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Editorial Caesarean section: a matter of choice? Women need more information, whether or not it leads to a decrease in caesarean section rates | 
MJA 1999; 170: 572-573
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With 20% of all births in Australia being by caesarean section (CS), we
have one of the highest rates among First World countries.1 There are, of
course, variations from State to State and between the public and
private sectors, but this high average rate is of ongoing concern to
obstetricians, health administrators and consumer groups. Many
reasons for these high rates have been advanced, including better
survival prospects for very preterm infants; the threat of
litigation leading to earlier intervention in labour; fewer
operative vaginal deliveries; and routine abdominal delivery for
breech presentation. The widespread use of electronic fetal
monitoring and epidural analgesia, and the need for repeat CS, have
also been cited. Despite much discussion, the appropriate CS rate for
any population has yet to be defined; for instance, the target CS rate
set by the US Department of Health and Human Services of 15% of births by
the year 2000 is an arbitrary figure widely questioned by
obstetricians in the United States.2,3
In this issue of the Journal, Turnbull et al present the results of a cross-sectional survey of South Australian women who underwent CS.4 Their aim was to determine the extent of women's involvement in the decision to perform the operation. Although more than 80% of women having elective CS and 50% of those having emergency CS reported such involvement, 20%-50% of women overall were not completely satisfied either with the decision, their input into it, or the amount of information provided to them. Turnbull and colleagues concluded that giving women more information might contribute to a drop in CS rates. Certainly, it is desirable that all pregnant women receive adequate information about the possible course of labour and the reasons why emergency CS might be recommended. Elective CS should probably be regarded differently as far as the decision-making process is concerned -- there is always time to discuss the surgery with medical advisers, partners and friends. But when labour, in particular first labour, has a high chance of ending in CS, women should be better informed of this so that they regard it as a possible normal event, rather than a surprising and disappointing outcome of a planned vaginal birth.5 Several studies have documented an association between emergency CS and subsequent psychological problems, especially postnatal depression.6,7 In the presence of high caesarean rates, such an association would pose a significant health problem for mothers and babies. The psychological sequelae have been linked to a sense of failure on the part of women who anticipated and prepared for a normal vaginal delivery, suggesting that the incidence of attributable postnatal depression might decline if women were more prepared for CS as a possible mode of delivery. Turnbull's article also raises the question of whether, given adequate information, most women who have had a previous CS will opt for an attempt at vaginal delivery in a subsequent pregnancy. Several studies indicate that about 70% of these women will be able to deliver vaginally; this is usually a happy outcome for the woman concerned, and uses fewer health dollars than a repeat CS. However, the 30% of women who will not achieve a vaginal birth also need to be considered; among these will be some with resulting severe psychological problems, as well as those sustaining complications, such as uterine rupture requiring hysterectomy. Although uterine rupture is uncommon, it is more likely to occur with trial of labour than with a repeat CS.2,3,8,9 Women considering vaginal delivery after a CS birth need full, unbiased information about all alternatives if they are to make an informed choice. There is evidence that there are some women who feel quite positive about CS, even requesting the operation when medical indications are slight or non-existent.3,10 More than 25% of the women in Turnbull's study indicated that they had "insisted on", or were "keen to have", a caesarean delivery. Mould et al, in a study of 102 women undergoing CS in a London hospital, found that more than 10% felt the decision for surgery to be entirely their own, and that 50% would opt for CS in a further pregnancy.11 How these women who insist on a CS would respond to extra information is unknown. Al-Mufti and colleagues surveyed the personal responses of London obstetricians (a highly informed group) to various hypothetical pregnancy situations: 31% of female obstetricians, and 8% of male obstetricians, would choose elective CS, for themselves or their partners, for an uncomplicated singleton cephalic presentation at term; higher percentages favoured CS for relatively minor indications. Possible stress incontinence, anal sphincter damage and compromised sexual function following vaginal delivery were among the reasons given. Al-Mufti rather archly suggests that perhaps CS should be offered to all pregnant women, "an option apparently available to all obstetricians".12 Turnbull's study is to be commended as an attempt to quantify the reasons for the decision to have a CS, and as a step towards providing the most appropriate and accurate information for women. However, certain assumptions were made in assessing the degree of satisfaction of the women surveyed, and there was no comparison with women experiencing a spontaneous vaginal delivery. Furthermore, Turnbull's final recommendation -- a randomised controlled trial of an information "package" -- would pose considerable methodological problems, including accruing sufficient participants; blinding the intervention (with some participants getting an information package and some not); and ensuring that patients in the control arm did not independently obtain the same information elsewhere. Regrettably, not all questions in medicine, especially those concerned with counselling, are answerable by randomised controlled trials.13-15 For the moment, it is clear that we must continue to monitor and assess Australian CS rates, and that women must be as well informed as possible about CS, especially emergency CS, long before labour. Many women may opt for a vaginal birth after a previous caesarean delivery, others will not, and others still may request CS for relatively minor indications. We must remember that providing full, unbiased information about birth and CS is not merely to enable health administrators to reach arbitrary targets, but to allow women to make a considered choice (even though that choice may be deplored by other groups of consumers or healthcare providers). Caroline M de Costa
©MJA 1999
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