Elective cesarean section

Mary Hannah concludes her commentary on elective cesarean section1 by suggesting that if, after appropriate counselling, a woman continues to perceive that the benefits of such a procedure outweigh the risks, her health and welfare “will be promoted by supporting her request.”

In this regard, it is important that all evidence on the benefits and harms be presented to the prospective mother. The UK's National Institute of Clinical Excellence (NICE), which provides authoritative, robust and reliable guidance on current “best practice” to patients, health care professionals and the public,2 is currently developing clinical guidelines on cesarean section,3 expected to be released in April 2004 [the guidelines have now been published; see CMAJ 2004;170(12):1779.—Editor].

According to the draft document (page 27),3 “maternal request is not on it's [sic] own an indication for [cesarean section],” and “pregnant women should be supported in whatever decision is made following these discussions.” The draft (pages 19–21) provides current evidence on length of stay, abdominal pain, perineal pain, postpartum hemorrhage, infection, breastfeeding, bladder and urinary tract injuries, need for further surgery, risk of thromboembolic disease and many other clinical outcomes, the majority of these data favouring vaginal birth over cesarean section.

Women should have a right to exercise their choice on the mode of delivery even when there are no clinical indications for cesarean section. However, providing this procedure in a publicly funded system such as the UK's National Health Service would increase the overall cost, and the opportunity cost thus incurred might deny services that would be of benefit to other users of the service.

Padmanabhan Badrinath Southend Primary Care Trust University of Cambridge Southend-on-Sea, Essex, UK