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Maternal request for caesarean section

13 June, 2008

Maternal request for caesarean section

The number of women requesting caesarean sections on nonmedical grounds is rising and the reasons for this are varied and must be taken seriously, as Jacqueline Dunkley-Bent explains.
The number of women requesting caesarean sections on nonmedical grounds is rising and the reasons for this are varied and must be taken seriously, as Jacqueline Dunkley-Bent explains.

Midwives magazine: June 2005 



The rates of caesarean birth are rising as are mothers’ requests for caesarean section (CS) where there is no medical need. The reasons for this are varied and complex and should be taken seriously by healthcare providers. A question that frequently presents challenges for health professionals today is: ‘Can women really choose to have a CS?’ The answer is not as straightforward as it seems.


We all know and probably agree that a woman cannot be forced to labour and give birth vaginally if she does not want to. Equally, it can be argued that a decision to perform CS for maternal request alone is unethical. Clinical reasons to perform CS should not be found in order to do what the women wants, as this practice serves to mask any psychological reasons for the woman’s request. Amu et al (2004) suggest that accepting maternal choice as the sole determinant of method of delivery is probably doing the woman a disservice and may constitute a lack of responsibility.


The International Federation of Obstetrics and Gynaecology (FIGO) committee for the ethical aspects of human reproduction has submitted that it is unethical to perform CS without medical indication, because of inadequate evidence to support a net benefit (FIGO, 1999). The reasons why women request CS should be treated with the same rigour and professional acumen as women who request other invasive procedures. Women are more likely to articulate their fears of childbirth and they expect and deserve to be taken seriously. The National Sentinel CS audit report 2001 revealed that almost 20% of women in the UK are afraid of childbirth and 5% request CS for nonmedical indications (RCOG, 2001). Jackson and Irvine (1998) report that over 3% of deliveries at a UK hospital were elective CS performed due to maternal request. More recently, Marx et al (2001) found that 7% of CS in the UK were performed because of maternal choice alone. There is no ‘correct’ rate for CS, but there is concern that the rate is rising in England and Wales (11.3% in 1989 to 1990, 15.5% in 1994 to 1995 and preliminary estimates for 1997 to 1998 suggest 17%). The National Sentinel CS audit report showed that the overall CS rate was 21.5% in England and Wales (RCOG, 2001). It would be reasonable to conclude that CS requested for non-medical reasons are contributing to the rising CS rate in the UK.


This article describes a multidisciplinary approach to supporting women who request CS for non-medical indication and alludes to some of the complexities involved in the dilemmas health professionals are now forced to embrace. Although the debate about women’s choices, ethical issues, moral codes and resource implications form a vital and integral part of the maternal request for CS discussion, this is beyond the remit of this article.


Why women request CS for non-medical reasons


A clear rationale for performing CS is essential and therefore exploration of reasons why this operation is a preferred method of birthing for some women is taken seriously and not discarded. The National Institute for Clinical Excellence (NICE) guidelines suggest that maternal request is not on its own an indication for CS, and specific reasons for the request should be explored, discussed and recorded (NICE, 2004). The potential of psychiatric problems should not be underestimated, as in some cases refusal of CS has resulted in severe psychiatric problems (Hofberg and Brockington, 2000). It is not known how many women in the UK who request CS for non-medical reasons have extreme anxiety or fear of childbirth. The term ‘tokophobia’ has been proposed to describe some women with such extreme anxiety or fear of vaginal birth (Hofberg and Brockington, 2000). Levels of anxiety vary, and it is unlikely that all women with extreme anxiety regarding vaginal birth would meet the classified criteria for this phobia. Despite this, all women should have appropriate levels of support provided. Bewley and Cockburn (2002) argue that to perform CS for maternal request or anxiety without firstoffering professional midwifery and psychological support is unethical – equally to refuse CS for a women who presents with severe anxiety, previous trauma experience or tokophobia is also unethical.


Supporting women who request CS


Practice at a large teaching hospital in southeast London involves working in partnership with women who request CS to explore their reasons using different support mechanisms. The aim of this approach is to work with the woman towards a good outcome for herself and her baby, ensuring mutuality between the practitioner/client relationship. The service involves counselling, psychological assessment and focused midwifery and medical support. Once the woman discloses her request, she is invited to have a consultation with the consultant midwife who explores the woman’s prior knowledge of childbirth and CS, and encourages the disclosure of fears and anxieties surrounding vaginal birth and reasons for the CS request. Women are told that childbirth is seen as a normal physiological process and prophylactic CS is not supported by the evidence and is not safer than vaginal birth. They are also informed that CS is not carried out for maternal request only, but there must be a medical or psychological indication to do so. The process for establishing this position is explained. The main reasons disclosed for CS requests are detailed in Box 1. Tears and expressions of anxiety, as the reasons for the CS request unfold, frequent many consultations. Women often attend the first consultation with their partners – it is not unusual for defensive behaviour to be expressed, until there is recognition and acceptance from the woman and her partner that there will be no intellectual fight or a battle of wills. Listening, expressing empathy and genuineness and believing the woman’s position is a prerequisite to a trusting and productive process as the foundation for further support is secured. Women tend to express anxiety about the forthcoming birth and describe symptoms including sleepless nights, bad dreams about childbirth and anxiety attacks.Many women have delayed having children or further children because of their fears. On rare occasions women have considered termination of pregnancy because of their fear of the birthing process. Several further consultations are offered with the consultant midwife, where fears and anxieties are addressed and myths explored. The overall benefits and risks of CS compared with vaginal birth are also discussed. A discussion visit to the birth centre continues this theme prior to any decision about the mode of delivery.


