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Health: Caesarean births: let women choose

Health Check
WE ARE the product of our experience. That is, presumably, what explains the remarkable finding that one-third of female obstetricians in London would opt for a Caesarean in a normal pregnancy if given the choice.

The figure was cited in a controversial article in the British Medical Journal which argued that pregnant women should be allowed to choose to have their babies by Caesarean section if they wished to avoid the problems associated with a normal labour. But should the experience of London obstetricians dealing with the most difficult labours be taken as representative of women's experience as a whole?

The subject of childbirth arouses strong passions and the article provoked a vehement response.The original argument, put by Sara Paterson-Brown, consultant obstetrician at Queen Charlotte's and Chelsea hospital, London, bears repeating. Although doctors have frowned on the idea of allowing women Caesareans on demand to fit in with busy lives and avoid the pain and unpredictability of labour without sound clinical reasons, attitudes are changing, she wrote.

A clearer assessment of the risks associated with normal labour and delivery has persuaded many women specialists in obstetrics to choose a Caesarean. The risks of vaginal birth include damage to the pelvic floor and to the urethral and anal sphincters which can result in incontinence and an increased long-term risk of prolapse of the genitals. There is also a risk to the unborn baby, with one in 1,500 non-premature babies weighing more than 1.5kg (3lb 5oz) dying during labour. Ms Paterson-Brown wrote: "Elective Caesarean section cannot guarantee normality but it avoids the above problems by virtue of avoiding labour and prolonged pregnancy."

Childbirth, as I have said, arouses strong passions and it is an area where demands for a woman's right to choose have been loudest. Over the last two decades considerable advances have been made in wresting from the doctors control of what is, after all, a natural process, and giving it back to women. This philosophy has entered the mainstream with the publication of the government report, Changing Childbirth, in the early Nineties, which stressed the importance of allowing women to have control of the process.

In the light of this and other government reports urging doctors to respect women's choices in maternity care, Ms Paterson Brown argued that it was unfair for their choices to be discredited because they are not the ones expected. "We are at a turning-point in obstetric thinking brought about not only by advances that have made Caesarean section safe... but also by the attitudes of society which reflect intolerance to risk. We encourage family planning, pre-pregnancy counselling and antenatal screening... can we do all this and then refuse a woman a safe mode of delivery?"

Her critics deny that Caesareans are safer than vaginal delivery, arguing that there is a higher risk of hysterectomy because of haemorrhage, and a greater risk of death. They also argue that doctors are not legally obliged to do everything that patients request, even if they are mentally competent to do so. One pointed out that a survey in Holland found only 1.4 per cent of Dutch obstetricians said they'd opt for a Caesarean in an uncomplicated pregnancy.

My own view is that a woman who feels strongly that she would prefer a Caesarean after hearing all the medical advice should have her wishes respected. In holding this opinion I have no doubt been influenced by the traumatic vaginal birth of my own first son - which ended with forceps under general anaesthetic, with mother's screams finally dulled and father weeping at what he was convinced was the imminent loss of both wife and baby son.

Colleagues who have had happier experiences think differently - that a woman with an uncomplicated pregnancy who refuses the opportunity of giving birth vaginally may be denying herself a rite of passage and a life-enhancing experience - as well as imposing heavy extra costs on the NHS.

Like much else in childbirth, this is an issue that will not yield to simple argument.