C-section on demand Not just a matter of choice

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by Abby Lippman with the Canadian Women's Health Network

Choice is central to women's health and it is a fundamental social and constitutional right for all women. However, notions of choice can be misused or misunderstood, in particular when we are speaking of how women give birth, and whether Caesarean sections will be made available “on demand.”

In a recent commentary in the Canadian Medical Association Journal, University of Toronto's Mary Hannah frames the issue of elective (not medically required) C-sections as one of choice (www.cmaj.ca/cgi/content/full/170/5/813). A similar position is found in a recent statement from the American College of Obstetricians and Gynecologists (www.acog.org/from_home/publications/ethics/ethics021.pdf).

While their views differ somewhat, both parties agree that if a woman has been advised of the risks and benefits of an elective C-section for her first pregnancy, and has no other medical complication, the choice should be hers.

All this talk of informed choice is curious. For starters, research on medically unnecessary elective C-sections for first pregnancies is sparse, and there is general agreement that we lack the full information needed to assess the risks of Caesarean sections for women and their babies when these are not medically needed. How can physicians view C-sections as a possible option when critical data about the effects of this unnecessary surgery are missing or incomplete?

When we are focused on pregnancy and birth, both normal experiences, it would seem especially important that we follow a precautionary principle and reject the use of procedures whose safety has not been clearly demonstrated, not offer them ad lib. For a physician to say merely that a C-section is a woman's choice would seem to reflect not so much paternalism, which we all reject, but some refusal of professional responsibility.

More than the biomedical facts are involved. Reportedly, a growing number of women request planned C-sections for reasons of convenience or because of worry about labour, fear of pain, or fear of harm to themselves or the baby. There is a paradoxical notion that surgery and its after-effects are a means to avoid pain.

Pregnant women do have concerns about what the birth will be like and do hope for a healthy baby. But there are good ways to deal with these worries that do not involve unnecessary surgery. Why not make these true options for women?

For example, why do we ignore women when they ask to give birth with a midwife, to have a doula (a trained support person for women in labour), to give birth at home, in a birth centre or even in their own community? To have one-to-one care from a labour and delivery nurse?

How do we ensure access to the programs and the people who can help women be comfortable and secure with their own bodies? How can we provide reassurance, support and comfort for vaginal deliveries, and not turn immediately to surgery? These are the questions we should be asking, and the options we should be making fully available to all women.

The issue of C-sections is not just a matter of choice, but a wake-up call to compromised care for pregnant women, and inattention to their needs. We must address this situation and do more, lots more, to improve the safety and circumstances of vaginal births. More importantly, we need to use the most appropriate responses -- social and societal supports, primarily -- to address women's birthing needs and leave surgical interventions for when they are truly medically necessary.

For years, lowering the rate of Caesarean sections has been a goal of pregnancy care. Thus, it is surprising to see health practitioners and professional organizations speaking now in favour of C-sections on demand. It is of even greater concern that women might request unnecessary surgery and see this as a choice. What a strange turn of events after decades-long fights against the medicalization of our bodies.

Thus, instead of debating merely the pros and cons of C-sections on demand, we would be wise to ask, as we should ask whenever a procedure (or drug) is proposed as an option: What is the problem, and what are the non-technical ways of addressing it? Only when these non-technical (and non-drug) choices are exhausted, non-existent, harmful or otherwise inappropriate, should the high-tech road be taken.

Consumer choice may make sense at the supermarket or car salesroom. It is not a model for doctor-patient relationships. In some (increasing) circumstances, choice may actually be a risk to women's health and well-being. Constantly expanding a list of options for women is too often primarily to the benefit of the list-maker. This may apply to C-sections, too.

For more information and resources on this subject, visit, www.cwhn.ca or call: 1-888-818-9172.

An earlier version of this article appeared in the Globe and Mail (March 3, 2004).

What other Canadian Associations are saying...

Canadian Association of Midwives (CAM)

*Vaginal birth is the safest method of delivery for most women and babies.

*Presenting interventions such as C-section as "options" puts maternity care providers and women in a consumerist relationship, and treats childbirth as a problem to be solved rather than a process to be respected.

