We need to fight the myth of 'too posh to push’

Are affluent middle-class women swallowing up precious NHS funds by insisting on caesarean sections? Are the “too posh to push” brigade following in the footsteps of celebrities like Posh Spice and Patsy Kensit in their desire to keep their nether regions unscathed by normal, messy childbirth? Do we, in fact, need psychiatric help to overcome our pathological fear of labour? Certainly, that seems to be the case if you read the draft of the latest guidelines on caesarean sections produced by the National Institute for Health and Clinical Excellence. According to Nice, women who are so afraid of giving birth normally that they want a caesarean section should be offered counselling by a mental health specialist, presumably to be helped to see the error of their ways; or as the watchdog puts it, to help them “address their fears in a supportive manner”. It also points out that, since a normal birth is £800 cheaper than a pre-booked c-section, every 1 per cent reduction in the number of women having caesarean sections would save the NHS £5.6 million. Yet there’s a problem here. While there certainly has been a dramatic increase in caesarean section rates – which now stand at about 25 per cent, more than double the proportion in 1980 – there is precious little evidence to support the myth that it’s the yummy mummies who are significantly driving up the rates. The last big national audit, undertaken by the Royal College of Obstetricians and Gynaecologists in 2004, showed that only about 7 per cent of all caesarean sections were undertaken at the mother’s request. The rest were (and are) carried out for compelling clinical reasons – such as infection, placental problems, or a baby being in the breech position. Significantly, the audit also found that nearly two thirds of caesarean sections in England and Wales were emergency procedures, for the immediate health and safety of the mother or baby. Another study, conducted by British scientists in 2010, found that while there was a large variation in caesarean section rates around England, most of the differences were due to decisions taken in emergency situations, rather than mothers from Chelsea or the Cotswolds asking for surgery that they did not need. So why are caesarean sections on the increase, and how can the numbers be reduced? Without more data, it is difficult to say. The fact that people are giving birth later in life is thought to be one factor: it is well established that older women have a higher chance of difficulties (such as placental problems) that require a caesarean section. Rising rates of obesity and diabetes may be another cause, since both increase the risk. And changes in clinical practice – for example, the continuous monitoring of babies during labour – may lead to more suspicions (not always warranted) that the baby is in distress, which can result in emergency surgery. This ties in to the fear of litigation: a c-section is less likely to get you sued if there are any doubts. Some have claimed that the rise of caesarean sections is due to a growing fear of natural childbirth – but we should remember that being afraid of the pain and loss of control involved in the labour process is entirely understandable, particularly for women who have had a previous traumatic experience. As doctors’ anecdotes suggest, if you’ve already been through a long and exhausting labour, at the end of which you had a harrowing emergency operation, it’s small wonder that you might ask for a caesarean section the second time around. But this ignores the fact that this procedure is not, as some may hope, a convenient way to avoid the pain and exhaustion of labour. It is a major operation, which involves a longer stay in hospital and a higher risk (albeit a low one) of maternal bleeding, infection and blood clots; it also usually involves a six-week recovery period with no driving, shopping or exercise. The fear of labour, and the loss of confidence many people have, can be managed with support, and with good information about other options, be they epidurals or hypnotherapy. To that end, it’s significant that the one-to-one care traditionally provided by midwives, both before and during birth, is fast disappearing – even though it’s the one factor that research has shown to reduce the likelihood of caesarean sections. Undoubtedly, giving more information to women to help them weigh up the risks and benefits of both approaches to childbirth can only be a good thing – and it must be better to talk through your deep-seated fears with a sympathetic counsellor, as Nice suggests, than battle it out with a reluctant consultant. But while counselling may help, it’s unlikely to make a major contribution to bringing down caesarean section rates. And when surgeons report that common operations such as hip replacements are being delayed – and even closer to home, when midwives are complaining that the labour wards are in crisis – you have to wonder where all the extra money for these perinatal mental health specialists would actually come from.