From MIDWIFERY MATTERS, Issue No. 101, Summer 2004
The Caesarean Section Debate
Reclaiming childbirth - Some thoughts from a midwife
Helen Shallow
I HAVE RECENTLY READ three local newspaper articles about the safety or otherwise
of caesarean section. This poses a dilemma for those women who request a caesarean
section when there is no clinical reason for doing so. For those readers who
did not read the articles let me summarise.
Suzannah Olivier in her article entitled A Caesar Drawback describes research
which has demonstrated a strong link between increased infant food allergies
and women who have had a caesarean section. Olivier describes how there may
be a disturbance to the baby's natural protective gut flora. During the surgical
procedure there is potential exposure to hospital bacteria; in addition all
women receive routine antibiotics during the operative procedure, either of
which, in some way may disturb the new baby's delicately balanced immune system
that ultimately protects baby from infection and subsequent food allergies.
Olivier points out that not enough is known about the effects of emergency caesarean
or caesarean performed for medical reasons (which may in themselves affect the
baby's immunity) and caesarean for maternal choice alone..
The second article, Caesarean births can lead to complications by Maureen Simpson,
discusses the complications that are linked to surgical delivery of the baby
and warns women that this is not a decision that should be taken lightly or
as a matter of convenience as it may have repercussions both for herself and
her baby. Simpson notes that last year there was an enormous rise in elective
caesarean sections and around 55,000 women in England and Wales chose to have
their babies in this way. Inevitably, this increased demand puts a great strain
on limited resources and already the discussion has started as to whether women
should be charged for this service.
The third and most concerning factor relating to caesarean and subsequent pregnancy
is the links that have been made to an increase incidence of stillbirth to women
whose first baby was born by caesarean section. This research, which was recently
published in The Lancet, raises once again the issue of safety not just in relation
to immediate risks of surgical delivery of our babies, but more importantly
the longer-term consequences. But how can this be if caesarean section is the
safe procedure, which in the main it proports to be?
It is thought that surgery could pose a risk to future births either by damaging
blood vessels to the womb, or causing placental implantation problems.
We already know that a scar on the uterus increases the risk of the placenta
implanting too low down in the womb (placenta praevia) but until now no link
has been made with the safety of the next baby following caesarean section.
Nevertheless, the researchers were at pains to point out that, despite a doubling
of the risk, the actual chance of having a stillbirth after a caesarean was
still very low at around 1:100.
In all the discussions around caesarean section I doubt anyone would dispute
that it can be and often is a life saving procedure for either mother or baby.
What is in question, however, is why the rate is on the increase and, more importantly,
why women are requesting this procedure when there appears to be no clinical
indication. I think it goes beyond the notion of 'too posh to push' and that
there are more deep seated fears of labour and childbirth which have pervaded
our society over the past 50 years. Before we consider taking away the option
of elective caesarean section perhaps we would be well advised to look at why
women are in fear of childbirth and what has led us to this point.
Why choose a caesarean?
In my experience the reasons women request a caesarean are complex and not always
obvious. Every woman is unique and therefore it is difficult to generalise.
Broadly speaking, however, there are three main reasons why women choose this
option.
There are an increasing number of women who have yet to experience labour and
birth and who have been influenced by what they have heard and seen through
the press and their family and friends. Society and the media play a major role
in women's perceptions of labour and birth. In our society today we have, in
the main, become socialised into the notion that we are unable to birth our
babies without the help of clinical interventions. Birth is not an illness for
most healthy well women and yet the stories that many women hear are from those
women who have experienced labour and births that were clinically managed despite
the fact that these women were well and healthy at the outset. The media perpetuates
this image ranging from the woman in ER being crashed through the doors to theatre
always in a dramatic scene of crisis, fear and tension, to the recent Mr Kipling
add that shows the struggling woman on stage acting out a horrendous bed birth
experience. We do not see applauded on TV or read in the papers accounts of
celebrities like Catherine Zeta Jones, Pamela Anderson, Jerry Hall and Kate
Moss who have all had straightforward and positive normal births? Is that because
it lacks the drama of the former? With the exception of a current series called
William and Mary, the media has consistently caricatured birth as a horrendous
and frightening process that anyone in their right mind would want to avoid
at all cost. So who can blame women when terrified, they come to the hospital
asking for an elective caesarean section?
Secondly, there are women who request a caesarean because they have experienced
labour and birth, were traumatised by it and feel they cannot go through 'that'
again. In their notes it may often say they had a 'normal birth'. However, when
you hear their story, what they had was a vaginal birth but which was in fact
far from normal or straightforward. Such experiences for some women leave deep
and unforgettable scars in their memory. We know that clinical interventions,
though sometimes necessary, have consequences and should not be used routinely.
We also know that we need to address these and other issues such as support
in labour in order to turn the tide.
Then there is a group of women who have had a previous caesarean who are then
actually offered a repeat caesarean section in the mistaken belief that 'once
a Caesar always a Caesar'. They lack confidence in their ability to have a straightforward
vaginal birth and when the offer is put to them it is sometimes too difficult
to resist. The recent national audit into the rising caesarean section rate
recognised that NHS staff need to address these issues and that VBAC (vaginal
birth after caesarean section) is a realistic option for most women depending
on the indication the first caesarean (RCOG, RCM and NCT 2002).
The Third Way
I'm beginning to sound like a politician when I describe to women the notion
of a 'third way'. When I meet the women I have just described I agree totally
that they should not have to repeat an experience that has left them traumatised
or lacking in confidence. I acknowledge the stories they have heard or their
previous birth accounts and I explore with them what the crucial issues are
for them around what is most important to them this time. With all the women
I meet I then raise the possibility that actually there is another way to do
this thing called birth and then we go on to explore the how and 'what ifs'
associated with their particular concerns.
It would be a mistake to see this as a natural birth versus caesarean section
debate. It is not. What is increasingly evident to me at least is that women
want to take control of what happens in their pregnancy, labour and birth. They
want to make sense of all the information they are presented with throughout
the nine months and they want desperately to feel valued, and most importantly
in control. They seem to see caesarean section as the only means available to
them of being in control. I then try to present them with the option of taking
charge of their labour. By teasing out what happened last time or what they
have heard it is then possible to plan what we can do and not do this time that
will go a long way to ensuring that this time her experience may well be different,
more empowering and most importantly positive.
For most women I would assert this means opting for a spontaneous labour wherever
possible and as long as labour progresses, keeping interventions to an absolute
minimum. For many women it is also the desire to be able to say when they would
like pharmacological pain relief or an epidural so that they don't in the end
feel coerced and denied control. For the very few and I believe it to be a very
small minority, control is achieved by looking at all the options and finally
determining that actually yes for her with her story a caesarean is the only
way she can see herself through to the other side.
I am known somewhat erroneously as the 'midwife in normality'. And, yes, I make
no apology for saying that most women when properly supported by their caregivers,
their partners, friends and family have the potential to birth their babies
with minimal interventions. Birth is NOT an illness and the more we loudly convey
that message alongside more positive birthing images the sooner we will be able
to stem the tide of rising caesarean section rates. We all have a lot of work
to do to build women's confidence in their ability to be birthing women and
empowered parents so let's start here, today.
REFERENCE
RCOG, RCM & NCT (2002) The Rising Caesarean section rate-from audit to action:
Report of a joint conference, RCOG Press, London.
LW updated February 4, 2005