Realities of MRCS

Eide and Bærøe’s conception of the MRCS as a possible site of conflict between the autonomous claims of health professionals (related to integrity) and birthing people’s preferences begins with the discussion of the dangers of caesarean for birthing people. The authors acknowledge that ‘There are no available evidence from randomised control trials comparing outcomes of vaginal versus caesarean delivery for low-risk women lacking obstetric indication.’1 However, they continue, ‘Still, CS is in general associated with increased risk for short-term and long-term health complications for both mother and child’.1 Even if we do not take these assumptions to be central to the arguments the authors make about power imbalances in the relationship between professionals and birthing people (though one assumes that this must play a key role since doctors as professionals are able to gate-keep what treatment is recognised as clinically appropriate in a given context), my response is still significant in pointing out the error in these assumptions about the claimed ‘increased risk’ of MRCS. The pervasive mischaracterisation of MRCS in debate about how requests are managed is a problem in itself that it is important to correct.

While the authors have acknowledged it, they commit a non sequitur in concluding that because caesareans (note they neglect to say—emergency caesareans) are associated with increased risks, MRCS must carry increased risks—without explanation.ii As many have pointed out, however, that ignores the realities of the confounding variables in the data—in particular the emergency circumstances that likely indicated the caesarean.2–6 MRCS likely has much better outcomes than unplanned caesareans,2 4 because it is performed in non-emergencies,5 meaning that the birthing person and newborn are not already in distress, surgeons are less stressed2 and safety protocol is better adhered to.4 7 Further, in stating that the risks of complications are higher following caesarean, the authors fail to consider risks in the proper context2–4; that is, they fail to acknowledge that the risks associated with vaginal delivery are also relevant—especially since many people who seek to opt for MRCS do so to avoid specific risks associated with vaginal delivery.2 3 8

This brings us to the framing of MRCS as ‘clinically unnecessary’,1 which has been increasingly disputed in ethical2–4 9 and clinical literature,10 11 and by organisations supporting birthing people’s rights in birth.8 The vast majority of requests are made by people with underlying health conditions they fear may be exacerbated by vaginal delivery or later emergency caesarean, and by individuals with experience of previous traumatic birth or other traumatic experience (eg, sexual assault).8 The threshold for what ‘counts’ as ‘clinical need’, in the hands of individual obstetricians, can often disregard the subjective experiences of individuals seeking access to MRCS. As I have argued with Nelson elsewhere, ‘health indications for caesarean can be much broader than an immediate physical health need, and in considering clinical indications in childbirth health should be considered holistically’.4 This means paying due attention to individual circumstances, rather than only looking at removed (and often flawed) data sets about physical health, and considering the ‘request’ element of MRCS when analysing harm. Significant harm is caused to individuals when doctors ignore their requests in place of clinical judgement.2

When we consider the realities of MRCS, namely that it is less risky than it is often portrayed to be and that clinical need motivates most requests, the portrayal of MRCS counselling as a site of conflict highlights a real problem. Most MRCS will have an anticipated clinical benefit for the individual. Healthcare professionals have considerable ‘discretionary power’ over people’s health because of the position they occupy in the professional–patient relationship on the basis of their ‘special knowledge, judgement and discretionary space to provide care’.1 Where doctors are recommending against MRCS, there needs to be an open and frank willingness to acknowledge the values that underlie that decision-making; and specifically where and why the benefits recognised by individual birthing people are not recognised by obstetricians. In particular, there needs to be investigation as to why birthing people’s mental health perhaps is not respected as it ought to be. Moreover, the pervasive framing of MRCS as a site of conflict between professional integrity (because it is a ‘risky’ practice) and personal autonomy actively perpetuates harm in making the decision harder for people to access and reinforces the notion of a doctor as a gate-keeper,2 3 rather than sharing in decision-making. Given the evidence demonstrating that MRCS is not significantly riskier than other birth choices when considered in context, a caesarean request should not be considered as a decision in which the professional considers their integrity threatened in considering/performing the procedure.

Framing the request

As Eide and Bærøe highlight, it is generally presumed that while patients have a right to refuse treatment, they do not have the right to demand treatment that is not clinically indicated.1 12 This is also the legal position in England and Wales.13 Challenging the perception of MRCS as clinically unnecessary is consequently important, and it is critical that in addressing MRCS it is not dismissed as a request made in the absence of a clinical reason without question. This will matter materially not only in terms of access (and rights to access) but also in terms of how counselling about mode of birth is approached by healthcare professionals who, as noted, have considerable power in how these discussions are framed. This is not an argument that obstetricians should perform every caesarean requested, but that the request needs to be taken seriously and the reasons for the request be appropriately considered. In particular, attention must be paid to the likely reality that many requests are based on clinical need when thinking is appropriately holistic.3 4 This again is why it is crucial that we do not continue to use the characterisation of conflict between patient and professional as the quintessential example of caesarean requests.

In their discussion of important commitments in an ethical MRCS decision-making framework, many of the criteria that Eide and Bærøe identify can only be (or are better) realised if MRCS is not inappropriately framed as clinically unnecessary. Eide and Bærøe’s objective is to consider how the power imbalance between professional and patient can be best equalised; but doing so is difficult without better appreciation for the nuance in MRCS decisions from the perspective of patients, and challenging the traditional professional-perpetuated frame. For instance, take the first criterion the authors mention that describes the importance of knowledge exchange and reciprocity in counselling.1 This is a crucial aspect of ensuring epistemic (testimonial) justice14 whereby birthing people are also afforded the respect of being ‘knowers’ in the context of birthing decisions. The pregnant person brings a considerable amount of knowledge to their decision about MRCS, much of which relates to its clinical necessity (such as past traumatic experiences). However, if MRCS continues to be framed as primarily clinically unnecessary based on closed and gate-kept readings of medical necessity, and the conflict narrative unchallenged in both academic work and clinical circles, there may not be adequate space made for the kinds of knowledge that patients bring to the discussion because it necessarily remains more focused on traditional clinical justifications. As the authors note, in consultations, professionals have considerable power to determine the frame within which conversations take place. Trust in healthcare providers is considerably undermined, where people feel that they are not listened to, and that the clinical judgement of the healthcare professional is completely divorced from their lived experiences or does not recognise aspects of their subjective experience that are principal.

Relatedly, the second criterion proposed explains that dialogue ‘must be carried out without any agenda of pressuring the woman to opt for vaginal delivery’,1 but where MRCS is routinely characterised as clinically unnecessary, it is difficult for professionals to avoid importing implicit biases about what constitutes clinical need into the counselling they provide. As one final example, the fourth criterion the authors suggest considers the importance of counselling being attentive to individual needs (by avoiding authoritative and inaccessible jargon), considering the individual, and ensuring that the probability of complications is communicated with the certainty of evidence. Unless the misconceptions about the evidence surrounding MRCS and the values brought to decision-making in obstetrics about what constitutes clinical need are openly challenged and scrutinised (and individual practitioners are encouraged to be transparent), it is difficult to see how such reform can be brought into practice. All of the suggestions made by Eide and Bærøe are indeed crucial in ensuring more patient-centred care, but to accomplish this, we need to begin by dismantling ideas about what constitutes clinical need in birth choices and of conflict between professional integrity and birthing people’s preferences in MRCS.