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Fear of pain' causes big rise in caesareans
Nearly a quarter of all births in Britain last year were by section - up from 9 per cent in 1980. Now a leading midwife says this is 'unacceptably high', and that women lack the confidence to have a natural birth.
Denis Campbell reports
Women comment on their C-section experiences Denis Campbell The Observer, Sunday October 26 2008
Caesarean rates in many London hospitals are notably high. Photograph: Christopher Furlong/Getty
Scented candles, a birthing pool, favourite music, primitive screams or injections of drugs: each of the 700,000 women a year who deliver a child in the UK has her own way of getting through the inescapable pain.
One in four end up giving birth by caesarean section, where the baby is born after surgeons cut into a woman's abdomen and uterus. Some choose in advance that they will have the operation while others - such as actress Billie Piper last week - are given it in an emergency.
There are people who regard how a woman gives birth as a barometer of her womanliness. Some view elective caesareans as a sellout, as evidence that mothers-to-be, afraid of natural childbirth, have taken the easy option. The decision of celebrities such as Victoria Beckham and Christina Aguilera to give birth this way has led to claims that some women are 'too posh to push'.
Now one of Britain's leading midwives has reignited the debate about caesareans. In an interview with The Observer, Louise Silverton, deputy general-secretary of the Royal College of Midwives, has controversially claimed that an increasing number of women under 40 are less prepared to undergo the physical trauma of childbirth than their predecessors, a trend that is pushing up the rate of surgical deliveries.
She argued that 25 per cent of births being caesareans is an 'unacceptably high and needlessly high' figure and that those 170,000 deliveries involve dangers for both the mothers and their babies. In 1980 it was just 9 per cent. While any woman can request the procedure, NHS guidelines say there should be good clinical or psychological reasons.
Silverton believes caesareans have become too easy to obtain, especially the 66,500 procedures - 9.5 per cent - that are planned in advance. 'Society's tolerance of pain and illness has reduced significantly,' she said. 'Women are less tolerant of labour pains because they haven't developed tolerance of pain. For example, if they get period pain they will either take Nurofen or go to their GP.
'Women are trying to remove the symptoms of pregnancy as much as they can. They are seeking to control everything. Choosing to have a caesarean gives you an element of control.'
But she added: 'A caesarean is major abdominal surgery. I don't think women realise that. They see it as just another way of giving birth. They see it as easy. And they think that if they can have an elective caesarean they will have no pain because they haven't been in labour.'
While acknowledging that labour is 'unbelievably painful', Silverton pointed out that the pain is temporary, unlike back pain, gallstones or kidney stones. She also claimed that women under 40 were more likely to have an 'epidural in a way that their predecessors wouldn't'.
The senior midwife argued that in some cases she doubted the 'medical reasons' given by doctors for approving caesareans. Some women, tired after a long labour, were wrongly given a caesarean at 10pm to save doctors operating at 2am, when they should be left longer in case natural labour developed, she claimed.
She also accused junior doctors of approving or undertaking emergency caesareans too quickly if there were any suggestion of risk to the child's health, because they feared they might be sued if something went wrong.
'Currently, the caesarean rate [in England] is 24.3 per cent. Therefore one has to question whether the women of this country are physiologically incapable of having normal births, and I don't think they are,' said Silverton, a midwife for 30 years. She wants Britain's rate brought closer to the 15 per cent recommended by the World Health Organisation and fears caesareans 'have been normalised in the minds not just of women but also midwives and obstetricians'.
She listed a caesarean's main dangers for mothers as 'the risk of infection, the effect on subsequent fertility and the effect on their ability to look after a newborn baby when they are post-operative'. There can also be respiratory complications for the baby, she added.
Silverton and the Royal College are worried that women have lost confidence in their ability to go through natural labour. She blames that on a decline in antenatal classes and the fact that scattered families means there is less 'folk knowledge about childbirth'.
The midwife shortage means that women have less time with them on antenatal visits than before, too. In addition 'the celebrity culture of having your baby and two weeks later being seen in a slinky dress, having lost weight, is affecting women's views of caesareans', Silverton added.
