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Over the last 40 years, the proportion of women giving birth through caesarean section has risen swiftly and steeply to reach levels once thought the preserve of the United States, where most medicine is defensive medicine. More than a fifth of all births in England and Wales are now caesareans - in 2000, they accounted for 21.3% and 24.2% respectively, according to the comprehensive audit carried out by the Royal College of Obstetricians and Gynaecologists published last October.
With England, Wales and Northern Ireland (23.9%) leaving most of Europe way behind to pace the US (22%), the burning question of the moment is whether we are on the way to becoming another Brazil, where the rate is over 35% and women actively seek caesareans even when there is no medical need for them. This contrasts markedly with the Scandinavian countries, which have half our caesarean rate (Sweden's is 12.2% and Norway's 12.6%) without any increased danger to mother or child.
The easy assumption is that the caesarean has become almost a style trend for affluent women who are, as the tabloids coined it, "too posh to push". But the image falls apart under closer analysis, not only in Brazil - where, according to recent studies in the British Medical Journal, women choose caesareans because of hospitals' poor labour care and lack of pain control - but also here. The truth, as is often the case, is more complicated.
The royal college's national audit gives us the clearest picture to date of what is going on, not just in the maternity wards but also in the heads of women having babies and the obstetricians caring for them. According to the consultants who were surveyed, just 3% of pregnant women requested a caesarean for completely non-medical reasons and about half of those requests were agreed to. Out of all the caesareans performed in 2000, 7% were done because that was what the woman wanted.
Out of 2,475 women in 40 different maternity centres who were also surveyed for the audit, 5.3% said they would prefer to deliver by caesarean section, and most of those were women who had delivered a previous child by caesarean. Almost all the women in the survey said they wanted a birth that was "the safest option for their baby".
The report notes that surveys in the UK and in Brazil have found that doctors under-appreciate their influence on a woman's decision-making. Their attitude towards caesarean sections is therefore arguably at least as important as that of the women themselves. The college audit found different views among obstetricians as to what was an acceptable caesarean rate. The median considered "too high" was 20%, but 21% of the consultants - all working in different units - said that they were not at all concerned by a high rate. While most (78%) agreed that a caesarean was not the safest option for the mother, a slim majority (51%) thought it was the safest for the child. The audit notes that obstetricians who are male or who are less experienced are likely to have a higher than average rate of caesarean sections.
Interestingly, obstetricians are keener on the idea of a caesarean for themselves or their partner than most of the rest of the population - a survey in Ireland found 7% wanted one and in the US 46% said they would opt for the operation. Their attitudes are completely the opposite of those of midwives, 96% of whom said in a separate survey that they would prefer a vaginal delivery.
The older the woman, the more likely she is to have a caesarean. With women choosing to have fewer children and to have their children later, the proportion of births to older women has gone up. In 1975, 6% of mothers were over 35, but by 1995 this had risen to 11% and now it will be higher still. Older women are more likely to have complications in their pregnancy, but the audit says that this is probably not the only reason why they have more caesareans - their own or their consultant's preference will also play a part.
While 37% of caesareans are "elective" - planned in advance - the majority are carried out as emergencies. Over 70% are carried out for one of four reasons: failure to progress during labour, foetal distress, breech and as a repeat caesarian in cases where the woman had gone into labour but not wanted or not been able to deliver vaginally.
Although a caesarean can be life-saving in some of these circumstances, the US and Canada have succeeded in bringing their rates down by focusing on other ways of managing some of these births. Given that other countries successfully and safely have much lower rates of caesareans, it is obviously possible to intervene less or less early, as long as the mother, midwife and consul tant are happy about it.
But that is where the issues around the institutionalisation of birth come in, as well as staff shortages. Time and again it has been shown that caesarean rates are brought down if women in labour are given one-to-one care by a midwife, while hi-tech hospitals are likely to do more caesareans (although that is partly because they are referred more complicated cases). The audit found that 93% of maternity units achieved continuous support of the woman in labour at least 60% of the time. However, the view from the ground is different. According to midwives and the National Childbirth Trust, midwives are often in such short supply that they find themselves moving between rooms, having to support more than one woman in labour at a time.
Sarah Boseley, health editor
The Guardian
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