Is there a right to choose C-sections?

Cross posted

Women could be given right to choose Caesarean birth

The National Health Service in the UK is considering giving women the right to choose a c-section, even when there is no medical need. That seems appropriate to me.

My reasoning goes like this. Yes, caesarians are risky, as all abdominal surgery is risky. However, mere risk alone is not enough to disallow particular activities. If it was, then none of us would ever be allowed to get into a car. Even high degrees of risk are not enough to rule out activities, such as studying volcanoes (volcanologists, especially those who study erupting volcanoes, have a very high death rate).

You might argue that caesarians can cause harm to a woman, but again, choosing an activity that causes harm to yourself is permissible. As it turns out, delivering babies vaginally can cause harm to women too, as women who have spent years and years doing Kegel exercises will tell you.

Perhaps we might worry about harm to the baby, but that only comes into play if we ascribe moral standing to the baby, and treat women merely as receptacles of precious objects. It does seem to be the case that babies are at higher risk of complications if they are delivered through a c-section, but in order to use that as a reason for refusing c-sections, we would have to say that the woman’s role in pregnancy and childbirth must be to be the best possible bearer of babies. That is, she is not important, and only the baby is important. If a woman says that she wants the best outcome for the baby, then it would be appropriate to take the risks to the baby into account when determining whether or not to have a caesarian, but only in the sense that in order to achieve the outcome she wants, that is, factors militating against that outcome must be considered.

We might be concerned about whether a c-section is medically necessary, with the underlying assumption that no medical procedure should be undertaken unless it is medically necessary. But if that’s the case, then there goes the entire plastic surgery industry, including plastic surgery or reconstructive surgery. Of course, we can defend plastic and reconstructive surgery on the grounds of psychological need, but in that case, the psychological needs of women preparing for childbirth need to be considered too, and those psychological needs may well be met by planned c-sections.

Following on from that, perhaps women choose c-sections because they are concerned about the process of labouring and delivering a baby. If that’s the case, then the answer is to provide more support for women who are preparing for childbirth, perhaps in the form of counselling and education, not just to prohibit one option for giving birth.

On the financial side, if planned c-sections are more expensive than other forms of childbirth, then given that the National Health Service in the UK is funded by taxpayers, then we might have some concerns about cost, both for the caesarian itself, and for the on-going care of mothers babies. However, it seems that allowing women to choose a c-section would just formalise existing practice, whereby women who want a c-section can already arrange to have one. Formalising the practice might well be preferable, because it would at least reduce the capriciousness of the health system, whereby women in one hospital might be able to access c-sections, but women in another might not, just because of differences in attitude.

In general, we tend to think that if someone has considered all the relevant factors, and chosen to engage in a particular activity (such as going bushwalking by themselves in the middle of winter), then that is their business. We might deplore their choice, but we don’t stop them from doing it. And if they get into trouble, we pile in resources to help them. I think that the same approach must be taken with respect to childbirth. Setting aside the matter of cost, if a woman wants to have a c-section, and she has considered all the issues, then that is her business. In fact, even if she hasn’t considered every last detail, we should still not put barriers in the way. To do otherwise is to treat women as though they were children, dismissing their fears and concerns, and telling them that they just don’t understand and that really, they had better just let the grown-up doctors and nurses and midwives make the decisions for them.

Update: Art and my Life (in comments) linked to a 2006 article by University of Orgao bioethics lecturer Claire Gallop looking at exactly the same issue: Women’s right to choose Caesarean.

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15 comments on “Is there a right to choose C-sections?

  1. Mindy says:

    I wouldn’t have normally chosen a caesar for my two children, but circumstances dictated that it happen that way. I am grateful that I had the choice. I did read a chilling article about a conference where the Obs discussed doing all births via c-section as being ‘safer’ for women. I think they meant more conveniently scheduled for Obs. It did not say what the gender balance of the conference was, but I’m guessing that many women Obs also like an unbroken nights sleep too.

    shorter me: I think having the choice is important regardless of why someone has made that choice. People claiming that women who have caesars are too posh to push have probably never recovered from abdominal surgery.

  2. johnsonmike says:

    All I can say about your rather, er, unfortunate, post is that I am reminded of the phrase:

    “Too posh to push.”

    That is where this massive increase in demand for routine c-sections has come from.

  3. artandmylife says:

    Funny I was talking about this issue with an obstetrician yesterday. Also this article is interesting from an NZ perspective http://www.nzherald.co.nz/opinion/news/article.cfm?c_id=466&objectid=10408693.

    In a very stretched publically funded health system can you “set aside the matter of cost”?

