A right to choose – as long as it’s a vaginal birth

Caesareans are often given a bad rap. Women are led to believe a caesarean is a last resort for emergency situations when things have gone (or are predicted to go) wrong. They are scared off by being repeatedly told ‘it’s major stomach surgery’ don’t you know. Or judged for suggesting a selfish choice which will put the life of their baby at risk. The overall message still – caesareans are something to be avoided wherever possible.

In fact, a caesarean can be an incredibly positive choice for many women and battling against the stigma just makes us feel bad when we really shouldn’t.

Birth practitioners and natural birth campaign groups quite rightly talk about:

  • A woman’s right to make an informed choice
  • The importance of a woman’s perception of control before, during and after her birth
  • The right to choose their mode of birth

So why am I complaining yet again?

Because for some practitioners and campaigners (and I want to make it clear this is definitely not all) this still excludes caesarean birth – by all means make an informed choice about your birth as long as it is in favour of a vaginal birth at home, in a birthing centre or at hospital.

An article by Tamara Parnay Birth of Mutual Understanding and Respect sums it up perfectly “Maternity care providers in all steps of the process, from pre-pregnancy though to postnatal care, need to move more in the direction of assisting people in personalised birth plans and helping them safely to realise these plans. In other words, they must consider the family to be an integral part of the decision-making process.”

She goes on to talk about the negative impact of competitive birth stories, the assumptions that are made about one’s own choices and outcomes compared with every other story we hear. The article is well worth a read!

It is of course wonderful to see such statements.

But the reality for many women is still that they will meet their clinicians and be told very little about one of the modes of birth – a caesarean. The balance of risk and benefit will still be skewed in favour of vaginal birth. And some women still find their informed request for a caesarean birth turned down flat.

In her book ‘Misconceptions’, Naomi Wolf says, ” Women deserve honest brokers and true advocates who will inform them about all risks and options available; who will explore what pain can be and what it might not have to be; who will make a concerted effort to eliminate unnecessary interventions; and who will stop romanticising either the control nature of high-tech mechanised labour or the culture of alternative birth.”

This is more like it – balance, reliable information and a non-judgemental approach to childbirth from absolutely everyone.

Book review of 2nd edition

I came across a lovely review of my 2nd edition the other day. Thank you Helen Mary Labao Barrameda for taking the time to share your thoughts.

This is a very good resource book for Caesarean. I wish I read this during my first C-section. It contains a lot of useful and practical tips especially on the post-operation side of things. The author is also very sensitive and inclusive of various nuances like LGBT couple births and paternal postnatal depression (I did not even know that it exists before reading this book). I am glad to have read this; it stands a good chance of improving my C-section experience.”

Once a caesarean, always a caesarean?

This is a fear many women experience following an emergency caesarean. No surprise really, an emergency caesarean is never planned, and some women find the experience highly traumatic, making it one they want to avoid ever going through again.

This is where being informed comes in.

In many cases a previous caesarean does not need to mean your next birth also has to be a caesarean.

Being informing about your rights is an important step in influencing such outcomes, but there are other factors to consider, namely:

  • The reason for your last caesarean – occasionally there are medical conditions or previous birth complications which are likely to recur, and which mean a repeat caesarean is a safer delivery method
  • How your current pregnancy is progressing – there may well be different circumstances this time round which indicate a repeat caesarean may still be a safer prospect
  • When is a recommendation for a repeat caesarean just that – a recommendation? Knowing the difference between recommendation and necessity means you can negotiate more effectively. For example, contrary to popular belief, your baby presenting in a breech position does not have to mean caesarean delivery

All that said, you may well want to choose a caesarean next time round for a whole host of valid reasons. Assuming this choice is based on solid information and the progress of this next pregnancy doesn’t dictate otherwise, there should be no reason why you should not be able to plan a repeat caesarean. Easier said than done of course, multiple barriers may well be put in your way. Here again, knowledge is power. Make sure you have clear reasons for your request and fight your corner.

