Caesarean section on maternal request: do we give in or decline? an ethical and a legal perspective

Abstract

Caesarean section on maternal request (CSMR), defined as the first caesarean section performed before the start of labour and in the absence of any maternal or fetal indications, has emerged as an entity due to the increasing willingness of women to accept this intervention and the willingness of the Obstetrician to oblige to this request. These account for 6-7% of all caesarean sections. However, the incidence could be much higher due to the irregularities in documenting the indication for the intervention. The past decade has seen a rise in the demand for CSMR. Much of this rise is as a result of the perceived myth of safety of caesarean section and the changing attitudes of the society and the medical profession to childbirth. The reasons for women to request for CS are fear of pain of childbirth (tocophobia), fear of the risks related to vaginal delivery and the convenience of being able to decide on the timing and mode of delivery. The latter two are evident in the higher socioeconomic groups. To give in to the woman's request for caesarean section (CS) is a manifest of honouring her autonomy but comes at the expense of the integrity of the Obstetrician who is reduced to a mere technician in this instance. Doctors are also bound to do good and avoid harm to patients (beneficence and non-maleficence). In a resource poor setting, where there is a social obligation to divert whatever resources available to the essential and lifesaving interventions, the woman’s right for a request for CS in the absence of any valid medical indication, becomes a privilege. However, when the woman is prepared to pay for the intervention, the balance of benefit versus harm between CS and vaginal delivery becomes crucial in deciding whether to oblige to the woman’s request for CS or not. When the risks of an intervention or refusing the intervention and allowing the natural course of events to take place are thought to be the same, the woman's choice can be reasonably considered when deciding on the mode of delivery. Remarkable advances in asepsis, surgery and anaesthesia have contributed to CS turning out to be a safe operation today. Maternal mortality following CS has become an extreme rarity. Nevertheless, caesarean section in the current pregnancy carries a risk in subsequent pregnancies of, bladder and bowel injuries, placenta praevia, placenta accreta, uterine rupture and hysterectomy, which could prove to be fatal for the individual. Although the patients have the right to decide whether or not to undergo medical intervention even where refusal may result in harm or death, it is still unclear whether a ‘positive right’ to insist upon an intervention that the physician is obliged to provide, ever exists in an ethical or a legal context. Whether the baby benefits by a caesarean section requested by its mother is debatable. Caesarean section rates above 13-15% do not result in improvement in perinatal mortality and normal babies still die following CS. Litigation in the medical profession is on the rise and where do we stand in the issue of caesarean section on maternal request (CSMR) within the legal framework? The largest payouts are predominantly associated with vaginal births. However, complications which occur as a result of a non-indicated major surgery would still remain hard to defend.