    • Deborah says:

      “Setting aside the cost” in the sense of setting that matter to one side, in order to focus on the issues of autonomy and choice. Mind you, there’s a whole set of issues around cost too, to do with rationing and whose medical expenses are deemed to be more important and more worthy of funding.

      Great article from Claire Gallop, which I hadn’t read until you linked to it. I’ll add it to the post.

  4. M-H says:

    A challenging post, Deborah. I don’t disagree with you, but I’d still like to see fewer Caesarians performed countries where basic health standards are high. It’s a conundrum.

  5. Giovanni says:

    I’m not sure that the comparison between having a C-section and becoming a volcanologist is very apt! The issue at hand is the elective medicalisation of a procedure that can but doesn’t necessarily need medical intervention. It also happens to involve a function that is essential for the continuation of the species – it is social in the sense of forming the basis for society as well as being wrapped in a lot of sensitive debates about acceptable norms and the role of women. It seems to me that it would be ghastly to live in a society that refused a woman the right to choose how she is most comfortable giving birth, but I also think that more efforts could be made to ensure that the choice is informed and meaningful. I don’t think there is nearly enough information offered to pregnant women (as opposed to being available who those who can research it) and that sometimes it actually ends up being the doctor’s choice (although not so much in New Zealand, it must be said.)

  6. Carol says:

    Well, I am someone who has both had a C-section and become a volcanologist!
    (Caveats: the C-section chose me rather than vice versas, and I’m a very tame office bound species of volcanologist).
    I agree with you in principle, Deborah, but I think there are issues associated with resource allocation, in that the choice to have a C-section is going to tie up surgical resources that arguably could be more valuably deployed.
    I’ve never been convinced by the “too posh to push” line. It’s got nothing to do with poshness and a lot to do with increasing age at which people are giving birth and attitudes towards risk avoidance.
    Nice new layout by the way.

    • Deborah says:

      Seriously?!! You’re a volcanolgist??!!!! I am deeply envious, and very, very impressed.

      Yes I think the resource allocation arguments are important too, but in that case, we need to have a look at a whole lot issues around resource allocation. It’s not just c-sections that tie up surgical and other medical resources that could be deployed elsewhere.

  7. Carol says:

    >impressed.
    Really, no need to be; I’m majorly impressed with your articulacy and grasp of so many different areas.
    Yes, seriously, though I’m involved with the impact assessment side of eruptions rather than thinking about magma – I go to some lengths to avoid eruptions in progress!

  8. bluebec says:

    Hi Deborah,

    Paragraph 4 doesn’t end and I want to know what it was going to say!

  9. I think your analogies are poorly chosen. On the matter of risk, the question here is not a woman’s right to decide what risks she will take, but rather whether she has a right to expect someone else to enable her. Secondly, the question of cost is central, as it is the National Health Service contemplating this policy. Does a woman have the right to choose a procedure that is not medically necessary; which therefore inevitably will require the doctor to subject the woman and her baby to a risk which s/he considers unjustified; and for which the community as a whole is expected to pay? I should cocoa! A woman who wants a caesarean that is not medically necessary has the same option as anyone else wanting unnecessary surgery — find a compliant surgeon and pay for the procedure herself.

    • Deborah says:

      I’ve addressed the point about cost in the post, and in a response to Carol upthread. With respect to requiring doctors to perform the procedure, if we are to respect patient autonomy, then that may well be a consequence. In any case, doctors perform medically unnecessary procedures already. That’s why we have a huge plastic surgery industry.

  10. Julie says:

    v. interesting post. My sister had an ‘elective’ c-section. There was not a physical indication but she has a significant mental health issue that led to psychosis during pregnancy. She was very clear in her mind that she could not deliver vaginally, nor cope with not knowing when the delivery would be. However, in an environment in which c-section rates are increasing, she had great difficulty getting an elective c-section through the public hospital system, and had to jump through many hoops, including an assessment by the hospital chief psychiatrist before it was authorised. Like Carol I’ve not been convinced by the ‘too posh to push’ line, but I do know many gynaecologists who, after a a career dealing with incontinence issues in older women, elect to have their own babies by c-section. So I guess, when assessing costs, the costs of uterine, vaginal and bladder prolapse which are somewhat increased in women who have had vaginal deliveries, might also need to be considered. Having said this, I was fortunate to not need c-sections and would not have elected one, even knowing the possible risks that may await me as I age. I suspect that making elective c-sections available would not increase the overall c-section rate by much, if at all.

  11. […] Reproductive rights Mothers For Choice Aotearoa NZ  thinks the moral stigma is real The distress of abortion while Deborah at A Bee of a Certain Age ponders Is there a right to choose C-sections? […]

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