C-Sections on Demand? Not Quite…

Stephen Latham has picked up a lead about NICE guidelines on the provision of caesarian sections:

An update of a new guidance document being developed by the UK’s National Institute for Health and Clinical Excellenct (“NICE”) would permit caesarian section on maternal request, even when there are no medical indications for the procedure. […] The new guidelines make me worry that the official availability of c-section on maternal request in the UK will lead to some non-medically-indicated c-sections being performed for reasons other than “maternal request,” like physician scheduling convenience. But it may work differently in the NHS; and anyway, the NICE guidelines include a number of steps to be taken before acquiescing in mom’s request for CS, like counseling on fear of childbirth, and proper discussion of the comparative risks of CS and vaginal birth.

Even allowing that this is accurate, I don’t quite see why Latham is worried about a CS being scheduled for reasons other than maternal request – it’s a heck of a leap from “maternally requested” to “requested by someone else”.  What worries I do have are versions of more general worries about providing any medical intervention at all on demand; as a rule of thumb, I think it’d be hard to justify providing any procedure just because it had been requested.  On the other hand, I can well imagine that there’re lots of situations in which a CS might be a perfectly reasonable thing to request, and in which acceding to such a request is just as reasonable.

A lot still hinges on whether Latham is accurate, though.  As far as I can tell, he isn’t quite right.   The guidance to which he links has a section on maternal requests for CS on page 17.

Maternal request for CS

34. When a woman requests a CS explore, discuss and record the specific reasons for the request. [new 2011]

35. If a woman requests a CS when there is no other indication, discuss the overall risks and benefits of CS compared with vaginal birth (see box A on page 14) and record that this discussion has taken place. Include a discussion with other members of the obstetric team (including the obstetrician, midwife and anaesthetist) if necessary to explore the reasons for the request, and to ensure the woman has accurate information. [new 2011] 

36. When a woman requests a CS because she has anxiety about childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her anxiety in a supportive manner. [new 2011]

37. Ensure the healthcare professional providing perinatal mental health support has access to the planned place of birth during the antenatal period in order to provide care. [new 2011]

38. For all women requesting a CS, if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS. [new 2011]

39. An obstetrician has the right to decline a woman’s request for a CS. If this happens, they should refer the woman to an NHS obstetrician in the same unit who will carry out the CS. [new 2011]

So there’s no mention of actually providing a CS until recommendation 38, and even then, recommendation 39 makes it clear that obstetricians have a right to decline the request.  On page 102, it’s made clear that

if an obstetrician feels a woman’s request for CS is not appropriate after the woman has received appropriate counselling and support, then s/he should be able to decline to support the women’s [sic] request.  This does not overrule the woman’s rights to express a preference for a CS however, and in this instance the obstetrician should transfer care of the woman to an NHS obstetrician within the same unit who is happy to support her choice.

So if the relevant medics think that the procedure isn’t warranted, they’re within their rights not to perform it.  That seems to be perfectly proper to me.  Still, I am a bit puzzled by the second sentence.  It’s obvious to me that a person’s right to express a preference is wholly different from their right to have that preference met – not least because having one’s preferences met is not a right when the preference is positive, so this statement seems somewhat de trop.  (Prefering not to be treated in a certain way is a different matter, of course.)

Yet the tone here implies also that a positive preference is all that’s needed to instigate a CS, and that there is some kind of a right to one (hence the requirement to refer the woman on).  That seems to treat the procedure as being significantly different from other procedures – if I want my broken arm treated with antibiotics, my doctor has no obligation at all to refer me to someone who’ll satisfy my preferences.  So there seems to be a need to explain what it is about CS that’s different.  The explanatory gap may be filled reasonably easily; but it does need filling.

One other thing.  The requirement obstetricians refer women on if they aren’t willing to provide a CS raises a question about pressure on other colleagues, and it’s related to a problem that has to do with conscientious objection.  Suppose Smith decides that a CS is unwarranted and – granted surgical risk and so on – unjustified, so refuses to provide one.  The woman is referred to Jones.  Jones happens to agree with Smith.  Now suppose that there is no third obstetrician available within a reasonable distance.  What happens then?  Is Jones under more of an obligation because of the Scylla of the request and the Charybdis of Smith’s refusal?  Or can he refuse, too?  In that case, what about the woman’s putative right?  And what about collegiality between Smith and Jones anyway?

There could be all manner of interesting disputes to resolve.

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