Whose C-section is it anyway?

The UK government advisory body the National Institute for Clinical Excellence (NICE), in conjunction with the National Collaborating Centre for Women’s and Children’s Health, has instructed NHS doctors to cut down on the number of, as the newspapers describe them, ‘posh’ Caesarean sections (1).

Apparently, following the wave of ‘too posh to push’ celebrity moms who choose to go under the knife to protect their work commitments/sex lives/continence, British women are clamouring to have elective Caesareans performed on the NHS. This is both a costly enterprise, and, more to the point, a selfish, unnatural, dangerous activity undertaken by women who are so reluctant to put their baby’s health and wellbeing before other aspects of their lives that they should probably not be permitted to become mothers at all. Or so the shrill anti-C-section campaign would have us believe.

It is strange that a routine, straightforward operation, which takes place as part of the everyday process of childbirth, should have become so controversial. What is it to NICE – let alone the various natural childbirth campaigns and po-faced commentators who glory in condemnation of the C-section – if increasing proportions of women choose to have their baby under local anaesthetic on the operating table rather than hooked up to drips and monitors in the labour ward? Whatever your personal preferences, it is fair to say that neither method is easy, painless or complication free.

But in childbirth, like so many other areas of life, the personal has been politicised, and practical questions have been turned into principles. Of all the areas of a woman’s medical life, childbirth is the one over which she has the least control – the baby has to come out, somehow, about nine months after it was conceived. Yet the limited range of choices that a woman does have about the precise method of the birth have become a battleground, upon which a range of political and moral disputes are fought.

The C-section question is where the battles rage most fiercely. It mixes together a number of issues, of women’s autonomy verses professional judgement, of the apparent interests of the expectant mother versus those of her child, of ‘natural’ versus medicalised childbirth. In all of this, what tends to get lost is the issue of what is best for a woman or her child.

About one in five births currently conducted in the UK involve Caesarean section (2); and much is made out of the fact that this is higher than the maximum limit recommended by the World Health Organisation (WHO), of 15 percent. But why is it high? As the NICE guidance illustrates, 93 per cent of Caesarean sections in England and Wales are carried out ‘as a result of a pre-existing medical condition or concerns about the health of women or babies’ (3). The five most common reasons given for women having a Caesarean section were presumed fetal compromise (the fear that a vaginal birth will put the baby in trouble) (22 per cent), failure to progress in labour (20 per cent ), previous Caesarean section (14 per cent), breech presentation (14 per cent) and maternal request (seven per cent) (4).

In other words – the vast majority of all Caesareans were done because of advice from health professionals; and presumably because this was considered to be the best clinical option for the expectant mother and her child. And there seems no evidence that Caesareans damage babies – while they are surely a good alternative to a vaginal birth with complications. As the NICE guidance puts it, following a Caesarean women are more likely to have a blood clot, bladder injury, or need further surgery, but they are less likely to have bladder incontinence or prolapse of the womb. Caesarean babies are more likely to have breathing problems at birth (which is presumably because they come out earlier, or as a result of complications with the pregnancy or birth). And ‘having a Caesarean section has not been shown to impact on the likelihood of breastfeeding, postnatal depression or sexual problems’.

But you wouldn’t guess any of this from the news reports – and you are hard pressed to believe it when reading the NICE guidance itself. Every story about the UK’s Caesarean rate focuses, with barely disguised contempt, on the woman who considers herself ‘too posh to push’. ‘The government’s clinical advisers are alarmed by the number of women who are asking NHS doctors to give them Caesareans merely because they are convenient’, said the Sunday Times, reporting in advance on the new NICE guidance (5). ‘[MPs] suggested that the first step should be to stop women from choosing to have a Caesarean for lifestyle reasons’, stated the BBC in June 2003, reporting on a call by the Commons health committee for a ‘crackdown’ on the number of C-sections (6).

The NICE guidance suggests a number of ways in which the medical profession can deal with those misguided women who choose to have a Caesarean. One option is to Just Say No: ‘If a woman asks to have a Caesarean section, the doctor will not automatically agree to arrange one if he or she does not think it will benefit the health of the woman or baby’, and ‘the doctor has the right to decline a request for a Caesarean section’ as long as he offers referral to another doctor. If the woman persists in her request, citing fear of vaginal birth, ‘she should be offered the chance to discuss her fears with a counsellor’ – so she can be talked out of it (7). The Sunday Times put the guidance more bluntly: women who want Caesareans for the hell of it should be told to sod off to the private sector, and pay £10,000 for the privilege.