What are the caesarean rates in my country?

Understanding the caesarean rate in your country, and specifically in the hospital where you are going to give birth, is really useful when devising your birth plans.

Like it or not, the preferences and beliefs of those assisting with your birth are going to play a part in the advice you are given as your vaginal birth progresses.

Planning a vaginal birth, is just that – a plan – it is not a guarantee. So knowing a bit more about the conditions under which you may need to negotiate is going to be an important factor in the outcome and knowing the rates plays a part in this.

Let’s take the UK as an example. The caesarean rate has been 1 in 4 for years. In 2018 it climbed slightly – getting nearer to 1 in 3. However, if you look at the rates for individual hospitals in 2016, some were 1 in 3, others 1 in 5. So if you are hoping to avoid a caesarean and your hospital has a rate of 1 n 3 rate, you might want to know what it is that makes it different from one with a 1 in 5 rate. This knowledge is just as important if you are hoping to plan one.

Playing a large part in these differences are the policies and preferences of the clinicians and the hosptials they work in. You might be able to get a bit of an idea by asking the PALs (Patient Advice and Liason Service) team at your hospital for any information about the caesarean policy (non-medical electives may be strongly discouraged for example), any limits placed on the duration of 2nd stage labour and the VBAC policy etc. They may or may not show you this. So also talking to local antenatal support groups and other mothers who have already given birth in your hospital might give you a bit more information.

Unfortunately, despite an acknowledgement by the World Health Organisation that there is “no empirical evidence for an optimum percentage” for caesarean deliveries, some hospitals are still directing staff to drive down their caesarean rate. While this is often claimed to be for medical reasons, it is in no small part also a cost cutting exercise. Don’t get me started on the problems with this – suffice to say material used to support this claim are hugely problematic because they generally group all caesareans together and then compare their cost with natural, drug free births. The two are not comparable – an emergency caesarean does not have the same costs as a planned caesarean, and a medicalised vaginal birth is not the same cost as a natural birth. In fact the cost of a medicalised vaginal birth and an emergency caesarean are almost the same and only around 50% of planned vaginal births are entirely natural (NHS Information Centre 2008). Enough said.

Anyway, it is worth trying to at least work out what you are facing at your hospital as you make your plans. In particular, understanding what constitutes a recommendation versus a necessity when being asked to go ‘off plan’ and then having your opinion backed up with solid information will help you negotiate.

Women are too posh to push!

Incredibly some women are accused of this to their face, while others are guilt tripped by  the media. In fact, the figures used to support such an accusation are very misleading. In the majority of sources, figures actually incorporate all maternally requested caesareans including those which follow recommendations from the mother’s practitioner, i.e. when medical situations or clinician experience indicates that a caesarean might be the safer method delivery.

Where the media talk about unnecessary caesareans, factors such as increased age of first time mothers; practitioner’s desire to reduce operative vaginal deliveries; an increase in the overall incidence of fetal monitoring and a fear of litigation are frequently ignored or conveniently overlooked.

Even if all these factors are taken into account, the figure describing women choosing a caesarean in the absence of a medical need still invariably includes women making the choice because of tokophobia (fear of childbirth), previous traumatic birth experiences or trauma arising from sexual abuse, and others making a positive, informed, prophylactic choice.

And if all of that is not enough. The figures are unable to take account of the discrepancy in the coding of births which can occur between hospitals and the financial and policy decisions made by individual hospitals, as a result of which ‘apparent’ rates of intervention can vary significantly. For example, my second caesarean was coded as an emergency by my hosptial, despite the fact it was a planned casearean, simply because I happened to go into labour before the planned CS date – there was no emergency, it simply wasn’t at the time scheduled, which of course helped make their elective numbers look that bit lower.

At the end of the day, very few women make such an important decision without good reason and such a slur is not only disrespectful but dismisses the complexity of the decision-making the majority have gone through.