Last October the American College of Obstetricians and Gynecologists (ACOG) Ethics Committe published Surgery and Patient Choice: The Ethics of Decision Making, to address the controversy of non-medically indicated cesarean delivery, or patient-choice cesareans. "While the right of patients to refuse unwanted surgery is well known," states the committee opinion, "less clear is the right of patients to have a surgical procedure when the scientific evidence supporting it is incomplete, of poor quality, or totally lacking -- a frequent scenario in medicine."

ACOG's publication has generated a strong response from several women's health organization and consumer groups. You can read ACOG's press release here as well as the response it generated.

The American College of Obstetricians and Gynecologists sent out this statement on October 31, 2003

New ACOG Opinion Addresses Elective Cesarean Controversy

FOR IMMEDIATE RELEASE
ACOG Office of Communications
communications@acog.org

Washington, DC -- A new committee opinion from The American College of Obstetricians and Gynecologists (ACOG) addresses the controversy of elective cesarean delivery, using it as an example of how doctors can ethically help patients make decisions about surgical treatment when there is a lack of firm evidence for or against such surgery.

In "Surgery and Patient Choice: The Ethics of Decision Making," ACOG notes that while the right of patients to refuse unwanted surgery is well known, less clear is the right of patients to have a surgical procedure when the scientific evidence supporting it is incomplete, of poor quality, or totally lacking -- a frequent scenario in medicine.

Examples might include a 30-year-old healthy woman without a family history of ovarian cancer wanting to have her ovaries removed to prevent such a cancer; a woman with fibroids wanting an experimental surgical treatment whose long-term effects are still unknown; or an 18-year-old woman without children wanting a sterilization procedure.

Where medical evidence is still limited, ACOG says there is no one answer on the right ethical response by a physician considering a patient request for surgery. Thus the decision on whether to perform an elective cesarean delivery (also known as "patient choice cesarean" or "cesarean on demand") will come down to a number of ethical factors including the patient's concerns and the physician's understanding of the procedure's risks and benefits.

In the case of an elective cesarean delivery, if the physician believes that cesarean delivery promotes the overall health and welfare of the woman and her fetus more than does vaginal birth, then he or she is ethically justified in performing a cesarean delivery. Similarly, if the physician believes that performing a cesarean 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. In this case, a referral to another health care provider would be appropriate if physician and patient cannot agree on a method of delivery.

ACOG's Ethics Committee, which produced the opinion, says that the burden of proof should fall on those who advocate for a change in policy in support of elective cesarean delivery (which replaces a natural process -- vaginal delivery -- with a major surgical procedure). Therefore, physicians are under no obligation to initiate discussions about a procedure such as elective cesarean that is unproven scientifically or that the individual physician may not consider medically acceptable.

An increasing number of women are requesting elective cesarean instead of vaginal delivery in the belief that the surgery will prevent future pelvic support or sexual dysfunction problems, or for other reasons. A number of physicians believe that such surgery should not be selected over a natural process without immediate and compelling medical need.

ACOG cautions that "both sides to this debate" must recognize that evidence to support the benefit of elective cesarean is still incomplete and that there are not yet extensive morbidity and mortality data to compare elective cesarean delivery with vaginal birth in healthy women. With better data, there may be a shift in clinical practice.

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The American College of Obstetricians and Gynecologists is the national medical organization representing over 45,000 members who provide health care for women.

Responses

In contrast, the Society of Obstetricians and Gynaecologists of Canada  SOGC) does not support cesareans on demand. The SOGC promotes natural childbirth and states that there is no indication that cesareans are less riskier than vaginal births and should only be performed based on medical indications.
Read the SOGC March 10, 2004 press release.

From the American College of Nurse Midwives (ACNM)
Women Urged to Proceed with Caution in Age of “Designer Deliveries"

Joint press release from Lamaze International, Doulas of North America (DONA), Coaltion for Improving Maternity Services (CIMS), and the Association of Nurse Advocates for Childbirth Solutions (ANACS)
Women's Healthcare Professionals Issue Warning About Cesarean Section on Demand

From Childbirth and Postpartum Professional Association (CAPPA)
One Voice Demonstration Project

From International Cesarean Awareness Network (ICAN)
ICAN Criticizes ACOG's Statement on Ethical Cesareans

"The Canadian Association of Midwives (CAM) allies with the Society of  Obstetricians and Gynecologists of Canada (SOGC) by stating that vaginal birth is clearly the safest birth for most women and babies, and that caesarean surgery on djemand will have disastrous social and financial consequences for heath internationally." Download the CAM Position Statement from
members.rogers.com/canadianmidwives/home.html