APPENDIX 41
Memorandum by Centre for Family Research,
University of Cambridge (MS 50)
This memorandum has been prepared as a submission
to the Health Committee Maternity Services Sub-committee Inquiry
by Jane Weaver, Helen Statham and Martin Richards, from the Centre
for Family Research, University of Cambridge. The Centre for Family
Research has a national and international reputation for research
into aspects of family life and a particularly longstanding expertise
in Maternity Services Research. The findings presented here are
drawn from the unpublished report of a recently completed study
that was funded by the Nuffield Foundation.
1.1 INTRODUCTION
Our recent study, (1999-2002) arose out of concerns
that the caesarean section rate in England was rising. Although
clinical issues have been identified as the most common reasons
for performing caesarean sections, a persistent claim has been
that mother's requests for the operation in the absence of clinical
factors have become frequent and are an important contributory
factor to the rising rate. The media have invested in this concept
and, with the suggestion that several high-profile celebrities
have chosen caesarean sections for non-clinical reasons, the idea
that women are becoming "too posh to push" has entered
popular discourse. It is still unknown how many caesarean sections
are performed purely at maternal request; the recent National
Sentinel Caesarean Section Audit identified 7% of caesarean sections
in England and Wales in which maternal request was the primary,
but not necessarily the only, indication. In addition to the rhetoric
around women's demands for caesarean section, an earlier Court
decision had upheld the right of a woman to refuse the operation
regardless of the consequences for herself or her unborn child.
Both scenarios raised questions about why women make choices concerning
caesarean section that are not in accordance with professional
views, and about the processes that ensue when such choices are
made; how professionals and women communicate and negotiate. This
study set out to investigate the place of women's choice in negotiations
with midwives and obstetricians both when women did not want recommended
caesarean sections and when women wanted caesarean sections in
the absence of obstetric approval.
1.2 RECOMMENDATIONS
ARISING FROM
THE STUDY
1.2.1 Further research to ascertain how
much risk information women receive and the place of this information
in their decisions about caesarean section.
1.2.2 Standardisation as to when a caesarean
section is recorded to be for maternal choice.
1.2.3 Better midwifery staffing of maternity
units to enable better support of normal labour and birth.
1.2.4 More clearly defined roles for midwives
in supporting women as they make decisions about mode of birth.
1.2.5 Reduce the tendency to blame women
for the rising caesarean section rate, but recognise the place
of maternal fear, driven in part by the clinical environment in
which much maternity care takes place.
1.3 RELEVANT
METHODOLOGY
Further detailed information concerning study
design and methodologies can be obtained from the authors. The
findings arise from qualitative data collected directly from 95
women, 28 obstetricians and 24 midwives in four district hospitals;
and from a questionnaire completed by 785 consultant obstetricians.
1.4 SUMMARY OF
FINDINGS FROM
INTERVIEWS WITH
WOMEN, OBSTETRICIANS
AND MIDWIVES
Findings from all phases of the study support
the position that women want to be involved in decision making
about caesarean section but provide little support for the notion
that women make requests that are based on "trivial"
reasons. Requests are made mainly because women have fears or
concerns about themselves or their baby. Where caesarean section
is viewed as a positive event, that is, a procedure that is safer
for them and their baby, this often appears to be because women
are less aware of evidence associating caesarean section with
morbidity and mortality.
1.4.1 Women's Perspectives on Childbirth
For every woman the wellbeing of her baby was
of paramount importance. Underpinning most women's accounts was
the assertion that vaginal birth was normal and the "best"
way to have a baby, although this was often balanced by conflicting
talk of how vaginal birth was unpredictable could go "wrong".
Women were concerned that they could end up
enduring many hours of painful labour only to need an emergency
caesarean section. Thus elective caesarean section was often presented
as a more favourable option than risking labour that might end
in an emergency. Caesarean section was seen as something involving
an ordered process of events, under the control of professionals
and safer for the baby than vaginal birth.
Women's talk of risk associated with caesarean
section was often vague and was usually about risk to the mother
rather than the baby. Women sometimes denied having been told
about risks by their obstetrician or conflated risk with inconvenience.
The experience of caesarean section, particularly
a planned operation, was also described positively — friendly
theatre staff; being the centre of attention, needs and feelings
acknowledged, relaxed environment, an overall air of normality.
Women also acknowledged drawbacks including a longer hospital
stay and protracted recovery period. It was often described as
a major operation although some of the women's texts belied much
understanding of what this meant. The label "major operation"
was sometimes accompanied by some sort of minimising qualification
eg but it's nothing to worry about.
1.4.2 Did Women Ask for Caesarean Sections
in the Absence of Clinical Indications?
It was hard to find women wanting caesarean
section in the absence of any clinical concerns about either self
or baby. Although professionals discussed women's non-clinical
requests for caesarean as if they were frequent, when questioned
further the majority admitted that the number of such requests
they received was very small.
1.4.3 Why did Women Ask for Caesarean Sections?
The most common reason why women requested caesarean
sections was fear relating to clinical outcomes. Sometimes such
clinical concerns were acknowledged by the professionals eg a
previous difficult birth and fear of the same thing happening
again.
