NHS Puts Limits on Cesarean Sections

From The Sunday Times on February 15, 2009:

Hospitals curb caesarean births

Sarah-Kate Templeton, Health Editor


NHS trusts have for the first time barred women from routinely having elective caesareans because they cost too much.

The procedure, which costs twice as much as a natural birth, will be rationed in Greater Manchester so that it is only available to women with specific medical conditions.

Some top obstetricians condemn the decision, arguing that, while it will curb the fashion for choosing caesareans to reduce the pain of childbirth, it will also penalise those who opt for them on the grounds that they are safer for the mother.

Caesareans have been placed on the same lists for rationing by the NHS trusts in Greater Manchester as infertility treatment, cosmetic surgery and acupuncture.

The lists, called Effective Use of Resources Policies, state that planned caesarean sections should only routinely be offered to women in particular categories. They include women who have previously already had at least two caesareans.

Dr Christoph Lees, an obstetrician and gynaecologist at Addenbrooke’s hospital in Cambridge, said: “I strongly disagree with this prescriptive condition setting. Sometimes well-informed women, often older and very unlikely to have further children, do request caesarean sections and it is unreasonable to refuse if they are fully informed.

About 23% of deliveries in Britain are by caesarean section, and, of these, more than half are emergency operations.

A spokesman for NHS Manchester said: “Where caesarean section is likely to be the safer option for the mother or baby, it will be the mother’s choice how the baby is delivered.”


The doctors interviewed in this article invoke the popular "choice" imagery. It doesn't appear from this coverage that anyone's choices are being limited, but women's choice for costly unnecessary surgery will no longer be paid for by the NHS in Greater Manchester. Presumably, a c-section for which there is no medical need can be bought. 

Efforts to limit the number of Cesarean sections performed are historically followed by a medical backlash to warn against lowering the rate, which relies heavily on the vaginal-birth-as-dangerous rhetoric. In 1999, four U.S. obstetricians recommended a moratorium on reducing the national c-section rate as a response to the "Healthy People 2000 Project" of the Department of Health and Human Services that sought to lower the then rate of 22 percent down to 15 percent.

Dr. Benjamin Sachs, the chief of obstetrics and gynecology at Beth Israel Deaconess Medical Center. called the setting of such a goal "a paternalistic approach to health care delivery" and stated that "[r]esearch into maternal and infant safety issues and a true cost-benefits analysis are needed to define the optimal cesarean delivery rate."

Sachs described the United States' childbirth record as one of the best in the world. "We should take pride in the incredible childbirth safety record that we have in this country,"said Sachs in 1999.

The U.S. currently ranks 41st among industrialized nations in maternal mortality.  The Cesarean rate has risen from 22 percent to 31.1 percent since Sachs and colleagues called for the moratorium.

In December, Dr. Marsden Wagner, former Director of Women’s and Children’s Health for the World Health Organization stated, “In the past twenty years in the U.S., the maternal mortality rate keeps rising and rising while the rate of c-section continues to rise. It can now be reliably calculated that [the] c-section is the number one cause of maternal mortality in the U.S.--at least 45% of all maternal death is associated with a c-section.”

Campaigns led by doctors against attempting to lower the c-section rate have historically claimed that saving money is at the heart of the issue rather than the well-being of women.

In the early 1990's in Los Angeles County, poor women delivering in overcrowded county hospitals and those on Medi-cal were the first targeted in attempts to lower the Cesarean rate, while women with private insurance remained twice as likely to have the surgery than their uninsured counterparts.  In essence, doctors themselves indicated that monetary compensation is a primary variable in deciding whether or not to section a woman.


Watch for additional coverage of the story about the NHS limits on c-sections to include a backlash loaded with terms like "danger" and "poor outcomes" and "injury."  Promoting a fear of childbirth fuels the childbirth industry.


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