Georgina Cooper's first experience of childbirth, in March, was what she had wanted: natural, in a birthing pool, with her husband, Doug, close by, constantly rubbing her back. But it also hurt a lot. 'The pain is the most intense pain you ever experience,' said Cooper, a charity press officer in London. 'But it's also different to any other pain because you know that at the end of it you're going to meet the baby you have been looking after inside you for nine months, which is exhilarating.'
The 31-year-old, who called her daughter Martha, used yoga, swimming and reflexology to improve her chances of a vaginal delivery. But she is not a natural birth snob. 'I'm totally unjudgmental about how women choose to give birth,' she said.
There were seven women in Cooper's National Childbirth Trust antenatal group and four had a caesarean. In each case, their condition involved an increased risk to mother or baby if exposed to the rigours of a normal delivery. One was carrying twins, another's baby was very premature.
'While I feel really fulfilled from having had a natural birth, I don't feel more womanly because I did,' added Cooper.
Many experts agreed, as they argued about Silverton's comments. 'It's very wrong to blame women for the caesarean rate being so high,' said Belinda Phipps, chief executive of the National Childbirth Trust. 'We do take more painkillers than we have ever before but that's not a cause of the caesarean rate being higher.
'What matters the most is that we care very badly for women in labour, which makes them frightened. That's what makes labour a cascade of horribleness, leads to more intervention and puts up the caesarean rate.'
She cited a recent study by the Healthcare Commission, the NHS watchdog in England, which found that one in five women were left alone during labour. That, and a shortage of up to 5,000 midwives, is the real reason behind the caesarean rate, according to Phipps.
Organisations such as the British Medical Association and the Royal College of Obstetricians and Gynaecologists (RCOG) point out that the NHS does not have enough obstetricians to give women the quality of care needed.
Dr Maggie Blott, a consultant obstetrician at University College Hospital, London and a RCOG spokeswoman on caesareans, insisted: 'There isn't any evidence to support Louise Silverton's view that increasingly pain-averse women are pushing up the caesarean rate. There's an undercurrent that caesarean sections are a bad thing, but they can be life-saving.'
She conceded that there are 'a tiny number of women who want a caesarean even though medically they don't need one. Those women are probably less than 1 per cent of all those who have a caesarean.' That equates to roughly 1,700 of the 700,000 women a year who give birth in the UK.
The safety of caesareans has improved significantly in the past 20 years. Natural births and planned caesareans now involve the same risk that the mother will die. But the risk of serious medical complications remain higher for surgical births. Those include what Blott calls 'infinitesimally small' risks that the woman might need a blood transfusion, catch an infection or have her bladder or bowel accidentally nicked during the surgery.
However safe caesareans are today, a growing volume of evidence links the procedure to a range of often serious medical risks, such as stillbirth. A study published in August found that babies born that way are also 20 per cent more likely to develop Type 1 diabetes.
Last year researchers from Oxford University said that caesarean deliveries reduced the risk during breech births, where the baby's lower body appears first in the birth canal. However, Dr Jose Villar's team also found that a woman having a caesarean ran twice the risk of suffering complications, including hysterectomy, blood transfusion and admission to intensive care.
'Many women tell us they feel they are a failure if they have had a caesarean, even though they shouldn't,' said Siobhan Freegard, a co-founder of Netmums a social networking site for mothers. Anecdotal evidence suggests that this belief may help cause postnatal depression in some women, she added.
Caesareans are a major talking point among women. A Netmums appeal for members to tell The Observer their story quickly yielded dozens of volunteers.
Freegard deplores what she calls the belief among some women that only a natural birth will do. 'There's this unspoken presumption that if you have had a natural childbirth, you are more successful as a birth mother', she said.
'I think the "too posh to push" tag has sullied the reputation of women who have had a caesarean. What's important is that you've got a safe, healthy baby, not how you got it. Every women who has a caesarean has their reason.'
'I had the moment of a newborn child being passed to me alive and well'
Emma Batey, a 37-year-old schoolteacher from Sheffield, had both her children - Max, six, and Poppy, two - by caesarean section.
'When I was pregnant with Poppy, I joined a couple of online birth clubs, where the members are mainly middle-class, working mums and a lot of first-time mums. The expectation was that everyone was trying to have a natural birth, that natural birth was better. There was quite a widespread one-upmanship to see who could have their baby at home, be as drug-free as possible, or use a birthing pool or a midwife-led unit.
