In Britain a woman has the right to choose a caesarean. This right exists within the National Institute for Health and Care Excellence (Nice) guidelines, and has done for five years. The rules do not lack clarity. The note on women for whom there is no reason to avoid a vaginal delivery, other than that they are scared or don’t want one, says “if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS” [caesarean section]”. When there is practitioner uncertainty, the guidelines are again perfectly clear. “An obstetrician unwilling to perform a CS should refer the woman to an obstetrician who will carry out the CS,” the note continues.
Although doctors and midwives may counsel women against having a C-section – which is “major surgery”, and requires them to sign a form saying they understand the small risk of bladder or bowel damage – in the end, if the woman would rather have this operation than have her baby squeeze out of her vagina, that’s up to her.
This has not stopped people, or the press, from talking about whether an incision in your abdomen is the best way to have a baby or not. That’s fair enough: this is an interesting subject, and one of the ideas advanced by doctors when the new guidelines were introduced was that if professionals did a better job of explaining the risks to women, the rate of caesareans might actually be reduced. Besides, not everyone agrees with Nice: last year the World Health Organisation said the procedure should only be carried out when medically necessary, because it has more risks than benefits.
The whole subject screams out for rationality: when expectant parents are filled with every combination of excitement and terror, and there are two lives involved – mother’s and baby’s – both of whose physical and mental health it is the professionals’ job to safeguard, everybody needs to think very carefully. But instead of reasoned debate, last week saw the renewed denigration of a subset of mothers portrayed as prosperous, indulged and “too posh to push”.
The latest accusation follows pronouncements from the Royal College of Obstetricians and Gynaecologists. It is concerned that in 2013-14 just under a quarter of C-sections in England were carried out before the recommended threshold of 39 weeks. The figure is much higher in some areas (43.9% in Worcestershire), which could mean hospital timetables are taking priority over patient care.
There are also big regional differences in the rate of emergency caesarean, and in the rates of “instrumental delivery” (forceps or vacuum) and episiotomy, where the opening of the woman’s vagina is cut. Researchers were also concerned about the quality of the data they were sent. One of the first questions I would ask about all this relates to finances. Are women in areas where hospitals are short of money being discouraged from having caesareans because they cost more? (£2,369 compared with £1,665, in 2011) But the Times instead chose to wheel on a stock figure from earlier rounds of this particular culture war, and declared in a prominent headline that the increased rate of caesareans is attributable to “Hampstead mothers”. The assertion was based on the rate at one London hospital, the Royal Free.
We know that the rate of caesareans has doubled since 1990. It increased by 0.5 percentage points in 2012-13 and by 0.7 in 2013-14. The rate of elective (non-emergency) caesareans is the reason why.
Elective caesareans went up from 10.2% to 13.2% of deliveries in England’s NHS hospitals over these two years, while emergencies went down. It is true that older mothers – who are also likely to be richer and more educated – are more likely to have C-sections. Statistics about celebrities don’t exist, but there is a view, since private hospitals have higher rates and some famous women have said so, that they prefer C-sections too.
It is important to be clear about what we don’t know. Since so-called “elective” caesareans include all such procedures not classified as emergencies, one can’t tell from the figures whether this rise is due to more doctors recommending caesareans, or more women choosing them on their own. But that detail is overlooked, which is not surprising – the idea that well-educated women, or “Hampstead mothers”, are “too posh to push” has been popular since the phrase was coined nearly 20 years ago. Those who use it to confirm their own prejudices aren’t likely to abandon it now.
Debates around childbirth are riddled with sexual politics. This is a moment in life when we are confronted by our biology, and hospitals reflect this division by sex back at us: while almost all midwives are women, most doctors (though not most GPs) are men. The debate is also about power. Last year an inquiry found the determination of a group of midwives at Furness hospital in Cumbria to deliver babies on their own, without doctors, led to 12 deaths. But the Hampstead mothers/too posh to push idea is nothing more than ugly prejudice: it says that somewhere on the way to getting an education, building a career and buying a nice house, these women have lost their true natures.
There is no easy way to give birth, though some find it harder than others, and there are pros and cons to each route out of the womb. The evidence is complicated. What is safest for mothers is not necessarily safest for babies, and vice versa. But against a backdrop of more caesareans, in 2014 infant mortality reached an all-time low. This, surely, is progress.
Most of us do our best to be rational, and listen to the advice we are given. Usually we give birth via our vaginas. That a minority opt for a caesarean is proof of our hard-won though incomplete reproductive freedom. In Hampstead or wherever, women should be able to make these choices without fear of stigma.
