It is doctors, not mothers, doing the pushing here

March 9, 2007

Caesareans are on the rise not because women are demanding them but because obstetricians are advocating them, says Helen Churchill

If the tabloid press is to be believed, women are becoming "too posh to push". The rich and famous have been blamed for sparking a huge rise in requests for Caesarean sections to avoid the pain of natural childbirth. Certainly, women are more than four times more likely to have a Caesarean now than they were 30 years ago and eight times more likely than 50 years ago.

In the 1950s, about 3 per cent of births were by Caesarean. The latest data show a rate for Britain in 2005 of just over 24 per cent. My research, presented this week, suggests this rise is not the result of maternal choice. This notion is a myth that has been fuelled by stories of celebrity mothers. Surprisingly, it is a myth that is widely believed.

The report from the Office of Health Economics that appeared in the press last week does not point to maternal request as a factor. But it appears that many obstetricians would disagree. When we conducted the first survey of obstetrician opinion 15 years ago, only 2 per cent mentioned maternal request as a reason for the rising Caesarean rate. In our most recent survey, published last year, 44 per cent said they believed the rise was due to more women asking for the operation. Perhaps obstetricians are confusing "choice" with "agreeing to". Or it could be that doctors are actively encouraging women to "choose" Caesarean birth.

From a small survey of women who had Caesareans in 2005, I found that the overwhelming majority had not asked for the procedure. In fact, out of 200 individuals, only 39 told me that they requested the operation and of them only six were first-time mothers. So it seems that if women are asking for a Caesarean - and only a small minority are - they are doing so on the basis of previous experiences. Almost 70 per cent of those requesting the operation had had previous Caesareans. Importantly, this figure has not changed much over the 15 years that I have been doing these studies.

So when women ask for the operation it is usually because of a pre-existing condition or previous experience that ended in a Caesarean. The National Sentinel Caesarean Section Audit in 2000 reported that in the UK only 5 per cent of mothers stated that they would prefer to deliver by Caesarean.

Again, women who had had a previous operation were more likely to express this preference. Interestingly, in England the ratio of planned to emergency Caesareans has remained constant over the past 20 years, further evidence that calls into question any argument suggesting that maternal request is driving the rate rise.

The media hype has focused on celebrity mothers. But affluent women are more likely to be using private hospitals where Caesarean rates are much higher than in the National Health Service, so it may have something to do with the culture of women in that position. It certainly does not apply to the rest of us.

We need to take media attention away from women being "too posh to push", having "designer vaginas" or any of these other attention-grabbing headlines and concentrate on what lies behind the fact that almost one in four women is not giving birth naturally. This is, indeed, a problem medically. A vaginal birth has always been safer for both mother and baby, with less mortality and morbidity than a Caesarean. Such births are also cheaper. Based on the estimate that a Caesarean costs about £1,500 more than a vaginal delivery, the NHS could save more than £80 million annually if it halved the Caesarean rate.

So if requests from women are not pushing up the rates, we need to look long and hard at other reasons for the increased use of Caesareans, such as presumed foetal compromise, dystocia (failure to progress), the management of breech presentation and the management of birth for women with previous Caesareans, together with the viability of vaginal birth after Caesarean.

Obstetricians we contacted also suggested another possible reason - the inexperience of junior doctors and the practice of defensive medicine. Some 52 per cent of consultants in our survey suggested that this was the reason for the rise. So perhaps we should be looking to obstetricians' pressure for Caesarean section and not women's.

Helen Churchill is health studies subject leader and senior lecturer at Manchester Metropolitan University and co-author of Caesarean Birth in Britain , published by Middlesex University Press, £18. She spoke at Birth: The Cultural Politics of Reproduction at Lancaster University on Wednesday.

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