Patient education is way to influence maternal requests for caesarean section

Editor—The issue of whether women who decide to have elective caesarean section should pay for it raises several important points. That women request elective caesarean section for maternal rather that obstetric reasons has a considerable cost implication: at Watford General Hospital it accounted for at least 38% of all elective deliveries by caesarean section over one year.¹ The reasons for such requests may in part be due to heightened public awareness and publications such as the General Medical Council’s Duties of a Doctor. Points pertinent to the management of obstetric patients are “Involve the patient in their management” and “Respect the patients’ wishes.”

This problem can be addressed in several ways. One is to decline requests, but this would run contrary to the recent recommendations of patient choice. Alternatively, women could be charged for the procedure,² but how much should be charged? A small amount is unlikely to dissuade patients and would not help health service funding. If patients were charged the full amount (and the actual cost of an elective caesarean section is disputed) this might reduce demand but would lead to ill feeling. Women might resent being treated in an NHS hospital by NHS staff but paying for their treatment, which is against NHS philosophy.

The third way to address the problem is through patient education—providing information on which patients can make informed choices. The commonest reason for patients to request an elective caesarean section is that they decline “trial of scar,” which accounts for over three fifths of requests.¹ Do they decline trial of scar because they fear that the chances of vaginal delivery are low or consider it to be dangerous to their baby or their own health? Much evidence suggests that a trial of scar after one previous caesarean section is safe to both the fetus and the mother, with a high chance of spontaneous vaginal delivery (85% in Learman et al’s study).³ The proportion of intrapartum deaths in 1994-5 that were due to rupture of a caesarean scar was 3.4%,⁴ and only one maternal death was due to rupture of a caesarean scar in 1994-6.⁵

With education and information the patient will still have a choice, but the number of women requesting elective caesarean section should fall. Surely this is a better way of reducing demand than by imposing financial pressure.