Making sense of rising caesarean section rates

Editor—In his editorial on making sense of rising caesarean section rates, Anderson does not mention why or whether rising rates are bad for women, or even disadvantageous if seen in a public health context.¹ One way to do this might be to compare perinatal and maternal outcomes or even a cost benefit analysis in women at term intending to try for a normal delivery versus those intending to have an elective caesarean section, matched principally for age and parity. A sizeable proportion of those trying for a normal delivery, and a smaller proportion of those having an elective section, would end up having an emergency caesarean section, where the risks of the operation to mother and baby particularly lie.

But to argue, as Anderson does, for large, well designed randomised trials for specific indications—for example, in relation to fetal distress or dystocia—is a bizarre non-starter. How could a woman in labour with fetal distress as evidenced by a profound bradycardia on cardiotocograph and acidotic results from fetal blood sampling be randomised ethically to a “non-delivery” arm? Similarly, could withholding a caesarean section from a woman with a transverse arrest in a prolonged dystocic labour be justified ethically?

Some procedures in current practice cannot practically and should not ethically be answered by randomised controlled trials. Before making a case against a woman's right to choose her preferred mode of delivery, some hard facts about the risks of elective caesarean section compared with those of an intended vaginal delivery would be welcome.