The woman may choose to have a vaginal birth or there may be consideration of CS for preventative mental health indication at this point. Women who choose to have a vaginal birth develop a plan of action with the consultant midwife that enhances the woman’s feeling of control and guides other professionals in the delivery of her care. This is particularly important for women who have had previous traumatic experiences.Women deemed to have tokophobia or psychological problems are offered an appointment to see a consultant psychiatrist who attempts to ascertain whether a vaginal birth experience will cause psychological morbidity. The consultant psychologist may offer cognitive behavioural therapy if deemed appropriate. The results of this are detailed in a report to the consultant midwife, lead midwife and consultant obstetrician.


A decision to perform CS on this premise is made with the woman. Women who make a decision not to see a psychiatrist are referred directly to their obstetrician, and it is mandatory for the obstetrician to get a second opinion from an obstetric colleague prior to making a final decision with the woman. This process is described as demonstrating the seriousness of executing women’s choices (Bewley and Cockburn, 2002). Women are not forced or cajoled into giving birth vaginally because of the potential for psychological harm, including postnatal depression and impaired mother infant relationships. Performing CS for maternal request without appropriate support as described above may mask the reasons why it was requested in the first place – the problem then continues to exist. CS request for lifestyle choice presents more of a challenge, as health professionals may subscribe to the notion that there is a limit to what choice includes. Can women have CS for lifestyle choice? Practice and professional guidance would suggest not, but equally a woman should not be forced to give birth vaginally.Women who present with this request should be provided with the same level of support described above. After discussion and education women usually accept and understand why vaginal birth would be encouraged above and beyond CS when lifestyle choice is the reason for the request.





Women who request CS for non-medical indication present many challenges for healthcare providers. Multidisciplinary support for women who request CS supports an holistic approach to health, synonymous with woman-centred care. Appropriate services should be provided for women who have anxiety about birth, previous trauma or tokophobia. Senior midwifery and psychological referral should be made prior to decisions being made. There should be no confusion about what choice in childbirth includes, but every woman’s reasons should be considered for their own merit.




Box 1. Common reasons cited for requesting CS

Fear of:

  • Baby dying

  • Being out of control

  • Failing to deliver the baby vaginally

  • Not being able to cope with a long labour

  • Things going wrong

  • Previous traumatic childbirth experience

  • Traumatic birth stories of significant others

  • Emergency CS

  •  Incontinence

  •  Perineal trauma

  • Ruined sex life

  • Rejecting the baby if labour is difficult.


Other reasons cited include:

  • Easier way of giving birth

  • The need to know the birth date in advance so that the household can be organised accordingly

  • Help from others is only available at certain times

  • Certain celebrities have had CS

  •  Feelings of helplessness – ‘just cannot do it’

  • Disbelief that the baby can be born vaginally

  • Disbelief in the body’s natural ability

  • Small hips and small stature.


NB: Previous sexual abuse is not frequently cited as a reason why CS is requested, but it is not uncommon for this information to be revealed during one of the consultations with the consultant midwife.





Amu O, Rajendran S, Bolaji I. (2004) Maternal choice alone should not determine method of delivery. British Medical Journal 233: 689-95. Bewley S, Cockburn J. (2002) The unfacts of ‘request’ caesarean section. British Journal of Obstetrics and Gynaecology 109: 597-605. Denyttenacre K, Lenaerts H, Nijs P, Van Assche F. (1995) Individual coping style and psychological attitudes during pregnancy predict depression levels during pregnancy and during postpartum. Acta Psychiatrica Scandinavica 91: 95-102. International Federation of Obstetrics and Gynaecology. (1999) Ethical aspects regarding caesarean delivery for non-medical reasons. International Journal of Obstetrics and Gynaecology 64: 317-22. Hofberg K, Brockington I. (2000) Tokophobia: an unreasoning dread of childbirth British Journal of Psychiatry 176: 83-5. Jackson N, Irvine L. (1998) The influence of maternal request on the elective caesarean rate. Journal of Obstetrics and Gynaecology 18(2): 115-9. Marx H,Wiener J, Davies N. (2001) A survey of the influence of patients’ choice on the increase in the caesarean section rate. Journal of Obstetrics and Gynaecology (21)2: 124-7. Nielsen D, Videbech P, Hedegard M, Dalby J, Secher N. (2000) Postpartum depression: identification of women at risk. British Journal of Obstetrics and Gynaecology 107(18): 1210-7. RCOG.(2001) The national sentinel caesarean audit report. RCOG, London.



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