'Some people do try to stigmatise it. There's this idea some women have one as the easy way out. But women shouldn't feel ashamed about having a caesarean. I feel no stigma about having had my children that way. Between me and my four close friends, four of us had a caesarean with our first baby for medical reasons, then had an elective with our second child, also for medical reasons.
'My first child was stillborn in 2001. She died in the womb and I gave birth naturally - a horrific experience. In 2002 when Max was due I was dreading it, but looking forward to pushing out a live child this time. But after two days in labour and my son failing to progress, his heart rate was irregular and then dropped. I was petrified I would lose another baby, so when the consultant suggested a caesarean I said yes immediately.
'Then before having Poppy I developed gestational diabetes, so there was a danger that the baby would be too large to come out safely, as Max had been. I had another caesarean on medical grounds.
'When people ask if I regret having a caesarean, I always say no, because I still had the moment of having a newborn child passed to me alive and well. I missed out on the delivery, but nothing took away my joy at two beautiful, healthy babies.'
'They didn't even give me the option of holding my baby'
Louise Hughes, aged 19 and from Cardiff, gave birth to her first child, Grace, last month.
'I feel I was pushed into having a caesarean. They didn't really give me options or speak to me about it. Nobody explained in detail what was going on. As it was my first baby, I would have liked to have known what was happening. The lack of information was really scary.
'It was 8.15pm and I'd been in labour for over 15 hours by this stage and the baby's heart rate had dropped. The doctors came in and said that enough was enough and that they were taking me down for a caesarean.
'Nobody said anything about potential risks. They were all on the consent form that they told me to read.
'When Grace came out they didn't give me the option of holding her, even with the help of hospital staff. I really feel that I missed out. That meant I wasn't able to bond with her. For the first two days, I didn't want Grace near me. When she was crying I just wished she would shut up and that someone would come and take her away.
'I didn't want to be around her because I'd had a caesarean and hadn't had the chance to bond with her when it mattered most, just after the birth.
'I still feel guilty for not being able to bond and I hate myself for having thought like that. But that's how I felt. But that didn't last and now I just love her to pieces.
Nearly a quarter of all births in Britain last year were by section - up from 9 per cent in 1980. Now a leading midwife says this is 'unacceptably high', and that women lack the confidence to have a natural birth.
Denis Campbell reports
Women comment on their C-section experiences Denis Campbell The Observer, Sunday October 26 2008
Caesarean rates in many London hospitals are notably high. Photograph: Christopher Furlong/Getty
Scented candles, a birthing pool, favourite music, primitive screams or injections of drugs: each of the 700,000 women a year who deliver a child in the UK has her own way of getting through the inescapable pain.
One in four end up giving birth by caesarean section, where the baby is born after surgeons cut into a woman's abdomen and uterus. Some choose in advance that they will have the operation while others - such as actress Billie Piper last week - are given it in an emergency.
There are people who regard how a woman gives birth as a barometer of her womanliness. Some view elective caesareans as a sellout, as evidence that mothers-to-be, afraid of natural childbirth, have taken the easy option. The decision of celebrities such as Victoria Beckham and Christina Aguilera to give birth this way has led to claims that some women are 'too posh to push'.
Now one of Britain's leading midwives has reignited the debate about caesareans. In an interview with The Observer, Louise Silverton, deputy general-secretary of the Royal College of Midwives, has controversially claimed that an increasing number of women under 40 are less prepared to undergo the physical trauma of childbirth than their predecessors, a trend that is pushing up the rate of surgical deliveries.
She argued that 25 per cent of births being caesareans is an 'unacceptably high and needlessly high' figure and that those 170,000 deliveries involve dangers for both the mothers and their babies. In 1980 it was just 9 per cent. While any woman can request the procedure, NHS guidelines say there should be good clinical or psychological reasons.
Silverton believes caesareans have become too easy to obtain, especially the 66,500 procedures - 9.5 per cent - that are planned in advance. 'Society's tolerance of pain and illness has reduced significantly,' she said. 'Women are less tolerant of labour pains because they haven't developed tolerance of pain. For example, if they get period pain they will either take Nurofen or go to their GP.
