Denise and her blog
Caesarean Birth Is Not A Lifestyle Choice!
The alarming rate of Caesareans, not just in the UK but in other countries too, is of grave concern. There is, of course, a multitude of reasons, not least the incidence of greater pathology in many women, lack of midwives to help maintain physiological birth, obstetric and managerial fear of litigation from failure to act when labour deviates from physiological progress and changing social trends in relation to childbirth and parenting. In the UK we are fast approaching a 50% Caesarean rate; in private care in South Africa, it can be as high as 90%. I cannot believe that almost 100% of the birthing population has so many issues that operative delivery is the only answer. However, with induction of labour rates at 60% or more in some UK units, it is hardly surprising that the “cascade of intervention” leads to increasing indications to manage and control birth.
Sadly, as I’ve mentioned before, Caesarean has become so normalised that young couples accept it as something that is, without challenge, part of their childbearing journey. My almost-daughter-in-law said she hadn’t made her mind up yet about the possibility of having a Caesarean, as if it is a lifestyle choice (no criticism intended, Ninka – and having twins in South Africa definitely increases the possibility of needing one). But Caesarean is not something on which you can make a decision until the time comes, usually shortly before or during labour, that indicates its necessity. It’s not like choosing whether to buy a new car or become vegetarian or change jobs.
Many expectant parents seem to take it in their stride that Caesarean may be needed, but I doubt they fully understand its implications. Caesarean is a major operation, the risks of which have been belittled by its frequency. It carries risks for both mother and baby that are rarely discussed at length with parents, just that it is “necessary”, with little opportunity to opt out. It has long-term sequelae that are almost never mentioned, not least a longer postnatal recovery time and the possibility of poor parent-infant bonding. Having a Caesarean is like having your appendix out – and having a baby as well. It is difficult enough recovering from physiological vaginal birth and caring for a newborn baby which, for most, is a completely alien concept until it happens. There is no rule book for caring for newborns – you are just expected to get on with it, deal with the sleepless nights, the difficulties of learning to breastfeed, the change in relationships between partners and sometimes the loss of identity for those who may, even temporarily, be stay-at-home parents rather than the competent professionals they were before pregnancy.
Caesarean birth – and its little sidekick, induction – are at risk of changing the microbiome of the human race. Will women evolve with zips down their abdomens that can conveniently be opened to lift the baby out? Women’s bodies are intended to become pregnant and to give birth – billions of people for thousands of years have been doing just that. Yes, there are some who experience difficulties or even die in childbirth, but that is not usually dependent on operative delivery – of course, in some cases, surgery can be a lifesaver for either or both mother and baby. But whilst we continue to normalise such deplorable and increasing rates of what can only be termed operative assault on women’s bodies, the higher the rates will rise.
Expectant parents need the facts, applied to their individual situations rather than a blanket policy of reaching for the scalpel as if all other avenues have failed. They need to know the benefits and the risks of both having or not having a Caesarean. As a society we need to stop treating major surgery as a minor inconvenience. And professionally, we need to acknowledge that childbirth is a normal biopsychosocial life event that, in the main, progresses without complications and brings a baby into the world without drama or trauma. Caesarean is NOT a lifestyle choice!
Birth Of My Son
My son, Adam, was born at home in July 1989, after a 24 hour labour with a four hour transition, ending in a forceps birth (yes, at home – it’s not what you know but who you know!) The consultant obstetrician was a friend who agreed to care for me even if it meant coming out to the birth. Adam was 10lb four ounces (4.3 kg). I was looked after by two midwives who were friends; my husband spent the very hot day washing cars and ordering in pizza for the midwives, whilst I huffed and puffed my way through first stage. To think Adam has just celebrated his 37th birthday is amazing.
See his proud grandfather with a newborn Adam.
Paternalism in Maternity Care: The “Just In Case Syndrome”
The recent intrusive national ‘phone alert advising us that the weather is hot (really?) and we should avoid bonfires and disposable barbecues (err…?) was a true example of the paternalistic nature of governments. Isn’t it common sense to consider the risks of fire on excessively hot days? It is just another example of the population being told what to do, what not to do, what to eat, how to bring up our children and all manner of things that should be the responsibility of individuals. Personally, I object to this patronising approach which implies that only those in government know what should be done – and I have turned off my ‘phone’s alert system. I work on the theory that if World War III breaks out, someone will tell me (or I’ll be dead so won’t have needed the national alert anyway).