Some professionals suggested that women sometimes
requested caesarean section to prevent damage to the pelvic floor,
and the risk of later gynaecological problems, or to avoid stretching
the vagina and diminution of sexual function. No woman in this
study expressed such anxieties, although women with previous bad
tears were often concerned about perineal damage.
1.4.3.1 How do obstetricians react to requests?
Some clinicians described exploring "physical"
issues with fearful women and helping them find alternative solutions
that avoided elective caesarean section. However obstetricians
also described "psychological" bases for some women's
fears eg tokophobia (extreme fear of childbirth), or in women
with a history of sexual abuse. A few obstetricians spoke about
referring such women to a psychologist, although such appointments
were difficult to come by. Most obstetricians appeared not to
question these women's need for the operation.
1.4.3.2 Obstetricians' Perspectives on Litigation
Many doctors were concerned about litigation arguing
that it was unusual to be sued for doing unnecessary caesarean
sections; the pressure was to err on the side of caution and do
a caesarean section whenever there was any doubt over a situation.
The devastating effect on doctors of being taken to court was
identified. Many, but not all, doctors argued that the wellbeing
of the woman and her baby was more important than their fears
of being sued.
1.4.4 The Role of "Others"—the
Media, Family and Friends
The negative experiences of friends or other
family members could increase women's fears that vaginal birth
could go wrong; friends and family could also sometimes persuade
women out of caesarean section by their own positive experiences.
Women used media images of birth to support
arguments for caesarean section. Although positive images of vaginal
birth are produced, women usually discussed media representations
in which caesarean section was promoted positively or vaginal
birth as different or dangerous.
1.4.5 Women who Decided Against Caesarean
Section
Several women reported considerable pressure
in pregnancy to agree to a caesarean section. This was usually
because potential problems with the birth were anticipated eg
in a twin or breech pregnancy, or when the woman was diabetic.
It was these accounts, of women not wanting a caesarean section
that was being recommended, which appeared to carry the greatest
impression of conflict and disagreement between woman and carers,
rather than accounts of demands by women for caesarean section.
However professionals, by and large, did not discuss such cases.
Staff described a different group of women—those who refused
caesarean sections during labour, usually in situations of fetal
compromise. Such women were often stereotyped as coming from different
cultural backgrounds to their carers and being influenced by different
mores. Language and communication problems featured large in such
accounts. Some professionals expressed concern that such women
were not always helped to express their fears and anxieties, and
that unjust assumptions might be being made about them.
1.4.6 The Role of the Obstetrician in Determining
the Caesarean Section Rate
Obstetricians did not report being swayed by
pressure to keep rates down, but of doing what was best, or right,
for individual women.
The general consensus from midwives and consultants
was that registrars received less training than had once been
the case and that because of this they were less experienced to
deal with problems in any other way than by resorting to caesarean
section. The role of registrars in decisions around caesarean
section was debated. It is clear that they played some part in
the emergency situation being, quite often, the most senior obstetrician
on duty out of hours. Except in the most immediate of emergencies,
however, junior registrars were usually expected to discuss cases
with consultants before performing caesarean sections. However
there was evidence from the interviews that registrars sometimes
communicated problems in such a way as to persuade the consultant
to accede to the registrar's opinion.
1.4.7 Midwives' Perspectives on Caesarean
Section
Many midwives who worked with women antenatally
appeared to believe that discussions about caesarean section were
the remit of the obstetric profession. Others were reluctant to
express personal views to women for fear of being considered biased.
Women's accounts supported the minimal role of midwives in their
decision-making.
Most midwives saw themselves as defenders of
vaginal birth, but some also expressed the view that caesarean
section held advantages for the baby. Caesarean section was perceived
as the safest option as soon as there were any problems.
Midwives often felt that women did not know
the risks associated with caesarean section, although they supported
the reports of obstetricians that women were informed of these
risks by doctors or with written information. There were problems
with telling women about these risks: they did not want to worry
women, or make them afraid if they did eventually need a caesarean
section. Many midwives felt that women were choosing not to listen.
Midwives had less to say about fears of litigation than obstetricians,
but described themselves as under pressure to avoid being blamed.
They talked of acting defensively to `cover' themselves: making
copious notes and obtaining consent for everything, and of involving
doctors in a case sooner rather than later to avoid being scrutinised
if things went wrong. The problem was that then, however minor
the aberration from normal, the remit to take action or be blamed
if something went wrong was passed to the doctor and the concerns
about litigation and pressure to take early action described above
were liable to come into play.
1.5 SUMMARY OF
FINDINGS FROM
QUESTIONNAIRES TO
OBSTETRICIANS
Key findings from the 785 consultant obstetricians
in the UK and Eire who responded to the questionnaire-based study
of attitudes to and experiences of caesarean section requests
include:
Although 77% of obstetricians cited women' choice
as one of the main explanations of the rising caesarean section
rate, most obstetricians reported few requests.
Individual obstetricians have different definitions
of a maternal choice with some recording "maternal choice"
as a reason even when the operation was recommended or was one
of other reasons for operating.
The reported presentation of risk information
to women varied between obstetricians although was usually greater
than that which women reported they received.
