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18 June 2001

Why mums are turning their backs on nature

Too posh to push? No: growing numbers of women think caesarean births are better

By Anna Picard

The Guardian‘s women’s page recently ran the following extract from an interview in Hello! magazine, in which Mandy Smith (the ex-child bride of the Rolling Stone Bill Wyman) described her experience of giving birth by caesarean section: “Ian took pictures of me giving birth and I’ve got my hair done, my lipstick on. Of course, everyone tells me it would have been quite different if I’d had a 40-hour labour. But that’s just the way I’ve been ever since I was a little girl, always wanting to look my best.”

What was the purpose of this? To give us a laugh at Smith’s expense. To mock her for getting above herself instead of squatting and grunting through the pain like the rest of us, all messy and sweaty and ugly. For being idle and vain. For being yet another of those bloody selfish women who just can’t be bothered to go through labour as nature intended. But, as Hello! magazine informed its readers – and the Guardian significantly didn’t – Smith’s caesarean was a matter not of maternal laziness, but of medical necessity: her baby was in the breech position. So much for sisterhood.

This year, at a cost of £26.6m to the NHS, more than one in five babies will be delivered surgically. In the face of a powerful professional and amateur natural birth lobby, caesareans have risen 17 per cent over the past 30 years. No one knows why. The National Childbirth Trust has blamed the scant availability of one-on-one midwifery. The Royal College of Midwives has blamed litigation-wary obstetricians. Then, at last month’s Royal College of Nursing conference, the finger was pointed at celebrity mothers – specifically, Victoria Beckham, Melanie Blatt and Zoe Ball. In the bitter words of the delegate Rebecca Gray, modern women are “too posh to push”, too busy with their “careers and social lives” to make time for an unscheduled labour.

Elective caesareans – those without medical reason – have become “trendy”, thereby presenting a serious financial challenge to the NHS, and an ideological challenge to the advocates of natural childbirth.

Are women really choosing surgical deliveries as a fashion statement? Or are they just sick of being told by the natural- birth brigade to grin and bear a painful and unpredictable process? In the absence of any hard epidemiological evidence, the entire responsibility for the rise in caesareans has been laid at the pedicured feet of Nurse Gray’s richly imagined Nemeses: impressionable and career-conscious girls who want to have their babies just like Posh Spice had hers. It’s quite an image – all fake tan and Filofax – but why the condemnation? The successful delivery of a healthy baby is the optimum result of every pregnancy, so, provided the mother’s wishes are respected, does it really matter how this is achieved? I don’t think so. But then, I chose to have my baby by elective caesarean.

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As Sara Paterson-Brown, a consultant gynaecologist and obstetrician at Queen Charlotte’s and Chelsea Hospital, says: “The old idea of vaginal delivery at all costs no longer holds true.” Traditionally, the more prosaic risks of prolapse, incontinence and sexual injury from a difficult vaginal labour have paled against a caesarean’s potentially fatal complications. But the oft-quoted 90 per cent risk of post-operative infection is drawn from all caesareans, including emergency, scheduled (due to gestational problems) and elective. Recent anecdotal evidence suggests that the risks are dramatically reduced in scheduled sections, and reduced still further in electives. Some radical surgeons have even suggested that, for healthy women, caesareans may now be the safest method of delivery. Add to this the low incidence of cerebral palsy, and it’s not surprising that some women are calmly exchanging one set of risks for another, and turning their backs on natural birth.

Ball, Beckham and Blatt have little to do with this. Outside the glossy world of private medicine, elective sections are hard to come by. It is not celebrities and their imitators who are leading the march to the operating theatre; it is professional middle-class women in their thirties or forties. They are the ones who will pick through the propaganda and statistics, argue until they have proved their understanding of the choices they have made, and change hospital in order to find a sympathetic consultant. For “posh”, read educated and bolshie.

Although the natural birth hegemony was formed on the back of a similar fight for autonomy, this latest step in empowerment has not been welcomed. While purporting to be in favour of “maternal choice”, the current culture does little to support those who actively want pain relief, who don’t give a fig about aromatherapy, who find the prospect of labour unromantic, and who just want to get on with the business of getting to know their as-yet unseen child, and supporting it. For those who have their baby by caesarean – planned or otherwise – it offers nothing.

Over the past three decades, natural labour has stopped being one of several choices; it is an imperative. What started out as a middle-class construct is now clothed in the mystique of a religion. The implication of the labour-centred orthodoxy is that if your child is born by C-section, you are not just being unsisterly by taking the attention of three midwives, you are also being unwomanly. Search through the pregnancy books for positive references to caesareans, and all you will find is commiseration. Small wonder that one Leicestershire nurse reported counselling a 60-year-old woman who still felt guilty for having “failed to give birth normally”.

“Nature knows best,” thundered the leader column of Scotland’s Daily Record last month. “Babies should arrive in their own time, not to fit in with a career mum’s timetable.” Nature can be an absolute bitch. Most first labours follow a decade or two of wearing unnaturally high heels and sitting in front of a computer. A cushy maternity leave (or a high-earning partner) will give you several months to get in touch with the teenage gymnast peasant within – if you’re lucky. Few first-timers manage the ideal of a drug-free labour. A significant proportion of women who set their hearts on natural labour will end up having an epidural, an episiotomy, an instrumental delivery, or even an emergency caesarean. For the sake of all these women, natural labour should not be accorded such superiority.

But natural birth is also politically, and financially, potent. Even the government’s plan for improving maternity services follows its model. The pledge from the Health secretary, Alan Milburn, to increase the number of midwives came with a strap-line highlighting greater freedom for women who wish to give birth at home. It’s grand stuff, but will more funding also be provided for the growing number of women who want caesareans? Caesareans are expensive. According to the National Childbirth Trust, the current cost is £2,500 per section (between £750 and £1,000 more expensive than a normal labour) – although, as more evidence of ongoing health problems after vaginal labour is factored in, these figures will also change.

Another delegate to the Royal College of Nursing conference, Denise Chaffers, asked: “Should women who opt for caesareans take midwives and paediatric staff and resources away from other women?” No, they should not. But nor should they feel blackmailed into vaginal labour because of chronic funding shortages.

The saddest aspect of this debate is how divisive it has proved among female health practitioners and their clients. Why are other women’s choices threatening? Why, in an age when we have achieved so much autonomy, is there such emphasis on childbirth without pain relief and such disdain of women who either want or need to get back to work? For most women, careers are not a luxury, but a necessity. The crude and reactionary classification of women as callous career-girls and smiling, suffering madonnas isn’t working. Male and female roles have been overturned in the past half-century. Families have transformed, and childbirth must change, too.

Perhaps the Spice Girls have played a part in the caesarean backlash, after all. In this post-feminist era, women – “posh” or otherwise – don’t take kindly to being bossed around by anybody, not even by a consultant or guru. A woman’s right to choose has to be defended, and paramount in the childbirth debate is the separation of social, financial and medical issues. If this is a question of the overall funding of maternity services, then let’s discuss it. But don’t dress up this debate as one of solidarity, sisters.

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