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Caesarean section: ethics, research, ICM position statement: rising worldwide rates of delivery by Caesarean section cause concern to midwives, whose role includes provision of information, advice and support to women.

Ethics of Caesarean section in the USA

The number of surgical deliveries in the USA has reached an all time high with more than one-quarter of all babies delivered in this way. In October 2003, the American College of Obstetricians and Gynecologists' (ACOG) ethics committee issued a statement that addressed the issue of elective Caesarean sections performed when there is no medical necessity.

Where medical evidence is limited, ACOG says there is no one right ethical response by a physician considering a patient request for surgery. In the case of an elective Caesarean delivery, if the physician believes that it will promote the overall health and welfare of the woman and her fetus more than will vaginal birth, then he or she is ethically justified in performing a Caesarean section. Similarly, if the physician believes that performing a Caesarean would be detrimental to the overall health and welfare of the woman and her fetus, he or she is ethically obliged to refrain from performing the surgery.

The ACOG cautions that evidence is still incomplete and that there are not yet sufficient morbidity/mortality data to compare elective Caesarean delivery with vaginal birth in healthy women. Women's health care organisations, including the American College of Nurse-Midwives (ACNM), the Association of Nurse Advocates for Childbirth Solutions, Lamaze International, Doulas of North America and the Coalition for Improving Maternity Services, believe this opinion downplays the risks to mother and baby when unnecessary Caesareans are performed and may be used to deny women informed consent regarding such procedures. With no definitive study on the benefits of Caesarean delivery, it is 'startling', they said, to give physicians the go-ahead to perform non medically justified surgery on women with normal pregnancies.

Research shows that the risk of maternal death following Caesarean section is five to seven times higher than vaginal birth. Complications during and after the surgery may include injury to the bladder, uterus and blood vessels, haemorrhage, anaesthesia accidents, blood clots in the legs, pulmonary embolism, paralysed bowel and infection.

The ACNM also said, 'Regrettably, the opinion issued by the ACOG Committee on Ethics may lead to an increasing level of distrust between health care professionals and the women who seek our services. The purported benefits of Caesarean section on demand are unproven and the known risks place the woman's life and reproductive future on the line.'

The ACNM statement pointed out that the baby also is at risk. With planned Caesareans, some babies are inadvertently delivered prematurely, may experience breathing problems and are five times more likely to be admitted to intermediate or intensive care. Premature babies also have more difficulty breastfeeding.

For more information visit the websites of the organisations mentioned above:,,,,,

Research uncovers new factor

A team led by Professor Gordon Smith at the University of Cambridge, UK, has concluded that delivery by Caesarean section in a woman's first pregnancy could increase the risk of unexplained stillbirth in the second. The authors' report opens by saying that Caesarean section is known to be associated with an increased risk of disorders of placentation in subsequent pregnancies, but effects on the rate of antepartum stillbirth are unknown. They aimed to establish whether previous Caesarean delivery is associated with an increased risk of antepartum stillbirth. An analysis of 120,633 births from second pregnancies showed that in women with one previous Caesarean deliver', the risk of unexplained antepartum stillbirth at or after 39 weeks' gestation is about double the risk of stillbirth or neonatal death from intrapartum uterine rapture.

Smith GC, Pell JP, Dobbie R. Caesarean section and risk of unexplained stillbirth in subsequent pregnancy. The Lancet 2003; 362:1779-84.

Survey results in the UK

A major study looking at Caesarean section in three countries of the UK was carried out in 2001. Results showed that, in many areas, one in three women have a Caesarean birth with the highest rates amongst women from minority ethnic groups and especially those who have English as a second language. According to the Royal College of Midwives (RCM), many of the operations are 'unwanted, unnecessary, and a financial drain on the National Health Service'. The RCM is concerned that in England, Wales and Northern Ireland, the overall Caesarean section rate has risen to 21.3%--a 5-fold increase since 1970.

J Thomas, S Paranjothy Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. National Sentinel Caesarean Section Audit Report. RCOG Press; 2001.

The ICM position

The ICM position statement 'Promotion of vaginal birth in preference to Caesarean section in the absence of evidence-based clinical criteria', agreed by the International Council in 2002, states that ICM 'deplores the use of Caesarean section for women other than when evidence-based clinical criteria are met ... and will:

* support member associations in their efforts to influence the unnecessary use of Caesarean section on a national level

* encourage midwives to be proactive as advocates for individual women

* work with medical colleagues to encourage appropriate use of the intervention.'

To read the position statements in full, visit or contact ICM HQ.
COPYRIGHT 2004 International Confederation of Midwives
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Title Annotation:Institute for Complementary Medicine
Publication:International Midwifery
Geographic Code:1USA
Date:Jan 1, 2004
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