We don’t browbeat women into having caesareans

By Florence Wilcock, an obstetrician specialising in care during labour. Response to ‘Yes, we do need to know‘ (THE GUARDIAN, 19/09/06):

Annalisa Barbieri claims that women are being bullied into having caesarean sections, despite the health risks (Yes we do need to know, September 11). “Once you’ve had one C-section you often have to fight for a vaginal birth,” she said, adding that “women find themselves browbeaten into having a ‘voluntary’ C-section.”As an obstetrician working in a maternity unit, far from “browbeating” women into having caesareans I spend a large amount of time counselling women regarding the pros and cons of a repeat caesarean and VBAC (vaginal birth after caesarean). Our unit is proactive in VBAC: in most cases our advice is against having a repeat caesarean, but it is often difficult to persuade women to attempt this. Barbieri represents only one viewpoint: there are also women who request a caesarean section for no medical reason, whom we actively dissuade.

Regarding the risk of haemorrhage and possible subsequent hysterectomy, Barbieri says “doctors and midwives rarely tell you that bit”, and “neither do many go into other caesarean risks”. In fact, the risks of any surgical procedure are always discussed as part of the process of informed consent – risks of infection, haemorrhage, thrombosis and damage to bladder and bowel are documented on the consent form, and discussed with women both in the clinic and prior to surgery. This follows recommendations published by the Royal College of Obstetricians and Gynaecologists last year.

Caesareans are not “easier to manage” than VBAC: they are more costly due not only to the prolonged hospital stay but to the increased manpower needed – obstetricians, anaesthetists, midwives and theatre staff.

Barbieri suggests that “doctors should read and act on research”. I can imagine few other professions where one trains for so many years and takes multiple exams before finally being considered a specialist. We are all subject to mandatory continuing professional development to keep up to date each year. There has been much discussion about the evidence for and against VBAC in medical literature, and a discussion of this was published in the National Institute of Clinical Excellence guidelines in 2004.

As doctors we carry a responsibility to both mother and baby; we have to balance the risks and issues of each individual case, and counsel women appropriately. On the occasions when we may seem to be at odds with a woman’s wishes it may be because we feel that she is putting her wishes above the increased risk to her baby – in a similar way that a mother who smokes or takes drugs may increase the risks. Yes, as Barbieri states, having a home birth after three caesareans is possible, but the risk of uterine rupture is higher with each subsequent caesarean – and if this rupture should happen at home, the results would be catastrophic for both mother and baby.

Describing doctors and midwives as “a legion of health professionals making [women] doubt themselves” is a negative and unhelpful comment. We are a group of people who give our utmost to ensure women and their babies have the safest and most emotionally rewarding experience.