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Your rights

Today, organisations like the National Childbirth Trust (NCT) and the Active Birth Centre quite rightly put strong emphasis on women's rights to make informed choices about the way in which they give birth. Such bodies have been excellent at highlighting and defending the rights of women to define their birth experience and in particular to make use of birth plans to help direct their vaginal birth. However in the UK it can be more difficult to find organisations or individuals who are prepared to extend this education to include an informative and balanced assessment of caesareans. Women are sometimes left feeling that a caesarean is a last resort and electing for a caesarean for non-medical reasons can label you "too posh to push".

Being comfortable with your choices

In the UK at present, delivery will, for 1 in 4 women, result in a Caesarean Section whether it was your original plan or not. The bias and negativity that caesareans are given both in the press and by some health professionals means that women are sometimes made to feel that their caesarean birth is "a shame" or a reason to be "disappointed" or "depressed".

We believe that one of the most important things is for a mother to be comfortable with the plans she is making for her birth. What is right for one woman is not necessarily right for another. A report in the Obstetrics & Gynaecology journal stated that "The risks of CS [caesarean section] and labour are real but different, and if fully explained to the woman, she should be allowed to accept one set of risks over the other - after all she is the person who has to live with the consequences. An elective CS in a fit healthy woman is neither unsafe nor bad practice if she truly understands the risks involved and is adamant that she cannot accept the risks of labour or vaginal delivery." 45

We believe that the lack of education and balanced messages about caesareans lead many women to face their birth with little or no information about what could happen to them during their birth. Research 20 is starting to back this up. To address this we believe that during pregnancy women should be informed about:

It is not uncommon for women to be unaware that in the UK it is their right to define the way in which they give birth. The National Childbirth Trust (NCT) and the Active Birth Centre are working hard to make sure women are aware of their rights. However we would suggest that birth education as a whole should do more to include information about emergency and elective caesareans.

Informed Consent and Informed Refusal

'Informed Consent' is the right of all women in the UK. It means that your health professional must explain the following:

If you choose to accept the advice then you will be asked to sign a consent form. However it is worth noting that you still have the right to change your mind.

If you choose not to accept the advice then you have the right to make an 'Informed Refusal'. Given that this process is available it is worth making the time to have these discussions with your health professionals prior to the onset of labour so that you are not making the decision in an emergency or stressful situation.

It is worth noting that "Treatment without valid consent is unlawful and a health professional may be liable to legal action by the patient and their own professional regulatory body" 35. The survey also showed that "of 243 (155 responded) obstetricians in England and Wales found that 69% of obstetricians would perform an elective caesarean on maternal request due to fear of litigation and pressure from patients."

If, while discussing your options with your health professionals, you still have questions, it is your right to insist that these questions be answered before you make your decision. Bear in mind however that if you are in a truly emergency situation i.e. your baby needs to be delivered in the next 30 minutes then you may find that this is quite difficult to achieve to the level of satisfaction that you may otherwise prefer.

Hospital policy

UK hospitals have the right to refuse a caesarean at the mother's request if there are no recognised medical grounds. However the National Institute for Health and Clinical Excellence (NICE) 27 also state that "the woman's decision should be respected, and she should be offered referral for a second opinion". Though "under British law…the medical profession has historically favoured the life of an unborn child and/or saving the mother's life over maternal autonomy." 35

It is possible to negotiate a caesarean for reasons of 'psychological fear of child birth' or Tokophobia. In some hospitals such an explanation would be accepted and your request followed. In other hospitals you would be asked to undertake counselling to address this fear, following which you may be able to have a caesarean or be referred to another hospital that would perform the caesarean (your hospital is obliged to offer this referral).

The difficulty facing a mother in requesting a caesarean is being able to stand up to those health professionals presenting the story of caesarean doom and gloom. If you are in this situation it may be helpful to be fully informed about the benefits, risks and options available to you.

Electing for a caesarean

You may request a caesarean on the basis of medical information provided by your heath professionals where the indications are borderline. For example, a breech delivery in a pregnancy that is otherwise progressing normally. Here you might choose either a vaginal or a caesarean delivery.

It is also possible to request a caesarean for non-medical reasons. Typical reasons might be:

If you fall into one of these categories a caesarean is unlikely to be offered to you automatically. It will be up to you to request it. However you may find that some health professionals find your choice strange and may try to dissuade you. "It would be wrong, manipulative and potentially dangerous for midwives or obstetricians to claim to be pro-women and yet reinforce the fears, whether the fears are about childbirth or interventions, rather than acknowledge the problems and manage them appropriately" 76. And yet it is well known that even raising the subject of a caesarean can create difficulties in anti-natal discussions with some health professionals even before reasons for a request are given.

The General Medical Council states that it is the duty of clinicians "to recognise that even when active treatment is not indicated, the duty to provide care to alleviate distress remains" In other words in cases of extreme tokophobia it may be possible to present your case in such a way as to justify the need for a caesarean in the absence of other medical need 94.

The unresolved issues of: "do no harm" versus "respect autonomy" I.e. a woman's right to choice, means that it is still impossible for a woman to guarantee a caesarean in the absence of medical need but it is difficult for an individual doctor to flatly refuse a caesarean request without a supporting policy directive from the hospital. Though it would be reasonable to suppose that at present "do no harm" does tend to override "autonomy" given the barriers women report when requesting a caesarean for non-medical reasons.It is important to note that while any of these reasons may appear totally valid in your eyes, UK hospitals are not obliged to conduct caesareans purely at a mother's request. The subject of fear of childbirth is now being studied 21 56, but is not yet recognised as a medical indication in its own right. It is still, however, your right to request a caesarean.

A survey conducted in London hospitals found that 31% of female obstetricians stated that for their own pregnancies they would request a caesarean section if the pregnancy was uncomplicated with no medical indications 1 29. Further studies conducted in Ireland and the USA found that obstetricians expressing a preference for an elective caesarean were 7% in Ireland and 46% in the USA 50 51. However the preference expressed in a survey of midwives found that 96% would prefer a vaginal delivery 52.

Putting your case when you have no recognised medical indications requires more planning on your part to reduce the amount of discussion and possible confrontation. The hospital may require you to undergo counselling and ultimately they may still refer you to another hospital rather than carry out the surgery themselves. They are obliged to refer you to somewhere that will carry out your caesarean 27.

A recent study commented: "The risks of CS [caesarean section] and labour are real but different, and if fully explained to the woman, she should be allowed to accept one set of risks over the other - after all she is the person who has to live with the consequences. An elective CS in a fit healthy woman is neither unsafe nor bad practice if she truly understands the risks involved and is adamant that she cannot accept the risks of labour or vaginal delivery" 45.

Avoiding a caesarean

If you are hoping to avoid a caesarean you have rights too. The most important thing perhaps is to be knowledgeable so that once in labour you can still fully participate in the discussions should the need for a caesarean arise. Pain and tiredness can make it difficult to have a coherent discussion and it can be difficult, once in this situation, to hear all the facts correctly.

The General Medical Council state that patients have the right to decide whether or not to undergo medical intervention. "A competent adult has the right to refuse treatment, even if to do so will result in death" 94.

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