The maternal request debate has been in the headlines once again. This interest comes in the month when the National Institute of Clinical Excellence (NICE) will issue the latest version of their guideline on caesarean birth.
This latest review of caesarean research by NICE reveals that “In general, [caesarean section] is a safe operation, especially when performed as planned procedure.” NICE have extended the rights of women to request a caesarean birth on the grounds of tokophobia (fear of childbirth) to all women recommending “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.” Clearly stating that “if an obstetrician feels a woman’s request for CS is not appropriate after the woman has received appropriate counselling and support, then s/he should be able to decline to support the women’s request. This does not over rule the woman’s rights to express a preference for a CS however, and in this instance the obstetrician should transfer care of the woman to an NHS obstetrician within the same unit who is happy to support her choice.”
Disappointingly there has once again been a rash of commentaries about the cost implications and selfishness of women making such a choice. Such commentaries continue to ignore the flawed data on which it is based as well as the fact that this tiny, tiny number of women who prefer to request a caesarean rather than attempt vaginal birth tyically have very good reasons for their request. For some the origin may be fear while for others it is an informed assessment of risk comparing vaginal and caesarean birth experiences and outcomes. But for a significant number the request is based upon an informed assessment of risk in relation to their own personal circumstances. An example of this latter group are those women falling into what could be considered the ‘grey’ area of clinical need. These women are often categorised as maternal request because, following discussion with their practitioners, they have been given a choice. Examples of ‘grey’ areas are breech, older mother, previous caesarean etc.