Why might women elect for a caesarean?

It appears that very few women are aware that they can even request a caesarean and very little is actually recorded about the number of women electing for a caesarean for non-medical reasons. The Association for Improvements in Maternity Services (AIMS) has investigated reasons given by women requesting a non-medical caesarean and these typically appear to fall into two categories:

• Their previous birth experience was vaginal and so negative that they want to avoid a similar experience
• They are expecting their first baby and most of their friends or relatives have had bad experiences and they want to avoid joining them

To date, AIMS is only aware of two cases where the women stated that they wanted caesarean procedures in order to protect their perineums and sex lives 34. The Nuffield study backs this up finding that it "quickly became clear that, in the hospitals involved in this project, women who asked for caesarean section in the absence of any clinical indication whatsoever were actually very rare." 56

"Few studies however have examined the experiences of women who have demanded caesarean section for non-clinical reasons. Those studies that have observed maternal requests for a caesarean option reveal that for the majority of women their requests were for 'relative' indications such as previous caesarean, breech presentation or previous difficult births 85 or justifiable reasons such as a history of a previous traumatic experience and a debilitating fear of pain associated with childbirth 83. There is limited hard evidence that women requested caesarean sections for matters such as convenience." 87

Studies are now beginning to investigate mothers reasons for electing for a caesarean and perhaps not surprisingly are finding that fear of childbirth is high on the list for discussing the option of a caesarean. "By far the most common reason why women requested caesarean sections was fear relating to clinical outcomes...[and on other occasions] such women might have been led to believe that the baby they were carrying was very large, for example, perhaps because of a throwaway remark made by a midwife, and comments about their size from friends and family…the woman's previous birth experience and the negative experiences of friends or other family members [means women] may decide they want or do not want a caesarean section" 56 Cosmetic reasons are seldom mentioned and usually not in isolation.

Although childbirth is a natural process, it is inherently unpredictable and for most, painful. It is not surprising that most women experience some degree of fear as the prospect of labour gets closer. This may be fear of pain, fear of dying, fear of their own incompetence during delivery or fear resulting from previous birth trauma. For some women this fear can become what is known as a "morbid dread". This is known as Tokophobia and can hamper a woman's ability to cope with her labour and may even impact the progress of that labour 88. It may cause others to request a caesarean in the absence of any medical need and for other women it may even cause them to choose to remain childless or even abort a much wanted baby.

According to AIMS, there has, to date, been virtually no assessment in the UK of the impact of fear of birth on the responses women give when retrospectively rating their birth experience 34. While the British media talks of women demanding caesareans because they are "too posh to push", Sweden has identified 21 fear of birth and bad birth experiences as a major cause of women requesting caesareans. A study conducted in the UK reported in the British Journal of Midwifery 2005 16 found that the most common reason given by women electing for a caesarean on non-medical grounds was fear of clinical outcomes. Factors contributing to this fear were reported as the size of the baby, previous birth experience and images of vaginal births in the media. And they found that "Although positive images of vaginal birth are produced, women usually discussed media representations in which caesarean section was being promoted positively or in which images of vaginal birth were made to appear negative." 56 What is clear is that the stigma attached to the media's definition of an elective caesarean is making it very hard for anyone facing birth to have a rational, balanced discussion about caesareans.

When confronted with a woman expressing fear of childbirth and requesting a caesarean a hospital may well ask that they undergo some form of counselling to help with the fear. (Agreeing to such counselling does not guarantee a caesarean at the end of the process should the counselling prove unsuccessful). Research indicates that support of this sort can reduce the level fear and increase levels of confidence in some women enabling them to try for a vaginal delivery 82 83 90. However it is worth noting that where fear arises from previous birth trauma, this may be very difficult to achieve. Research suggests that regardless of mode of delivery, 2% of women may have such negative reactions to their delivery that their symptoms register on the Post Traumatic Stress Disorder scale 91. And in the case of emergency caesarean delivery as much as a third of women may experience "intrusive stress reactions" 92. Such studies serve to reinforcing the importance of understanding the caesarean procedure and developing an open-minded and flexible birth plan when preparing for birth.

The results from a study comparing "the psychological reactions of women after emergency Caesarean section, elective Caesarean section, instrumental vaginal delivery and normal vaginal delivery" suggests that that for women suffering from extreme tokophobia it may actually be beneficial to elect for a caesarean as the psychological reactions following the birth are more positive than if the woman has undergone an emergency caesarean section or instrumental vaginal delivery 93.

In an article by Dr Susan Bewley in The Lancet discussing fear of childbirth and reporting on this study and others concluded, "When a request for a caesarean section originates from anxiety, it may be unethical to operate without first offering professional midwifery and psychological support. On the other hand, to refuse a section for a woman who has unresolved severe anxiety, previous traumatic experience, or genuine tokophobia is also cruel...Services should be designed around early screening or detection and prompt referral." 98

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 on the grounds of extreme distress and in the absence of any other medical need 94.

A survey of London obstetrician's preferences, in relation to their own births, found that 31% chose elective caesarean section over a vaginal delivery even when there was no medical indication for the caesarean 1. 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. While the London and USA percentages are high, it should be remembered that the majority would still prefer to attempt a vaginal delivery initially and that "Obstetricians may not be personally objective: they may be self-selected by their mothers or families' obstetric disasters; they are vulnerable human beings who may be biased by their exposure to the complications of childbirth" 76. Perhaps unsurprising is the result on a survey of UK midwives found that 96% would prefer a vaginal delivery 52.

An article in the Times 62 gives one of the few, truly balanced commentaries on caesareans that we have found.