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We Are Not Obligated to Perform Patient-Choice Cesarean Delivery
Rebecca G. Rogers, MD
Rates of cesarean delivery are increasing. It is estimated that 1 in 3 women
had cesarean delivery in 2004, and approximately a third of those births
will be upon maternal request.1 Why the increase?
Recent literature reviews and consensus statements are clear that evidence
to support elective cesarean delivery are lacking. ACOG published an ethical
opinion recommending acceptance of patient-choice cesarean based on the principles
of patient autonomy and informed consent. In contrast, the Federation of International
Gynecology and Obstetrics and the American College of Nurse-Midwifery oppose
patient-choice cesarean due to the lack of data demonstrating that primary
elective cesarean delivery is beneficial. While proponents of cesarean delivery
on maternal request point to potential benefits including a reduction in incontinence
and pelvic organ prolapse, opponents point to increased costs and neonatal
morbidity.
The physician’s role in providing guidance when evidence is lacking is
not foreign. Patients often demand interventions that health care providers
do not fulfill; demands for pain medication, genital plastic surgery, and elective
hysterectomy are all examples of requests that ObGyns routinely decline in
clinical practice, despite ardent demands from patients. Deference to a woman’s
autonomy assures that actions will not be taken without a woman’s consent,
and dictate that a woman should not undergo cesarean delivery without consent.
The converse, however, is not true. The right to refuse does not necessarily
impute the right to demand, and a request for cesarean delivery does not necessarily
dictate compliance from the physician.
While the importance of considering maternal needs and desires in the birth
of her baby can only be applauded, consideration of what factors influence
women’s decisions to request cesarean delivery is important. A recent
qualitative study queried women regarding motivations behind asking for elective
cesarean delivery; the majority of women who had requested cesarean did so
because of the belief that vaginal birth was potentially harmful to her baby.
The same study asked obstetricians to indicate reasons for increases in cesarean
delivery rates and found that fear of litigation and the practice of defensive
medicine helped drive increases in physician performance of cesarean.2
This combination of patient and provider fears comprises a perfect storm of
decision-making guided by emotion rather than deliberation, hampering constructive
patient-provider dialogue and rational decision-making. The tension between
what women want and what health care providers want to do is often best resolved
through constructive dialogue. Patients and providers can usually come to consensus
on what the best course of action is, taking into consideration evidence that
informs the dialogue as well as individual desires and preferences. When consensus
cannot be obtained, patients can still request; however, we are not obligated
to perform.
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Rebecca G. Rogers, MD, is Assistant Professor, Department
of Obstetrics and Gynecology, and Director,
Division of Urogynecology, University of New Mexico School of
Medicine, Albuquerque.
References
- National Institutes of Health State
of the Science Conference Statement; Cesarean Delivery on Maternal
Request, March 27-29, 2006. Obstet Gynecol. 2006;107(6):1386-1397.
- Weaver JJ, Statham H, Richards M.
Are there “unnecessary” cesarean sections? Perceptions
of women and obstetricians about cesarean sections for nonclinical
indications. Birth. 2007; 34(1):32-41.
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