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Too posh to push? More C-sections on demand in UK

By Maria Cheng
AP Medical Writer / November 4, 2011

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LONDON—Pregnant women in Britain, where the government provides free health care, may soon be able to get a cesarean section on demand thanks to a rule change that critics describe as the health system caving into the "too posh to push" crowd.

Currently, British women who can't afford to pay private doctors for their baby's delivery have been allowed to have planned C-sections only if there are health concerns for mother or baby. Emergency C-sections are done when the situation demands it.

But new guidelines set to take effect later this month say pregnant women "with no identifiable reason" should be allowed a cesarean if they still want it following a discussion with mental health experts.

"It's about time women who have no desire to view labor as a rite of passage into motherhood be able to choose how they want to have their baby," said Pauline Hull, who has had two children by cesarean because of medical reasons. "The important thing to me was meeting my baby, not the experience of labor."

Hull runs the website, Elective Cesarean, from her home in Surrey, south of London. She said midwives tend to overexaggerate the risks of C-sections and underestimate those of vaginal births.

The new draft guidelines come from the National Institute for Health and Clinical Excellence, or NICE. The agency's guidelines are usually accepted by the government and determine what will be paid for by its health system.

"In general, a C-section is a safe operation, especially when performed as a planned procedure," the new guidance says.

The agency says it routinely updates guidance every few years and denies there was any pressure to change its more restrictive C-section advice. But in recent years, advocates and some doctors have slammed the U.K. health system for not giving women a greater say in childbirth.

The change comes at a price for Britain's cash-strapped health system. NICE estimates C-sections cost about 800 pounds ($1,280) more than a vaginal birth, although that doesn't include the price of treating possible long-term complications like urinary incontinence from vaginal births.

The report notes that for every percentage point the C-section rate falls, the health system could save 5.6 billion pounds ($8.9 billion).

In the U.K., about 25 percent of women have C-sections, versus about 30 percent in the U.S. In both countries, rates have doubled in recent years, though doctors say that's not just due to demand, but because pregnant women increasingly have other problems like obesity and diabetes.

About 10 percent of all U.K. births are planned C-sections while about 15 percent are emergency procedures, according to NHS figures.

The World Health Organization has previously said wealthy countries should aim for a C-section rate of about 15 percent, though it also says there isn't enough evidence to know what the ideal rate is.

The National Health Service estimates that about 15 percent of British births take place in private hospitals, which tend to have higher cesarean rates. At Portland Hospital in London, where many celebrities check in, the C-section rate ranges from 35 to 40 percent.

The issue of women having C-sections on demand has long been a hot button issue in the U.K., with celebrities like Madonna and former Spice Girl Victoria Beckham having scheduled procedures at upscale hospitals. Criticism for the wealthy getting these elective surgeries led to the phrase "too posh to push."

But some experts say the new British guidance won't dramatically change how pregnant women are treated.

"It's only a small percentage of women who ask for a C-section," said Cathy Warwick, chief executive of the Royal College of Midwives.

Warwick said doctors and midwives regularly talk to women who have concerns about childbirth and after addressing their fears, most women agree to skip a planned C-section.

"As long as it's safe for both mother and baby, a vaginal birth is absolutely the best way for anyone to deliver," said Dr. Daghni Rajasingham, an obstetrician and spokeswoman for the Royal College of Obstetricians and Gynaecologists. She said the physical stress put on a baby's lungs during labor helps them adapt to breathing after being born.

Rajasingham also said while C-sections are safe, the operation comes with risks including infections, bleeding, and the potential for problems with future pregnancies.

"As an obstetrician working with limited resources, I want to make sure we have safe and high-quality health care for all women and not be skewed by a few women who want something specifically," Rajasingham said.

For women like Hull, however, the policy shift is long overdue.

"Women shouldn't think a C-section is going to be a walk in the park, but they should have all the information they need to help them make an informed choice," she said.

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