Jenny Clery, Head of Midwifery at Whittington Hospital, said “you shouldn’t force anything on anybody, i.e. go into labour and we’ll see what happens.” The report finishes by stating the new guidelines are there to help women make an inform decision regarding mode of birth (BBC, 2011a).
Discussion of ethical issues: There are many ethical issues surrounding a woman’s choice regarding the mechanism of delivery for her unborn child. Doctors are faced with decisions requiring them to take each case individually, taking a consequentialist approach to each mode of birth, whilst also considering patient autonomy. The Changing Childbirth report (Expert Maternity Group & Cumberlege J., 1993) makes it an explicit right for a woman to be involved in decisions regarding all aspects of her pregnancy and childbirth.
NICE employs a multidisciplinary group of healthcare professionals, economists, ethicists and patient representatives to look at the research evidence and current good practice, in order to develop guidance on the management of diverse health-related problems. Within the current CS guideline, reference is made to women having the right to give birth by CS (NICE, 2011). Thomas & Paranjothy (2001) showed that 50% of women said they would have liked more information on the risks and benefits of CS. The most recent guidance advises healthcare professionals to give evidence-based information to their patient to help them make an informed decision regarding the mode of birth (NICE, 2011), thereby helping to increase patient autonomy, which is one of a doctor’s ethical duties (Beauchamp & Walters, 1999).
But how much autonomy is too much?
The recent guidance has created considerable debate amongst healthcare professionals and women themselves as to whether it is the right of the woman to choose a CS. Woman may want a CS for many different reasons centered around physical and psychological complications if a vaginal delivery is pursued. These include maternal pain, trauma to the baby and potential damage of the pelvic floor. Critics have labelled many of these women as simply “too posh to push”, arguing that there is often no identifiable medical reason for a CS (Cheng, 2011). Hopkins et al. (2004) reflect on the role popular press stories about celebrities who have the financial capacity to pay privately for a CS may influence other women’s decisions over mode of birth. However, Cathy Warwick, Chief Executive of the Royal College of Midwives, says that the proportion of women asking for CS via the NHS as a lifestyle choice is very small (BBC, 2011b). Studies support the view that this is not a factor contributing to high CS rates (Bragg et al., 2010; NHS, 2010; Smith, 2010).
The 2011 NICE report highlights areas that may be confused with “too posh to push” such as patients with a history of sexual abuse or tokophobia, that is a profound fear of childbirth (NICE, 2011). Deontologically, it would be wrong to force a woman to go through vaginal delivery if it were to be psychologically distressing, even if there is no other clinical indication to do so (BBC, 2011a). Teleologically, negative outcomes to a CS could be perceived as more significant when there is no clinical need. The actions of a healthcare professional need to be beneficent (Beauchamp & Childress, 2001) when making a decision on whether a CS is appropriate. They need to ensure appropriate information is provided to the patient, so they can make an informed decision (NICE,2011).
Opinion is divided regarding whether or not the NHS has a duty to provide CS for women who do not have an established medical justification. Pauline Hull, an elective caesarean campaigner, believes that since we already intervene in “natural” childbirth by, for example, providing pain relief, then women should be able to choose their mode of birth (BBC, 2011c). Conversely, independent midwife Virginia Howes states that “normal birth is what women are designed to do” and therefore they should give birth vaginally (BBC, 2011c). There are resource allocation implications; a CS costs around £800-1000 more than a vaginal birth (Cheng, 2011; Iqbal, 2011) therefore a utilitarian argument might argue that money spent on non-essential CS is restricting other potential uses. Section 13 of the NICE (2011) guideline deals with the health economics of CS versus vaginal birth. It concludes that, based on their model the immediate cost of a planned vaginal birth is less than a maternal requested CS; but is inconclusive over the long term cost effectiveness of one mode over another (NICE, 2011).
In the current economic climate, it could be argued that unnecessary operations should not be performed. However classifying an operation as unnecessary is difficult; it is a duty of the doctor to explore the woman’s reason for choosing a CS over a vaginal birth, and in many cases a second opinion is vital. Although it is wrong for a healthcare professional to make decisions driven primarily be economic considerations (Beauchamp & Walters, 1999; Crawshaw et al., 1995), the cost of any treatment deemed unnecessary has to be carefully considered in the health economy (Brimelow, 2010).
The current guidance gives women the autonomy and opportunity to discuss mode of delivery, whilst still allowing physicians to be beneficent. An individual surgeon may not support the woman’s decision but has a duty to refer the woman to a colleague who can offer her a CS (NICE, 2011). The proportion of women requesting CS without clinical reason is small (BBC, 2011b; Bragg et al., 2010; NHS, 2010; Smith, 2010) and therefore the cost implications to the NHS are minimal. In all such cases, the clinician has to make a judgement based on the relative significance of the principles of beneficence and respect for autonomy (McCullough & Chervenak, 1994).
BBC (2011a) Women can choose Caesarean birth. Available at http://www.bbc.co.uk/news/health-15851185 [Accessed 20th February 2012]
BBC (2011b) Woman can choose Caesarean birth. Available at http://www.bbc.co.uk/news/health-15853698 [Accessed 20th February 2012]
BBC (2011c) Should we have the right to choose Caesarean section on the NHS? Available at http://www.bbc.co.uk/news/health-15522675 [Accessed 20th February 2012]
Beauchamp, T. L., & Childress, J. F. (2001) Principles of Biomedical Ethics. New York: Oxford University Press.
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Bragg F., Cromwell D.A., Edozien L.C., Gurol-Urganci I., Tahir A Mahmood T.A., Templeton A. and van der Meulen J.H. (2010) Variation in rates of caesarean section among English NHS trusts after accounting for maternal and clinical risk: cross sectional study. British Medical Journal 341:c5065.
Brimelow, A. (2010) Doctors sign up to take over control of budgets. Available at http://www.bbc.co.uk/news/health-11940653 [Accessed 20th February 2012]
Cheng, M. (2011) Too posh to push? More C-sections on demand in UK. The Guardian. Available at http://www.guardian.co.uk/world/feedarticle/9929873 [Accessed 20th February 2012]
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Expert Maternity Group and Cumberlege J. (1993) Changing Childbirth: Report of the Expert Maternity Group. HM Stationery Office
Hopkins S., Chivers L., Bassett C. and Lehane M. (2004) Too posh to push Nursing Standard 18:22-23.
Iqbal N. (2011) New rules give women the choice to have a Caesarean. Available at
http://www.bbc.co.uk/newsbeat/15850329 [Accessed 20th February 2012]
McCullough L. B. and Chervenak F. A. (1994) Ethics in Obstetrics and Gynecology. New York, USA: Oxford University Press. pp. 91-92.
NHS (2010) Too posh to push mums ‘a myth’. Available at http://www.nhs.uk/news/2010/10October/Pages/caesarean-birth-choice-a-myth.aspx [Accessed 20th February 2012]
NICE (2011) Caesarean Section NICE Clinical Guideline 132 Available at http://guidance.nice.org.uk/CG132 [Accessed 20th February 2012]
Smith, R. (2010) High caesarean rates are not down to women being ‘too posh to push’. The Telegraph Available at http://www.telegraph.co.uk/health/healthnews/8045956/High-caesarean-rates-are-not-down-to-women-being-too-posh-to-push.html [Accessed 20th February 2012]
Thomas J. and Paranjothy S. (2001) Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. The National Sentinel Caesarean Section Audit Report. ROGC, London.
Headline Bioethics Commentaries are short articles on the bioethical issues raised by a story in the news. The articles are authored by second year undergraduates at the University of Leicester (UK). A printable version of this article is available via this link.