Caesarean section: ethics, research, ICM position statement: rising worldwide rates of delivery by Caesarean section cause concern to midwives, whose role includes provision of information, advice and support to women.

• Tenlastelegging: Institute for Complementary Medicine

Ethics of Caesarean section in the USA

The number of surgical deliveries in the USA has reached an all time high with more than one-quarter of all babies delivered in this way. In October 2003, the American College of Obstetricians and Gynecologists' (ACOG) ethics committee issued a statement that addressed the issue of elective Caesarean sections performed when there is no medical necessity.

Where medical evidence is limited, ACOG says there is no one right ethical response by a physician considering a patient request for surgery. In the case of an elective Caesarean delivery, if the physician believes that it will promote the overall health and welfare of the woman and her fetus more than will vaginal birth, then he or she is ethically justified in performing a Caesarean section. Similarly, if the physician believes that performing a Caesarean would be detrimental to the overall health and welfare of the woman and her fetus, he or she is ethically obliged to refrain from performing the surgery.

The ACOG cautions that evidence is still incomplete and that there are not yet sufficient morbidity/mortality data to compare elective Caesarean delivery with vaginal birth in healthy women. Women's health care organisations, including the American College of Nurse-Midwives (ACNM), the Association of Nurse Advocates for Childbirth Solutions, Lamaze International, Doulas of North America and the Coalition for Improving Maternity Services, believe this opinion downplays the risks to mother and baby when unnecessary Caesareans are performed and may be used to deny women informed consent regarding such procedures. With no definitive study on the benefits of Caesarean delivery, it is 'startling', they said, to give physicians the go-ahead to perform non medically justified surgery on women with normal pregnancies.

Research shows that the risk of maternal death following Caesarean section is five to seven times higher than vaginal birth. Complications during and after the surgery may include injury to the bladder, uterus and blood vessels, haemorrhage, anaesthesia accidents, blood clots in the legs, pulmonary embolism, paralysed bowel and infection.

The ACNM also said, 'Regrettably, the opinion issued by the ACOG Committee on Ethics may lead to an increasing level of distrust between health care professionals and the women who seek our services. The purported benefits of Caesarean section on demand are unproven and the known risks place the woman's life...