KEY POINTS:
An ongoing controversy in obstetrics was recently highlighted at the national College of Midwives conference in Christchurch.
The Midwifery Council's deputy chairwoman said women who chose to have a medically unnecessary Caesarean section should be aware that "there actually is a price to pay". She warned that middle-class white women were putting themselves and their babies at risk.
Fostering a strong partnership between women and midwifes and promoting women's choices are at the heart of midwifery. Ironically, this emphasis can support medically unnecessary Caesareans in some cases. If women understand the price of a Caesarean and are willing to pay it, then we should be extremely wary of standing in their way.
In New Zealand in 2002, 22.7 per cent of all births were performed by Caesarean, a figure significantly higher than the World Health Organisation's 1985 recommendation of 10-15 per cent. Although there is no consensus in New Zealand about what an ideal rate is, there is agreement that something is not right.
Why would a woman want a Caesarean? Fear of childbirth, pressure of time constraints, belief in technology, past bad experiences or - implausibly - the desire to be like Victoria Beckham, are all cited as reasons for the increase (if in fact there is one) in demand. Some of the reasons seem absurd, while others make more sense.
It is difficult to establish what proportion of Caesareans are requested by women and medically unnecessary. Private obstetrician Dr Philip Beattie estimates that 3-5 per cent of Caesareans in New Zealand are performed on request of the woman, equating to around only 1 per cent of all births in the country.
It is also difficult to work out the exact increase in risk of a medically unnecessary C-section. A C-section is major abdominal surgery and there are a number of serious potential complications for both the mother and baby. Side-effects of anaesthetic, blood clots, post-operative pain and infection are just some of the risks of any operation. Added to this are problems unique to a surgery involving a mother and baby.
Regret at not experiencing natural delivery, bonding and feeding difficulties have all been attributed to Caesarean section. For the baby, potential risks involve respiratory complications, prematurity and laceration.
Despite these potential problems, it must be noted that there are limitations in the evidence against medically unnecessary Caesareans. Most data is based on emergency and clinically indicated elective Caesars - which are made more dangerous due to the medical complications for mother and baby.
Nevertheless, the risks are real and significant, so how can supporters of a woman's right to choose possibly defend their position in the face of such damning evidence?
Focusing solely on harms ignores the fundamental principle of respect for maternal autonomy - the physical health of the mother and baby are not the only factors in the birth equation.
As midwives know, there is a lot to be said for trusting the instincts of women when it comes to their birth experience. If this is true for women wanting home birth, water birth, or hospital birth, then it is true also for women wanting Caesareans. Some women know they want a C-section, have one, and are happy with their choice. There may be instances when women make poor decisions and regret their choices but this does not mean the practice is all bad.
Women should be supported with enough information so they can make the best choice for them and their baby in the circumstances. A disempowering birth can be an extremely negative experience. Maternity care should involve respecting the decision-making ability of the woman, rather than uncritical adherence to some idealised form of birth.
Protecting women's autonomy is a central philosophy in midwifery. In New Zealand, we are supremely lucky to have the midwifery profession we have.
Its reinstatement as an autonomous profession heralded the expansion of choice for women and the erosion of a medicalised model of pregnancy and birth. The move to autonomous midwifery was a move to empower women.
One of its logical consequences is to allow women to choose a medically unnecessary Caesarean if they want one. This might seem paradoxical, since the move against medicalisation of birth has been a driving force in midwifery.
However, I am not advocating a return to the days of induction and surgical intervention to suit the golfing timetable of the consultant. Rather, for the minority who genuinely want a surgical birth, a Caesarean should be available without having to make up a medical reason to get it.
The Midwifery Council deputy chairwoman is right; there is a price to pay for a medically unnecessary caesarean. It may be financial, physical or emotional. Women who choose one should be aware of this. They should not, however, be prevented from choosing it.
What we want in maternity care are good outcomes for all concerned. The best way to ensure this is to empower women to choose the birth they want, even when it is not the birth that we would choose.
* Claire Gallop is a lecturer and researcher at the University of Otago's Bioethics Centre
