A fact often cited in a discussion of modern childbirth is the increasing rate of Caesarean sections, particularly as performed on women who do not need them.

One side of this is that doctors intervene unnecessarily. However, another side is that in a time of improving maternal choice, it has become increasingly common for a woman to seek a Caesarean section even when this is not (or not absolutely) medically indicated.

This comes from CSections.org, a website aimed at providing women with information and balanced discussion about Caesareans. It is from a section entitled “your rights”:

Electing for a caesarean

You may request a caesarean on the basis of medical information provided by your heath professionals where the indications are borderline. For example, a breech delivery in a pregnancy that is otherwise progressing normally. Here you might choose either a vaginal or a caesarean delivery.

It is also possible to request a caesarean for non-medical reasons. Typical reasons might be: Fear of labour or pain, Fear of pelvic floor damage, Previous bad experience of vaginal delivery, A rational assessment of the benefits and risks of a vaginal delivery versus an emergency caesarean, Concern about the impact of vaginal delivery on sex life, Viewing a caesarean as more modern, Needing to co-ordinate the birth with a busy or difficult lifestyle.

If you fall into one of these categories a caesarean is unlikely to be offered to you automatically. It will be up to you to request it.

However you may find that some health professionals find your choice strange and may try to dissuade you. It is important to note that while any of these reasons may appear totally valid in your eyes, UK hospitals are not obliged to conduct caesareans purely at a mother’s request. The subject of fear of childbirth is now being studied, but is not yet recognised as a medical indication in its own right. It is still, however, your right to request a caesarean.

Is it right that Caesareans should be performed freely for any woman who requests one? I think that to answer this question we need to think about why women are making such requests, and what the consequences are if Caesareans are given on demand.

Fear / misconceptions

The website noted above refers to fear: fear of labour, fear of pain, fear of pelvic floor damage, fear of a negative effect on the mother’s sex life. These are also reasons cited by contributors to this discussion on ARM, who refer to the misconceptions behind these fears about, for example, the safety of vaginal compared with surgical birth. But is surgery really an appropriate response to fear?

Fear and misconceptions can often be dispelled by the provision of good information, or by counselling. A woman worried about, say, her pelvic floor or her sex life could talk to mothers about how vaginal birth affected their bodies. Where the issues are more complex, counselling would seem to be called for. In her 2000 article, Caesarean Section for Maternal Choice? (ARM again), Sara McAleese reports that when counselling was given to women requesting Caesarean “on psychosocial grounds”, around half changed their minds and opted for a vaginal birth instead. Other studies have shown that “labour debriefing” can be helpful for women who have had previous bad experiences of vaginal delivery.

So, where fear or some similar psychological issue is the driving factor, it would seem more appropriate to respond with information and counselling than with surgery. Indeed, the psychological issues could perhaps be avoided in the first place, if appropriate post-natal counselling was given to those mothers who had a difficult experience first time around.

Social pressures / Perceptions of “modernity”

Although the ARM discussions commented that social issues (“too posh to push”) were only rarely the reason for Caesarean requests, such requests are made. CSection.org suggests that “viewing a caesarean as more modern” or “needing to co-ordinate the birth with a busy or difficult lifestyle” are valid and real reasons given by women for requesting this surgery.

Without wishing to denigrate the probably complex circumstances in which women wish to choose a Caesarian for these “social” reasons, I have to say that I find the whole idea pretty astonishing. Viewing Caesarean as more modern? Needing to co-ordinate the birth with a busy or difficult lifestyle?

From what planet do such “reasons” come?

How could women be so seduced by what is “modern” that they ignore the seriously increased risks to both themselves and their babies? How could they have come to a mindset in which modern=better, with no serious attempt to understand life as more complicated than that? How could anyone see surgery as a valid diary tool? Since when did women come to distrust and despise their bodies so much that they feel the need to modernise and organise them?

And since when was childbirth so trivial? These women are not choosing a kitchen, or arranging a haircut. They are having babies. They are doing something which will profoundly change their lives forever.

That a world in which these “reasons” can be conceived as valid is allowed to exist strikes me as absurd and scandalous, even (dare I use this word?) disgusting.

