Birth rights

KAREN Sanderson has two words for the kind of modern woman who feel it is their right to 'book a birth'. "They are bonkers," she says robustly. About 1.5 per cent of all births in England and Wales are caesareans carried out for non-medical reasons.

It is a phenomenon that has led to the label 'too posh to push' to describe the type of woman who chooses a caesarean in preference to natural birth for no other reason than to fit it into their busy lives, or because they are frightened by the thought of labour.

Karen has little sympathy for them. Her own first child - daughter Abigail, who is nearly seven - was born by emergency caesarean in a hospital in Rotherham when medics became worried that the baby was in danger.

As it turned out, she had not been at risk at all. But Karen, who now lives in Huntington, York, has been left with an overwhelming feeling of loss and guilt at missing out on the birth of her first child.

The operation was carried out under a general anaesthetic. Karen was unconscious for two hours and, because of the effects of the anaesthetic, remembers very little of the four days she spent in hospital.

"I feel I missed out completely," she says. "Abigail was my first baby and I missed out on being a parent. I wasn't there when she was born."

To this day, she admits, she still feels overly protective towards her eldest daughter as a result.

"I feel as though I have to make it up to her," she says. "As though I wasn't a proper mum."

When her two other children - Gabrielle, now four, and Luke, 22 months - came along, it was a very different story.

Despite having had two miscarriages after Abigail was born, Karen opted for a home birth when it was time to have Gabrielle - mainly because she was determined she wasn't going to have another caesarean. The hospital had told her that because she'd had a caesarean previously, she would have to be under close supervision during labour in case she needed another.

Instead, she chose a water birth at home, supervised by independent Yorkshire midwife Chris Warren.

Everything went smoothly. Labour lasted 12 hours, and it was like a 'classic first-time birth' says Karen because she had not given birth naturally before.

But the feeling of holding this tiny scrap of humanity in her arms immediately afterwards was "unbelievable", she says.

"I have never felt so empowered in my life. The midwife passed her up to me and I held her straight away.

"There was this enormous feeling of relief that I had done it, and I felt more of a woman than I had ever felt."

It was the same with Luke and it is that overwhelming feeling of satisfaction that makes her so cross with women who want to efficiently book a date in their diary to have a pre-planned caesarean.

Not that she has anything at all against caesarean sections for those who need them for medical reasons. "There are women who are never going to be able to give birth naturally so, thank God, we have got the ability to help them," she says.

The fact is, however, that the number of women giving birth by caesarean is rising.

Most recent figures reveal that on average, 21.5 per cent of all births in England and Wales are by caesarean. Most of those are for what medical staff describe as medical reasons - but in 1.5 per cent of births, the caesarean is carried out for non-medical reasons.

There are a number of reasons for the rise in caesarean births according to Adrian Evans, consultant obstetrician and gynaecologist at York Hospital.

Better diet means babies are getting bigger and there is some evidence that mothers are getting less exercise before birth, which can make it more likely that a caesarean will be needed.

Some women also have a genuine phobia about going into labour, which in itself can justify a caesarean on medical grounds, he says.

Then there is a very small minority of women who want a caesarean because they think it will be easier or more convenient.

In a bid to reduce the number of women having operations they don't really need, new guidelines from the National Institute for Clinical Excellence (NICE) urge doctors to discuss the pros and cons of caesarean versus natural births with women whenever a caesarean is being considered.

They stress that doctors should not automatically agree to a caesarean when a woman asks for one if they don't think it will benefit the health of either woman or baby.

"If a woman is frightened of giving birth, she should be offered the chance to discuss her fears with a counsellor," the guidelines say.

"The doctor has the right to decline a request for a caesarean section but should offer to refer the woman to another doctor."

The most common medical reasons for recommending a caesarean include lengthy labour that is failing to progress; risk to the mother or baby and breech presentation.

Women who have had one caesarean are also more likely to recommended for a caesarean next time around.

There are, however, complications involved with caesarean sections.

A caesarean, says independent Yorkshire midwife Chris Warren, is a major operation, and carries all the risks that go with that.

Exactly what the risks are will depend on individual women and their condition. In fact, the evidence is unclear about whether caesarean involves more or less risk for a baby.

But women who give birth by caesarean are overall five times more likely to die than women who give birth naturally (though the figures are tiny, 82 women out of every one million dying as a result of caesarean, compared with 17 out of every million as a result of natural birth); they are more likely to suffer abdominal pain and bladder injury and they are more likely to need a hysterectomy.

Added to all this is the fact that women who undergo caesareans typically take much longer to recover from the effects of giving birth, and have to stay in hospital twice as long (three to four days, compared with one or two days for a natural birth).

Chris Warren is saddened by the growing number of women having caesareans. Sometimes it can be the best option, she concedes - whether for medical reasons, or for emotional reasons such as a fear of labour.

"But the fact that some women are opting for what is clearly a more dangerous procedure is a sad reflection on how we in society view birth," she says.

Adrian Evans says that after discussing the situation fully with a woman, if she is still determined to have a caesarean, he will respect her wishes.

"If they are aware of the risks of a caesarean compared with normal delivery then we cannot categorically say no," he says. "A woman does have the right to choose. We have to give patients choice."

But while the rise in the number of caesareans may not in itself be something to celebrate, there is good news, he says.

In 1970, when only about five per cent of births were by caesarean, about 25 out of every 1,000 babies died. Now, when more than 20 per cent of births are by caesarean, only 7.5 out of every 1,000 babies die.

That is progress in anyone's book, even though the increased survival rate is down to a number of factors, not necessarily the use of caesareans.

Mr Evans points out that, regardless of the method of delivery, his concern is simply with the health of mother and baby. "What we want is to have a healthy mother and baby leaving the hospital, irrespective of their route." he says. "That's what we are aiming to achieve."

No one would argue with that.

Pros and cons of having a caesarean

Caesarean birth

Risk of mother dying: 82.3 deaths per million women giving birth

Risk of abdominal pain: 9 per cent

Risk of bladder injury: 0.1 per cent

Likelihood of admission to intensive care: 0.9 per cent

Length of hospital stay: 3-4 days

Likelihood of readmission to hospital: 5.3 per cent

Risk of incontinence three months after giving birth: 4.5 per cent

Natural (vaginal) birth

Risk of mother dying: 16.9 deaths per million women giving birth

Risk of abdominal pain: 5 per cent

Risk of bladder injury: 0.003 per cent

Likelihood of admission to intensive care: 0.1 per cent

Length of hospital stay: 1-2 days

Likelihood of readmission to hospital: 2.2 per cent

Risk of incontinence three months after giving birth: 7.3 per cent

Updated: 10:43 Thursday, April 29, 2004