*Widespread use of intervention and technology creates fear and doubt about the adequacy of the female body, and reinforces distrust about the reproductive powers of women. When women request interventions that are not medically necessary, and when professionals offer unnecessary technology rather than support and reassurance, it may simply be an expression of those doubts.

*CAM advocates safe, sensitive care within a health system that maximizes women’s ability to have a normal physiologic labour and birth.

*More resources are needed in Canada to support continuity of maternity and infant care, one-to-one care in labour, and increased access to midwifery services.

*Caesarean surgery on demand would have disastrous social and financial consequences for the Canadian health care system.

*Offering all women the choice of Caesarean section is not safe and not ethical. Empowerment comes through a process of shared decision making, not a “menu” of choices.

*To build maternity care that is truly woman-centred will require beginning with the fundamentals: trusting women and supporting their ability to trust themselves, their bodies and the birth process.

For more information, visit:
The Canadian Association of Midwives at http://members.rogers.com/canadianmidwives or call: (604) 859-0777.


Society of Obstetricians and Gynecologists of Canada (SOGC)

*The SOGC does not promote Caesarean sections on demand but promotes natural childbirth. The decision to perform a Caesarean section during labour and delivery should be based on medical indications.

*The SOGC endorses and promotes evidence-based medicine. At this time, there is no evidence that a Caesarean section carries less risk than a vaginal delivery for mother and baby.

*Each individual woman should receive the best information available on her options for labour and birth. The final decision rests between the woman and her health care provider as to the safest route for the birth of the baby.

*Elective C-sections would create added pressure on health care resources that are already over-extended in Canada.

*Women during labour and birth should be accompanied by a trained health care professional, and adequate resources should be provided for them to offer continuous support during labour and birth.

For more information, visit:
The Society of Obstetricians and Gynecology at www.sogc.org or call: (613) 730-4192.

Possible Health Risks Associated With C-sections

Caesarean births, when medically necessary, can be a life-saving procedure for mother and baby.

However, for most pregnancies, C-sections have greater health risks than advantages for both mothers and babies, compared with vaginal birth.

According to the most comprehensive data available to date, the following possible risks are associated with C-sections:

For the mother

  • Reactions by the mother to anesthesia, and other possible complications related to surgery;
  • Hemorrhaging (severe bleeding);
  • Possible bladder, bowel and blood vessel injury;
  • Longer hospital stay and recovery time; more likelihood of a return visit to the hospital due to possibility of infection;
  • Longer-lasting pain (for several weeks after the birth);
  • Poorer birth experience and poorer overall mental health after birth;
  • Early relationship with baby may be affected, such as less early contact with the baby, and less likelihood of breast-feeding;
  • Possibility of requiring other follow-up surgeries, such as a hysterectomy (removal of the uterus);
  • More risks for subsequent pregnancies, such as major bleeding, etopic pregnancies (pregnancies that develop outside the uterus), difficulties with the placenta, and the rupture of the uterine scar;
  • More difficulty in getting pregnant in the future.

For the baby

  • Breathing problems, including a higher incidence of neonatal respiratory distress;
  • More likely to experience asthma in childhood and adulthood;
  • May be cut accidentally during surgery, though the cut is typically minor;
  • Less likely to experience early contact with the mother;
  • Less likely to experience the benefits of breastfeeding.

For more information, see:
What Every Pregnant Woman Needs to Know About Cesarean Section (2004)
www.maternitywise.org/mw/topics/cesarean/booklet.html or call: (212) 777-5000.

Now available online!

Giving Birth in Canada: Providers of Maternity and Infant Care (2004)

This is the first in a series of four documents on Canadian birthing trends to be released from the Canadian Institute for Health Information.

The report findings includes the following data:

*Canada’s Caesarean section rate reached an all-time high of 22.5% in 2001-2002.

*There is a declining number of family doctors providing full maternity care – fewer than 19% in 1999.

*Canada’s overall birth rate dropped from 14.5 per 1,000 to 10.5 per 1,000 in 2001-2002.

*Canadian mothers are getting older. The number of mothers over 30 years of age has increased to 42%.

*An increasing number of expecting mothers (3% nationwide in 2000-2001) reported receiving prenatal care from midwives. The number of jurisdictions regulating and funding midwives in Canada is also increasing.

For more information, visit:

or call: (613) 241-7860.