'Women are trying to remove the symptoms of pregnancy as much as they can. They are seeking to control everything. Choosing to have a caesarean gives you an element of control.'
But she added: 'A caesarean is major abdominal surgery. I don't think women realise that. They see it as just another way of giving birth. They see it as easy. And they think that if they can have an elective caesarean they will have no pain because they haven't been in labour.'
While acknowledging that labour is 'unbelievably painful', Silverton pointed out that the pain is temporary, unlike back pain, gallstones or kidney stones. She also claimed that women under 40 were more likely to have an 'epidural in a way that their predecessors wouldn't'.
The senior midwife argued that in some cases she doubted the 'medical reasons' given by doctors for approving caesareans. Some women, tired after a long labour, were wrongly given a caesarean at 10pm to save doctors operating at 2am, when they should be left longer in case natural labour developed, she claimed.
She also accused junior doctors of approving or undertaking emergency caesareans too quickly if there were any suggestion of risk to the child's health, because they feared they might be sued if something went wrong.
'Currently, the caesarean rate [in England] is 24.3 per cent. Therefore one has to question whether the women of this country are physiologically incapable of having normal births, and I don't think they are,' said Silverton, a midwife for 30 years. She wants Britain's rate brought closer to the 15 per cent recommended by the World Health Organisation and fears caesareans 'have been normalised in the minds not just of women but also midwives and obstetricians'.
She listed a caesarean's main dangers for mothers as 'the risk of infection, the effect on subsequent fertility and the effect on their ability to look after a newborn baby when they are post-operative'. There can also be respiratory complications for the baby, she added.
Silverton and the Royal College are worried that women have lost confidence in their ability to go through natural labour. She blames that on a decline in antenatal classes and the fact that scattered families means there is less 'folk knowledge about childbirth'.
The midwife shortage means that women have less time with them on antenatal visits than before, too. In addition 'the celebrity culture of having your baby and two weeks later being seen in a slinky dress, having lost weight, is affecting women's views of caesareans', Silverton added.
Georgina Cooper's first experience of childbirth, in March, was what she had wanted: natural, in a birthing pool, with her husband, Doug, close by, constantly rubbing her back. But it also hurt a lot. 'The pain is the most intense pain you ever experience,' said Cooper, a charity press officer in London. 'But it's also different to any other pain because you know that at the end of it you're going to meet the baby you have been looking after inside you for nine months, which is exhilarating.'
The 31-year-old, who called her daughter Martha, used yoga, swimming and reflexology to improve her chances of a vaginal delivery. But she is not a natural birth snob. 'I'm totally unjudgmental about how women choose to give birth,' she said.
There were seven women in Cooper's National Childbirth Trust antenatal group and four had a caesarean. In each case, their condition involved an increased risk to mother or baby if exposed to the rigours of a normal delivery. One was carrying twins, another's baby was very premature.
'While I feel really fulfilled from having had a natural birth, I don't feel more womanly because I did,' added Cooper.
Many experts agreed, as they argued about Silverton's comments. 'It's very wrong to blame women for the caesarean rate being so high,' said Belinda Phipps, chief executive of the National Childbirth Trust. 'We do take more painkillers than we have ever before but that's not a cause of the caesarean rate being higher.
'What matters the most is that we care very badly for women in labour, which makes them frightened. That's what makes labour a cascade of horribleness, leads to more intervention and puts up the caesarean rate.'
She cited a recent study by the Healthcare Commission, the NHS watchdog in England, which found that one in five women were left alone during labour. That, and a shortage of up to 5,000 midwives, is the real reason behind the caesarean rate, according to Phipps.
Organisations such as the British Medical Association and the Royal College of Obstetricians and Gynaecologists (RCOG) point out that the NHS does not have enough obstetricians to give women the quality of care needed.
Dr Maggie Blott, a consultant obstetrician at University College Hospital, London and a RCOG spokeswoman on caesareans, insisted: 'There isn't any evidence to support Louise Silverton's view that increasingly pain-averse women are pushing up the caesarean rate. There's an undercurrent that caesarean sections are a bad thing, but they can be life-saving.'
She conceded that there are 'a tiny number of women who want a caesarean even though medically they don't need one. Those women are probably less than 1 per cent of all those who have a caesarean.' That equates to roughly 1,700 of the 700,000 women a year who give birth in the UK.