Obstetricians mostly believed that midwives
should have a role in helping women make decisions about caesarean
section.
1.5.1 Demographic Information
74% respondents were male and 26% female. Female
respondents were significantly younger and had been practising
obstetrics for less time than males.
1.5.2 Personal Caesarean Section Rates
Only 44% of respondents knew their personal
caesarean section rate. The overall mean reported personal rate
was 19.5%. Personal rate was not related to obstetrician's age
or sex.
1.5.3 Attitudes and Beliefs about Caesarean
Section Rates
Thirty eight per cent of obstetrician thought
that the current reported rate of 20% (at the time this questionnaire
was administered) was "too high", 4% thought it lower
than it should be and 52% thought it "about right".
Female obstetricians were more likely than males to believe the
rate was too high.
Eighty eight per cent of obstetricians believed
that attempted vaginal birth was safest for a woman in a completely
straightforward pregnancy but only 50% thought this was safest
for the baby. Only 1.5% thought caesarean section was safer for
the women than an attempted vaginal birth, 25% thought it was
safer for the baby.
1.5.3.1 Relationships Between Caesarean
Section Rates and Beliefs About Caesarean Section
Personal caesarean section rates varied with
beliefs about the current rate of 20%. Rates were 16.6/ 20.8/
27.0% respectively for those who believed the current rate was
too high/ about right/ too low.
1.5.4 Explaining the Current Rate
Obstetricians' main explanations for the rising
caesarean section rate were women's choice (77% of obstetricians
cited this); litigation (67%); training of junior doctors (38%);
previous caesarean section (24%); breech (21%).
However, when asked directly about requests
to them personally, most obstetricians reported having had few.
Overall, 725 obstetricians reported requests for 8,254 elective
caesarean sections in the previous 12 months from women who, in
their opinion, had no clinical indication for the operation. However,
50% had six or less requests. A small number received most of
the requests. However obstetricians did not agree to all requests.
1.5.5 What is a Maternal Request
Not everyone meant the same by maternal choice.
12% of obstetricians reported that they would record "maternal
choice" as a reason for a caesarean section even when the
operation was recommended and 65% of study participants would
record maternal choice if it was one of other reasons for operating.
Only 23% only record woman's choice as a factor when there is
no other reason for doing the operation. This has particular ramifications
for studies that rely on case note records to define cases involving
maternal choice.
1.5.6 Risks of Caesarean Section and Vaginal
Birth in the Absence of Clinical Indications
Obstetricians reported that they were more likely
to discuss risks to the mother of both caesarean section and vaginal
birth than discuss risks to the baby. 65 obstetricians would not
discuss any risks for the mother, 402 did not report discussing
any risks to the baby.
419 obstetricians reported that they did not
discuss any risks for the mother of vaginal birth and 586 that
they did not discuss risks for the baby. The risk for the mother
most likely to be discussed was that of needing a caesarean section
and for the baby that of unexpected problems/distress.
These findings need to be considered in the
context that women do not report that risks of caesarean section
are discussed and reasons for this mismatch is an important area
for future research. Women may not take risk information in, as
midwives suggested. Other reasons are likely to be related to
the context, timing, format or way in which such information is
given.
1.5.7 Influences on Women's Choices
Three quarters of obstetricians thought that
midwives should have a role in helping women make these decisions
about caesarean section. Midwives should be promoting vaginal
birth as normal but they were often reported as encouraging women
to ask for a caesarean section. Midwives could be advocates for
women and should be able to reassure women about normal labour.
One third (32%) of those who thought that midwives should not
have a role believed that midwives did not know enough about caesarean
section and would give women incorrect information.
1.6 PUBLICATIONS
Horey D, Russell H, Weaver J (2002) Information
for women about caesarean birth (Protocol for a Cochrane Review):
In the Cochrane Library, Issue 4. Oxford: Update Software.
Weaver JJ (2002) Court-ordered Caesarean sections.
In MPM Richards, A Bainham and S Day Sclater (Eds.) Body Lore
and Laws, Oxford:Hart.
Weaver JJ (2002) The birthing body—talking
about childbirth. The Psychologist, 15 (4) 188-190.
Statham H, Weaver J, and Richards M (2001) Why
choose caesarean section? Lancet, 356, 635.
Weaver J, Statham H, and Richards M (2001) High
caesarean section rates among women over 30. High rates may be
due to perceived potential for complications. British Medical
Journal, 323, 284-5.
Weaver J (2001) In the spotlight. Obstetric
preferences and caesarean section. MIDIRS Midwifery Digest, 11
(4), 516-518.
Weaver JJ (2001) Thoughts on Caesarean Section.
MIDIRS Midwifery Digest, 11 (3), Supplement 2, s16-s18.
Weaver JJ (2000) A study of choice and decision
making in caesarean section. RCM Midwives Journal, 3(3), 77.
Weaver, J.J. (2000) Culture, choice and caesarean
birth. In: The Rising Caesarean Rate. Causes and Effects for Public
Health. Proceedings of the second joint conference organised by
the RCOG, RCM and NCT, held in Manchester on 7 November.
February 2003
| 
