Do we need a drive to bring down the caesarean section rate?

The president of the Royal College of Obstetricians and Gynaecologists (RCOG), David Richmond, has called for an NHS-wide drive to reduce the number of first-time mothers having caesarean sections, according to a report in the Observer.

About one in four babies are delivered by caesarean section in England and Wales. You can see why Richmond is concerned: it’s a high rate of surgical intervention for something that is supposed to be a natural physiological process. It also carries risks for the mother and baby, involves a longer recovery rate for the mother and is more expensive for the hospital.

Richmond points out that the proportion of caesarean sections varies from hospital to hospital, suggesting that the high rate in some hospitals isn’t entirely related to medical necessity. He is quoted as saying that the increased rate of c-sections is being fuelled by “the rise in maternal obesity, obstetricians’ fear of being hit with a lawsuit if something goes wrong during labour, and a small number of women asking to have the procedure.”

So, is he right? Well, perhaps. The difficulty is that we don’t know why so many first- time mothers with apparently normal pregnancies have caesarean sections. The “small number” of women who ask for c-sections is unlikely to have a major impact on total numbers. As for the rise in maternal obesity, and obstetricians’ fear of lawsuits, we don’t know how much these factors influence the c-section rate. It’s possible, too, that the variation between hospitals is not about a difference in attitude but a difference in the profile of patients: a hospital with a greater number of older first-time mothers is probably more likely to have a higher c-section rate.

The trouble with having a drive to reduce the number of c-sections is that it encourages clinicians to focus on the target rather than on the individual women. In my work with the Birth Trauma Association, I’ve seen numerous horror stories of women with difficult, prolonged or dangerous labours whose requests for caesareans were initially denied, but who ended up having one anyway. In one case, the woman eventually delivered her baby by caesarean under general anaesthetic, a much riskier procedure than a caesarean under local anaesthetic. The consequences for the mental health of the mother in circumstances such as these can be devastating.

It is, of course, a good thing to look at a high caesarean section rate and ask what’s causing it. If it turns out that women are being given caesareans unnecessarily, then it makes sense for doctors to look at what they could do differently. In the Observer article, Cathy Warwick, chief executive of the Royal College of Midwives, says that women’s fear of giving birth makes them tense, and therefore less able to have a “normal” birth: in which case, why not make hospitals more relaxing and welcoming places to give birth? Noisy, bustling labour wards where women are left unattended for hours on end are bound to make anyone tense.

But simply trying to drive down the caesarean rate without looking at the root cause is asking for trouble – and could result in poorer outcomes for both mothers and their babies.

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