Are there ‘unnecessary’ Caesarean sections? Perceptions of women and obstetricians about caesarean sections for non-clinical indications BIRTH (2007) 34 : 32 – 41

Attitudes to the mode of delivery have reflected the preferences of mothers, the press, midwives, health economists, healthcare trusts and not in the least, obstetricians. This paper reports the findings of a study funded by the Nuffield Foundation, UK. It used quantitative and qualitative methods: reviewing events diaries completed by pregnant women and interviewing others postnatally; interviewing middle and senior obstetricians and analyzing postal questionnaires from 785 UK Consultants. Incorporating the foregoing mix alone, makes this paper a relevant read for all those who care for women who may require a caesarean delivery (CS).

The aim of the study was to explore the perceptions of women and obstetricians to non-clinical requests for caesarean sections. An introduction cites the well-known catchphrase; ‘too posh to push’, explores the NICE guidelines and the findings of the National Sentinel Caesarean Section audit – among others. Even at this juncture of the paper, it is clear that the authors have a pretty impressive grasp of the issues.

The technique of information-gathering in this study was rather complex, consisting of the use of self-completed questionnaires, diary-entries, a check on details of birth and semi-structured interviews of recently-delivered mothers. Data was collected from Obstetricians by way of interviews and questionnaires. There was an amusing phrase about the authors’ choice in purposive sampling of ‘Consultants…known through publications…to hold strong but diverse views on reasons for CS’.

The most unbowed and un-shakable advocates of a cause rarely talk much about it; talk less of writing about it! It is not clear how many female obstetricians were interviewed. One good step of fine-tuning had to do with back-up phone calls to crosscheck questionnaire entries by post-natal women. Expectedly, the authors point observe that since complex descriptions and images were explored, new codes were developed to facilitate use of the Atlas-ti program, use to aid data analysis.Majority (69%) of the antenatal women would prefer a vaginal delivery.

Safety for the baby, rather than the route of delivery was the overriding concern. Health professionals, friends, sisters and mothers (!) appeared to induce fear about vaginal delivery. However, when there was any worry over baby’s safety, a CS was preferred.

It would appear that obstetricians tended to overestimate the number of mothers request for CS. This impression, superimposed on their perception that the rising CS rates were (mostly) due to maternal requests, sounds rather puzzling. Six Obstetricians ‘refused’ to participate. Strange.

Unfortunately, this is a 9-page paper may not be seen or read by many obstetricians in the UK – but it could stimulate reflection and purposeful debate. One also wonders why Midwives were not involved in this study. After all, they play an influential role in facilitating childbirth.