Does antenatal education set women up to fail?

Sit any group of women down to talk about caesareans and you will hear all sorts of alarming ‘facts’. Common ones are:

  • You will have to have a caesarean if your baby is breech
  • You cannot pick up your baby or drive for 6 weeks
  • Bonding with your baby will be severely affected
  • Once you have had a caesarean, your next birth will have to be a caesarean too
  • the list goes on and on

What is really alarming about these facts’ is not one of them need be true.

Hard as it may be to hear, antenatal education often does little to disabuse women of these misconceptions. Rather, it can perpetuate the idea that this important procedure is a last resort best avoided.

In reality, in addition to being lifesaving in an emergency context, caesareans have significant benefits in certain pre-labour situations where attempting a vaginal delivery carries greater risk for mother or baby. Add to these, those women who view a caesarean as preferable because of the unbearable fear and uncertainty they associate with vaginal birth (tokophobia) and there are a lot of women who can benefit from planning a caesarean delivery.

Unfortunately, many women still understand so little about caesareans it will perhaps be no surprise to hear some find their caesarean experience so traumatic they go on to develop post-traumatic stress disorder (PTSD). And those who do want (or need) to plan a caesarean are left totally unaware of the opportunities for making their birth feel special and personal.

Nearly one in three women in the UK will have a caesarean, with unplanned caesareans accounting for two thirds of these.[ii] They are a possible outcome of even the most straightforward pregnancy yet are barely touched on in many antenatal classes.

This reluctance to talk positively about caesareans has forced them to the periphery of antenatal education. Books and classes can be biased in favour of vaginal delivery making it impossible for women to have open, rational discussions with those responsible for their care. Most remain unaware of the huge benefits of preparing for the possibility of caesarean birth, either planned or emergency.

Helen Walsh, author of Go to Sleep,[iii] said of her antenatal classes:

“They did not prepare me for a caesarean outcome and perhaps more importantly, the implications of such an outcome. Had I known more I would have opted for an elective caesarean and I would not have endured such a traumatic birth experience [breech baby] which I firmly believe contributed if not triggered my descent into postnatal depression.”

It is well known that a woman’s preconceptions can affect her labour[iv] and realistic expectations are significant in determining both how she ultimately perceives her birth[v] [vi] [vii] and how she approaches her recovery.[viii] Yet women are still unable to get access to the information they need in order to develop a flexible approach to birth. All too often the risks of vaginal birth are downplayed while caesareans are portrayed as an intervention to avoid wherever possible, with those planning a caesarean labelled selfish or ‘too posh to push’. This systematic bias (intentional or otherwise) leaves women in the dark about what they face.

The likelihood of needing intervention (epidural, instruments, induction or caesarean) during vaginal birth is made light of, but actually effects a significant number of women – over half of UK women will experience some form of intervention[ix] yet many remain poorly equipped to negotiate their way through the experience.

The feelings of distress and loss of control that can become associated with such a birth can have a significant impact both physically and emotionally on mum and baby.[x] [xi] Women need to know more about their options so they can assess the risks for themselves. While some would prefer to leave things in the hands of their carers, many more would prefer to play an active role in decision-making. [xii] To achieve this they need realistic information about the experience they face. Women need to know the implications of the decisions they might be tempted to make, and they need to know their rights in this regard. In the case of caesareans: knowing how to prepare for the procedure; being aware of the opportunities open to them during surgery; learning alternative positions for breastfeeding and ways to improve recovery can all radically improve the experience for many women, even if the caesarean was not their original preference.

Fortunately, in the UK at least, the National Institute of Clinical Excellence (NICE) are addressing the issue of antenatal education, in relation to caesarean birth.[xiii] They agree:

“It is important that women are presented with evidence based information in order that they are able to make an informed decision…For all women requesting a caesarean, if after discussion and offer of support a vaginal birth is still not an acceptable option, offer a planned caesarean.”

This was a huge step forward back in 2011. Unfortunately, the reality is that the extent to which this guidance is followed is still very much in the hands of the individuals providing the care – their personal opinions (as well as hospital policy), consequently perspectives can vary widely.

The toxic combination of out of date or inadequate information and biased advice means women will continue to face their birth with huge gaps in their knowledge. Failing to inform women properly contributes significantly to the mismatch between their birth expectations and birth experience exposing many to unnecessary levels of trauma.

[ii] J. Thomas, S. Paranjothy and Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. National sentinel caesarean section audit report. (London: RCOG Press, 2001)

[iii] H Walsh ‘Go to sleep’ (Canongate Books Ltd, 2011 ISBN:978-0857860057)

[iv] K. Hofberg, M. R. Ward, ‘Fear Of Pregnancy And Childbirth’ Postgraduate Medical Journal, 79 (2003) 505-510

[v] J. Lally, M. Murtagh, S. Macphail et al, ‘More in Hope Than Expectation: A Systematic Review of Women’s Expectations and Experience of Pain Relief in Labour’ BMC Medicine, (2008) 6:7doi:10.1186/1741-7015-6-7

[vi] C. Oblasser, The Faceless Caesarean (BoD, 2009)

[vii] C. Francome, W. Savage, H. Churchill et al, Caesarean Birth in Britain: A Book for Health Professionals and Parents (London, Middlesex University Press, 1993)

[viii] L East, Caesarean Birth: A positive approach to preparation and recovery, (Tiskimo 2011  ISBN: 978-0-9568480-0-0)

[ix] NHS, Latest Maternity Statistics Show How the Pattern of Giving Birth in England is Changing, (NHS Information Centre, 2008)

[x] J. Lally, M. Murtagh, S. Macphail et al, ‘More in Hope Than Expectation: A Systematic Review of Women’s Expectations and Experience of Pain Relief in Labour’ BMC Medicine, (2008) 6:7doi:10.1186/1741-7015-6-7

[xi] L East, Caesarean Birth: A positive approach to preparation and recovery, (Tiskimo 2011 –  ISBN: 978-0-9568480-0-0)

[xii] K.L. Ingold, author of ‘A phenomenological exploration of women’s experiences of giving birth in Leeds and discussion within the context of NHS maternity policy’ (Masters dissertation in Public Health, University of Leeds Academic Unit of Public Health, 2011)

[xiii] National Collaborating Centre for Women’s and Children’s Health, Caesarean Section Guideline, Draft (Commissioned by National Institute of Clinical Excellence, RCOG, 2011)