I am at a loss to say more than this, except one thing: where devaluing and trivialising childbirth and motherhood are concerned, where distrusting and despising the natural processes of the female body are found, it is the patriarchy that is behind it.

Informed choice

To my mind, a “rational assessment of the benefits and risks of a vaginal delivery versus an emergency caesarean” is the only good reason I have come across for an elective Caesarean.

This means, however, that the woman must be truly informed about the risks she faces if she elects for a vaginal delivery and the risks she faces if she opts for a Caesarean, and that she should receive, if she needs it, expert counselling to enable and empower her to make a truly free choice.

Given such information and empowerment, I would imagine that few women would freely opt for unnecessary surgery because to do so seems so clearly to be against her own and her baby’s interests. The risk of death is higher for both mother and child, the risk of complications is also much higher and – let’s not forget this – a Caesarean is seriously invasive abdominal surgery. It is not a thing to be undertaken lightly.

(I may be wrong about “what informed women would choose”, as this report suggests – you wouldn’t have thought that you could get much more informed than an obstetrician, yet a significant proportion of obstetricians say they would choose elective Caesarean for themselves or their partners. Of course, obstetricians are not necessarily well-informed about normal birth, because they may not see if very often. So perhaps they are not the best people to ask. What about midwives? They are involved in the full range of births and, according to this report, 96% of surveyed midwives would choose a vaginal birth.)

And I would emphase one key point: the information given must be clear, balanced and fair and must be given in such a way that it is readily understood and capable of being rationally assessed. Is such information given to all women making decisions about a Caesarean?

No, it isn’t.

Those thinking of choosing a planned C-Section, of course, can find out anything they want to by carrying out their own research. The website mentioned previously in this post looks like a good place to start. But not everyone has skills or the will to carry out their own research.

Most people (and I put myself in this category, although less firmly now than in the past) are happy simply to trust their doctors and midwives, not many of whom will have had decent training in the presentation of information in an open non-judgemental, empowering way. If my own experiences of doctors and other health professionals is anything to go by, they are wholly unempowering. Many women given information by health professionals are, I strongly suspect, very likely to simply accept the information uncritically and follow the advice they are given. On this point, a previous post of mine might be worth reading.

And not everyone’s Caesarean is planned. What if things had gone wrong for me in labour and a Caesarean had been proposed? Would I have felt able to make an informed choice? No. I had not been given any real preparation for such a decision and had not made the effort to prepare myself. In the middle of labour is no place to start a “rational assessment” of the relative risks. I would have done what I was told.

So, is it right that Caesareans should be performed freely for any woman who requests one?

Yes, and No. For different reasons.

I believe that a woman requesting a Caesarean, whether for medical or non-medical reasons, should have the opportunity to discuss this with her care providers, including trained counsellors where appropriate. They should give her all the tools she needs to assess the risks and make a decision for herself. If she takes the view that a Caesarean is the lower risk option in her particular circumstances, I see no reason to go against her wishes.

(Similarly, if she rejects a Caesarean after being given full and clear information about the risks, her decision should be respected.)

However, I also believe that Caesareans should be discouraged, because I believe that they are performed too often and that too often the reasons are bad. I think that making the operation too freely available, making it too normal, will undermine normal childbirth even further and so it is something that we should guard against.

To expand only a little: I think that the fears referred to above as reasons for choosing Caesarean are likely to be caused by a lack of familiarity with normal birth, by a lack of faith in doing what nature intended – in short, by the normalisation of “modern” alternatives. The more that these alternatives are chosen the more they will be seen as normal, and more that they are seen as normal the more they will be chosen.

I think I have run out of steam now, so here are my conclusions:

YES women should have access to Caesareans where they need them and YES they should be able to have elective Caesareans if, aware of all the ramifications, they have made an informed choice. But NO doctors and others should not promote Caesareans as normal by presenting them as just one more valid choice for childbirth, no better or worse than any other.

PS I think there is a useful parallel here with formula feeding. Perhaps I will blog about that another day, but it seems to me that nearly everything I have said about choosing Caesareans over normal birth could be said about choosing formula over normal milk.

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