The safety of caesareans has improved significantly in the past 20 years. Natural births and planned caesareans now involve the same risk that the mother will die. But the risk of serious medical complications remain higher for surgical births. Those include what Blott calls 'infinitesimally small' risks that the woman might need a blood transfusion, catch an infection or have her bladder or bowel accidentally nicked during the surgery.
However safe caesareans are today, a growing volume of evidence links the procedure to a range of often serious medical risks, such as stillbirth. A study published in August found that babies born that way are also 20 per cent more likely to develop Type 1 diabetes.
Last year researchers from Oxford University said that caesarean deliveries reduced the risk during breech births, where the baby's lower body appears first in the birth canal. However, Dr Jose Villar's team also found that a woman having a caesarean ran twice the risk of suffering complications, including hysterectomy, blood transfusion and admission to intensive care.
'Many women tell us they feel they are a failure if they have had a caesarean, even though they shouldn't,' said Siobhan Freegard, a co-founder of Netmums a social networking site for mothers. Anecdotal evidence suggests that this belief may help cause postnatal depression in some women, she added.
Caesareans are a major talking point among women. A Netmums appeal for members to tell The Observer their story quickly yielded dozens of volunteers.
Freegard deplores what she calls the belief among some women that only a natural birth will do. 'There's this unspoken presumption that if you have had a natural childbirth, you are more successful as a birth mother', she said.
'I think the "too posh to push" tag has sullied the reputation of women who have had a caesarean. What's important is that you've got a safe, healthy baby, not how you got it. Every women who has a caesarean has their reason.'
'I had the moment of a newborn child being passed to me alive and well'
Emma Batey, a 37-year-old schoolteacher from Sheffield, had both her children - Max, six, and Poppy, two - by caesarean section.
'When I was pregnant with Poppy, I joined a couple of online birth clubs, where the members are mainly middle-class, working mums and a lot of first-time mums. The expectation was that everyone was trying to have a natural birth, that natural birth was better. There was quite a widespread one-upmanship to see who could have their baby at home, be as drug-free as possible, or use a birthing pool or a midwife-led unit.
'Some people do try to stigmatise it. There's this idea some women have one as the easy way out. But women shouldn't feel ashamed about having a caesarean. I feel no stigma about having had my children that way. Between me and my four close friends, four of us had a caesarean with our first baby for medical reasons, then had an elective with our second child, also for medical reasons.
'My first child was stillborn in 2001. She died in the womb and I gave birth naturally - a horrific experience. In 2002 when Max was due I was dreading it, but looking forward to pushing out a live child this time. But after two days in labour and my son failing to progress, his heart rate was irregular and then dropped. I was petrified I would lose another baby, so when the consultant suggested a caesarean I said yes immediately.
'Then before having Poppy I developed gestational diabetes, so there was a danger that the baby would be too large to come out safely, as Max had been. I had another caesarean on medical grounds.
'When people ask if I regret having a caesarean, I always say no, because I still had the moment of having a newborn child passed to me alive and well. I missed out on the delivery, but nothing took away my joy at two beautiful, healthy babies.'
'They didn't even give me the option of holding my baby'
Louise Hughes, aged 19 and from Cardiff, gave birth to her first child, Grace, last month.
'I feel I was pushed into having a caesarean. They didn't really give me options or speak to me about it. Nobody explained in detail what was going on. As it was my first baby, I would have liked to have known what was happening. The lack of information was really scary.
'It was 8.15pm and I'd been in labour for over 15 hours by this stage and the baby's heart rate had dropped. The doctors came in and said that enough was enough and that they were taking me down for a caesarean.
'Nobody said anything about potential risks. They were all on the consent form that they told me to read.
'When Grace came out they didn't give me the option of holding her, even with the help of hospital staff. I really feel that I missed out. That meant I wasn't able to bond with her. For the first two days, I didn't want Grace near me. When she was crying I just wished she would shut up and that someone would come and take her away.
'I didn't want to be around her because I'd had a caesarean and hadn't had the chance to bond with her when it mattered most, just after the birth.
'I still feel guilty for not being able to bond and I hate myself for having thought like that. But that's how I felt. But that didn't last and now I just love her to pieces.
