Maternal request is not a myth

There have been a number of media reports in response to the publication this week of the study, 'Variation in rates of caesarean section among English NHS trusts after accounting for maternal and clinical risk: cross sectional study' by Bragg et al.

Below are a few examples of these stories, plus the comment I have posted in most of them:

*Who's Too Posh to Push? High Cesarean Section Rates Aren't Moms' Fault, TIME.com
*Too posh to push mums 'a myth', nhs.uk
*High caesarean rates are not down to women being 'too posh to push', The Telegraph
*Wide variation in Caesarean rates in UK, hc2d.co.uk

My comment

Aside from the fact that persistent use of the derogatory term ‘too posh to push’ is both irrelevant and unhelpful in discussions about whether women are choosing a caesarean birth plan, the idea that this study has exposed it as a myth is flawed.

The authors write: “It seems unlikely that maternal request in the absence of any clinical indication contributes substantially to the rates.” This is not the same as saying that maternal request is not contributing to the rates ‘at all’ or that women choosing caesareans is a myth. As far as I am aware, no media report as yet has actually cited the number (or percentage) of non-medically indicated caesareans found in this study, and I have contacted the authors for further clarification of this precise figure.

As it stands, the current estimate of rates of caesarean delivery on maternal request is around 5% of all births. This is clearly a very small number. However, it is more than double the number of women who request a homebirth, and yet these women and their birth choice are afforded greater support and respect by many birth support groups and the Department of Health.

As a final point, here are some other reasons why this study (which analysed routinely collected hospital episode statistics and did not involve any interviews with women or doctors) does not provide categorical proof that women are not choosing caesareans themselves or that caesareans in the absence of any clinical indication are not contributing to overall caesarean rates:

1) A medical indication and maternal request are not mutually exclusive. Anecdotally, I chose to plan a caesarean for both my births but my hospital data reads ‘breech presentation’ for the 1st (as this was discovered in the 8th month of pregnancy) and ‘repeat caesarean’ for the 2nd. I have also been contacted by other women via my website whose situation is the same.

2) It is not unknown for a medical indication to be cited by doctors on a woman’s records rather than draw attention to the more controversial indication of maternal request.

Please note that this comment is not in any way a criticism of the study itself or its authors; only the wider interpretation of maternal request caesareans that is being reported. In fact, the study itself presents extremely useful data and suggestions for NHS trusts going forward.