Electing for Caesarean

The number of women in the UK giving birth by Caesarean has doubled in the past 20 years. Pat Thomas looks at recent research which highlights the risks of surgical intervention

Posh didn’t push. Neither did All Saints’ Melanie Blatt. Neither did the mother of all popstars, Madonna. But according to a new study involving three London hospitals, celebrity mums who choose convenience Caesareans rather than normal birth, risk life-threatening complications, by opting for major surgery when they don’t really need it.

More than 20% of women in the UK now give birth by Caesarean – 20 years ago the figure was 9% – and while doctors have long maintained that the operation is safe, a recent overview of the procedure, published in The Lancet, showed otherwise. It revealed that women who have Caesareans are three times (some studies put the figure as high as six times) more likely to die during the procedure than during a normal delivery.

However, so few women die in childbirth these days that researchers believe maternal death figures don’t give the full picture. At King’s College, Guy’s and St Thomas’s hospitals in London, doctors have been looking at what they call ‘near misses’ – the number of women who experienced life-threatening complications during labour. Their study, published in The British Medical Journal (May 2001), involved 49,000 women, and found that for every woman who died there were 118 near misses. Caesareans, whether ‘emergencies’ or planned, accounted for a fourfold increase in the risk of serious complications, including haemorrhage, infection and rupture of the uterus.

Caesareans are a life-saving option and a necessity if:

  • The mother has severe pre-eclampsia
  • The mother has placenta praevia (when the placenta covers the cervix)
  • The baby is in transverse position in the womb

    A number of women choosing private care do elect to have a Caesarean. They may view the operation as the ultimate form of pain relief or simply want to plan a date for their delivery. But for the majority of women, I strongly suspect that fear, rather than convenience, may be the real motivation.

    ‘Women phone us and say they want a Caesarean because they’ve already had one bad birth experience and don’t want another, or they’re afraid of being left alone and in pain during labour,’ says Beverley Beech of AIMS (The Association for Improvements in Maternity Services). ‘Very few really choose Caesareans for convenience. I think, also, that the media-fuelled image of birth is largely a negative one. The portrayal of birth as full of drama and danger adds to women’s fears.’

    In the cash-strapped NHS, the element of ‘choice’ may not come into play, but the consultant’s preference certainly does. Some obstetricians like the convenience of being able to plan the delivery – a survey of female consultants in 1997 found that 31% would choose a Caesarean over any other method. Perhaps not surprisingly, women who are cared for by midwives during labour are far less likely to end up with an unnecessary Caesarean.

    The way birth is managed in hospitals also plays a part. Some hospitals place a time limit on the first stage of birth of around 12 hours for first-time mums (less for second-time mums). If women go into ‘overtime’, they may be advised to have a Caesarean. This practice continues in spite of studies, such as the one published in Obstetrics and Gynaecology in 1996, which showed that normal labour is longer than doctors think. According to researchers, the average first (or dilating) stage of labour for a first-time mum lasted nearly 20 hours, not 12. The average second (or pushing) stage of labour was 7.7 hours, not 2.5.

    Some mothers and babies obviously do need surgical intervention in the birth process. But the World Health Organization recommends that the optimum rate for Caesareans should be 9% of births. Latin America has some of the highest rates in the world, with Brazil at around 32% and Chile at 40%. The USA rate stands at 25%, while Holland is the closest to the WHO recommendations, with a Caesarean rate of 9.5%. The UK rate is more than double that, and with substantial evidence to show that the risks of choosing a Caesarean genuinely outweigh the benefits, it’s surely time to question the trend of Caesareans for convenience.

    Risks to mum

    • Risk of death is 3-6 times higher
    • Risk of infection is higher – 20% of women may develop infection and fever
    • Increased use of painkillers and antibiotics by Caesarean mums during their recovery period
    • Longer recovery time – few women are fully recovered by six weeks post-partum
    • Increased risk of miscarriage and ectopic pregnancy next time around
    • Increased risk of placenta praevia (the placenta covering the cervix) and placenta abruptio (the placenta prematurely separating from the uterine wall) in next pregnancy
    • Increased risk of uterine rupture in next birth
    • Increased incidence of post-natal depression following a Caesarean
    Risks to baby
    • Increased likelihood of premature birth, since elective Caesareans are often booked in a week ahead of the due date. This is because it’s easier and safer to cut a non-contracting muscle (the uterus) and do an operation when all the theatre staff are on site and prepared.
    • Significant increase in respiratory distress syndrome (RDS)
    If you have had or may need a Caesarean, contact:

    Caesarean Support Network
    55 Cooil Drive
    Douglas
    Isle of Man IM2 2HF
    01624 661269
    Emotional support and practical advice for women who have had or may need a Caesarean delivery.