It might just be possible to read these recommendations, from the professional-sounding National Institute for Clinical Excellence, as being somehow grounded in clinical judgement – until you find this recommendation: ‘Women should be informed that continuous support from another woman, with or without prior training, during labour reduces the likelihood of Caesarean section.’ (8) This is because, as the BBC explains: ‘Men can become distressed at seeing their partner in pain, or try to take control of the situation.’ (9) And you would hope so too. The idea that a woman in labour is best helped, not by her partner who loves her and wants to reduce her pain, but by a midwife or relative who will talk her out of the easy option, is highly dubious from any ‘woman-centred’ or medical point of view.

The ‘other woman’ recommendation flags up two of the most disturbing aspects of this official anti-C-section advice. The first is that women must be dissuaded from a Caesarean, whatever the cost to their pain or peace of mind – as though the woman’s wellbeing during childbirth is of less importance than the precise method of her labour. The second is that there is a conflict of interest between the wishes of the father-to-be and the wellbeing of the expectant mother and the baby-to-be, and that fathers should simply leave it all to professionals who know best. It’s a bit harsh for men, who for the past 20 years have been chivvied into the labour room and preached to about the importance of involvement and bonding, now to be presented as a malevolent presence in the whole business.

More disturbing still is the implication, running throughout the NICE guidance and the coverage of it, that there is a conflict of interest between the wishes of the expectant mother and the wellbeing of her child. The focus on reducing the proportion of elective Caesareans emphasises the problem of women making choices for their own apparent benefit, rather than for the obvious benefit of the baby. But it is not possible to separate the interests of a pregnant woman from the child she is carrying – and attempts to do so are very dangerous.

In Salt Lake City, USA, a woman is in jail after one of her twin babies died in childbirth. The prosecution alleges that she ignored medical advice to have a Caesarean – she denies the charge. The state of Utah has a new law that states that a woman can be prosecuted if she kills or harms her fetus through her lifestyle, drinking or drugs (although doing so through abortion is thankfully exempt). Last week in the UK, an inquest was held into the death of a twin baby girl during a home birth, whose parents allegedly refused medical intervention by midwives. Tensions do arise between professional judgements and pregnant women’s choices – and on the rare occasions when a pregnant woman insists on making the wrong choice, the consequences can be tragic.

But women are not incubators. They are living, autonomous people with choices and responsibilities about themselves and their child, and without the ability to make such choices – even if they are the wrong ones – they are incapable of carrying the responsibility for caring for their child. What benefit would it do anybody, least of all the newborn baby, to hand over such decisions to judges, doctors and midwives?

It is worth noting that the professionals are not always right, either. If the UK’s Caesarean rate is indeed higher than strictly necessary, this is not because of the seven percent of women who choose the operation, but the doctors who recommend it. Some have pointed out that doctors may be C-section happy for the wrong reasons – excessive risk aversion, failure of litigation, mere impatience – and that may be the case.

There is an interesting discussion to be had about this. However successful the outcome, Caesareans are not outpatient appointments – they are major operations that cause a significant amount of pain for the pregnant woman, which is a good reason why doctors should avoid recommending them unnecessarily. But this is a different question to the overblown panics about the possible consequences for the fetus, and the miserly moans about the extra few hundred quid a Caesarean costs the NHS. Certainly we don’t want the alternative – for doctors to try to save money and strife by avoiding C-sections when they think they are needed.

Expectant mothers want the best for their babies. They also understand, far better than doctors or midwives, that what is best for their babies is intimately linked to what is best for them. If a woman feels that she will have a better birth experience with a C-section than a vaginal delivery, with an epidural than with gas and air, at home in her own bed rather than stuck in hospital, then her ability to make that choice is crucial to her ability to embrace motherhood as something she is capable of and responsible for, rather than as something that is alien to her wishes and experience. It’s the woman who has to raise this baby – at least credit her with the ability to decide how to give birth to it.

(1) Caesarean section, Clinical guideline 13, April 2004

(2) ‘New Guidelines will standardise care for women undergoing Caesarean sections’, National Collaborating Centre for Women’s and Children’s Health, 28 April 2004

(3) ‘New NHS guidelines on Caesarean sections set out best care for women and babies’, National Institute for Clinical Excellence, 28 April 2004

(4) ‘New Guidelines will standardise care for women undergoing Caesarean sections’, National Collaborating Centre for Women’s and Children’s Health, 28 April 2004

(5) ‘Doctors told to curb “posh” Caesareans’, Sunday Times, 25 April 2004

(6) Caesarean crackdown urged, BBC News, 18 June 2003

(7) ‘New NHS guidelines on Caesarean sections set out best care for women and babies’, National Institute for Clinical Excellence, 28 April 2004

(8) ‘New NHS guidelines on Caesarean sections set out best care for women and babies’, National Institute for Clinical Excellence, 28 April 2004

(9) Caesareans ‘must be discouraged’, BBC News, 28 April 2004