Could a randomised trial answer the controversy relating to elective caesarean section? National survey of consultant obstetricians and heads of midwifery

Introduction

International concerns about rising rates of caesarean section are counterbalanced by arguments that planned caesarean section without specific clinical indication (such as breech presentation or HIV infection) falls within legitimate maternal choice.1 Professional opinion is divided. To perform a caesarean section without clinical reason is seen as ethical, in response to maternal request, by the American College of Obstetricians and Gynecologists; is enshrined in law in Italy; but is viewed as unethical by the International Federation of Gynecology and Obstetrics. The National Institute for Health and Clinical Excellence recommends that a second opinion should be offered.2 A well designed, randomised controlled trial of planned caesarean section compared with planned vaginal birth could provide important evidence.3

Participants, methods, and results

We aimed to survey all consultant obstetricians and heads of midwifery (gatekeepers to such a trial) practising in England between January 2003 and May 2004. We explored their views of women's requests for caesarean section without clinical indication and of a possible randomised controlled trial in a postal survey. We used semistructured questionnaires with closed questions followed by free text spaces to provide supporting rationale. Comparisons were made between professionals and according to parental status, sex, and type of unit where they worked. We used χ² tests to compare the proportion of respondents saying “yes” to each question. Two of the authors (TL, CK) manually analysed qualitative responses.

Altogether 660/924 (71%) eligible obstetricians and 123/169 (73%) midwives responded (table). Almost half of the obstetricians and a quarter of midwives believed that a woman should choose her method of delivery. A minority thought a trial was feasible, ethical, or desirable. Female obstetricians were less likely to support a trial than male ones. Whether or not the obstetrician and midwife had children did not influence their responses; nor did the type of unit in which the professionals worked.

A full description of qualitative findings will be presented elsewhere. Most respondents providing qualitative commentary wished they had the results of a randomised controlled trial. Obstetricians and midwives who were opposed to a trial offered similar reasons, motivated by unease with routine caesarean section (interference with nature, maternal morbidity, and impact on organisational resources and professional roles). Marked differences occurred in the responses of health professionals who supported a trial: obstetricians mainly believed that lack of evidence prevented women making informed choices, whereas midwives were confident that a trial would prove that vaginal birth was superior.

Comment

Our quantitative findings indicate that a minority of professionals would recruit to a trial comparing planned caesarean section with planned vaginal birth. However, the qualitative finding—that midwives who favoured a trial did so because of their confidence in the benefits of vaginal birth—adds complexity because it negates the necessary individual professional equipoise.4 We explored the opinions of senior obstetricians and midwives simultaneously and nationally, and we identified views about a possible randomised trial. To gain unbiased views, we deliberately did not present participants with a protocol, rather than give the impression that a trial was planned. We also believe that evidence about benefits and risks is insufficient to develop a protocol.

If caesarean birth were shown to be as safe as normal birth in a non-inferiority trial, the NHS would have to consider whether it would be willing to offer such a choice, given the huge resource implications.2 If the cost makes offering choice to all women unfeasible then carrying out a trial would be unethical. The ethical, moral, and practical challenges to a trial are considerable and would require involvement of women and society at large.