Examples of paternalism in healthcare include Covid vaccinations, fluoridisation of public water supplies, taxing foods with high sugar content to discourage consumption and restricting the number of aspirins allowed in one purchase. Now don’t get me wrong, there are some examples of positive paternalism which are for the greater good of the population, such as compulsory education for children or imposing speed limits when driving. However, even a well-intentioned paternalistic approach affects people fundamentally without their consent and focuses on populations rather than individuals.
In maternity care, we see this all the time, with increasing frequency and for increasingly spurious reasons. This is what I call the “just in case syndrome” – the “you’re 42 weeks so we’ll just book you in for induction on Thursday” or “I’m just going to attach a clip to the baby’s head to monitor the heartbeat” or “we’ll just transfer you to labour ward because …” approach. And let’s not even get into the almost unspoken actions of routine synthetic oxytocics to manage third stage labour or vitamin K injections for all babies.
There is an arrogance about these litigation conscious, risk-averse interactions (or lack of) with expectant and birthing parents that presumes that professional expertise is superior to individual choice. I absolutely endorse the role of midwives and obstetricians in guiding parents towards safe childbirth, but we see many examples of unthinking bias in decision-making. Much of this comes from a professional autonomy that presumes authoritative knowledge and experience, yet increasingly this is not the case.
University-led education for midwives supposedly encourages critical thinking but does not emphasise skills and the application of detailed theoretical knowledge to demanding clinical scenarios. Midwifery management focuses on institutional numbers – staff, money, risks etc – but seems incapable of applying these statistics to the provision of high-quality care. National directives, especially NICE guidelines, make clinical recommendations based on “evidence” – either in support of an intervention or dissent for humanistic and – dare I say it – physiological non-interventions.
“Informed consent” is another example of paternalism in maternity care. Parents may be given the reasons why a particular action is “necessary” but rarely are they given comprehensive information about the risks of that action. They are, of course, always given the risks of not “agreeing” to the proposed action. It is conveniently forgotten that “informed consent” also means the “right to decline” – and this should be an unconditional right without censure or coercion to conform.
When I was first a midwife in the 1970s, there was definitely an element of midwives and doctors “knowing best” – and perhaps at that time, this was true. The public respected authority and felt happy with their interactions with the professionals. Certainly, we had more time to care for women. There were far fewer choices to make, and women were guided by the information they were given. However, as more information has become available to the public, expectant parents are generally better informed (despite – or perhaps, because of - “Dr Google” and Co-pilot). People want to remain in control of their experiences of having children, yet the fear factor of professional caution, compounded by the media’s influence on healthcare knowledge, leads to courses of action that leave parents feeling dissatisfied and sometimes traumatised by their experiences.
We have had numerous investigations over the last fifty years, and I have seen them all come and go. Maternity Care in Action, Changing Childbirth, Better Births, Amos and Ockenden – and NOTHING has changed – or at least not for the better. Yet another set of “experts” comes out with yet another solution to the maternity care situation – and nothing works.
The sooner we relinquish our paternalistic approach to pregnancy and birth care, the more parents are treated with respect as individuals rather than a cog in a government-managed wheel, the better we will be able to get back to what maternity care is about – helping women through a normal physiological life-event that does not (usually) need to be medicalised and does not need to be controlled by paternalistic professionals and a paternalistic government.
Previous articles
Caesarean Birth Is Not A Lifestyle Choice!
Birth Of My Son
Paternalism in Maternity Care: The “Just In Case Syndrome”
Transitioning Role From Midwife To Grandmother
Midwifery, Aromatherapy and Natural Birth Under Attack Again
About Midwifery
Quality Of Education In Midwifery Complementary Therapies
Safe Maternity Care
The Publication Of The Ockenden Report
More from Denise at the 34th ICM Congress in Lisbon
