Doctor calls for women's right to have Caesareans on demand

PREGNANT WOMEN should be allowed to choose to have their babies by Caesarean section if they wish to avoid the problems associated with a normal labour, an article in the British Medical Journal says today.

The idea of allowing women Caesareans on demand to fit in with busy lives and avoid the pain and unpredictability of labour without sound clinical reasons, has been frowned on by doctors. But attitudes are changing, according to Sara Paterson-Brown, consultant obstetrician at Queen Charlotte's and Chelsea hospital, London.

A clearer assessment of the risks associated with normal labour and delivery has persuaded many women specialists in obstetrics to choose a Caesarean. A study last year showed one in three female obstetricians in London would opt for a Caesarean if given the choice. Other research has shown that Caesareans are popular with women who have had them. Half those who have already had a Caesarean would choose to have another.

The risks of vaginal birth include damage to the pelvic floor and to the urethral and anal sphincters which can result in incontinence and an increased long-term risk of prolapse of the genitals. There is also a risk to the unborn baby with one in 1,500 weighing over 1.5kg (3lb 5oz) dying during labour. Ms Paterson-Brown says: "Elective Caesarean section cannot guarantee normality but it avoids the above problems by virtue of avoiding labour and prolonged pregnancy."

As reported in The Independent earlier this month, the number of Caesareans has grown sharply in the past 20 years to around one in six of all deliveries. The increase has been blamed on the rise in defensive medicine in response to the threat of litigation, although it is not known how many Caesareans are carried out at the request of the woman.

Recent government reports have urged doctors to respect women's choices in maternity care and it is unfair for their choices to be discredited because they are not the ones expected, Ms Paterson-Brown says. "We are at a turning point in obstetric thinking brought about not only by advances that have made Caesarean section safe ... but also by the attitudes of society which reflect intolerance to risk. We encourage family planning, pre-pregnancy counselling and ante- natal screening ... can we do all this and then refuse a woman a safe mode of delivery?"

In a response, Olubusola Amu and colleagues from Leicester General Hospital argue that there are still risks associated with Caesareans including a 10 times higher rate of hysterectomy due to haemorrhage. In some women, feelings of inadequacy, guilt and failure in not completing a natural process may affect bonding between mother and child, especially if the operation is conducted under general anaesthetic, they say.

They add: "Conflicts between maternal and fetal interests are potentially complex, ethically and emotionally, and difficult to resolve." They support choice for women but say they must be given full and honest advice about the risks and benefits so that they can make an informed decision.