The kindest cut?

The imminent birth of Madonna's child is the most public of the year; that she may elect to have it by Caesarean is a much-touted rumour. Would it be a shocking choice, or a good idea? By Emma Haughton

When Lucy Turner, a London midwife, became pregnant with her first child she was very clear about what she wanted for the birth. Thirteen years of witnessing difficult deliveries and their aftermath had persuaded her that, although she had no problems during pregnancy, there was only one civilised option: a Caesarean.

"I was worried about the pain of labour," she says. "I know you can have an epidural but they don't always work. And then there's the chance of ending up with forceps or an emergency Caesarean.

"I've seen women so exhausted by long labours they can't even hold their baby, and others left with bad tears, long-term incontinence or pelvic floor problems. And in labour, babies can become distressed or come out all bashed about by forceps. I just didn't want all that."

Six months on, Lucy is the mother of a baby boy and has no regrets about her decision. Knowing her delivery date, she was able to plan ahead for the birth, while epidural anaesthesia meant she could undergo the operation alert and pain-free, with her husband by her side.

"It was marvellous, much better than my expectations, and there was absolutely no trauma for the baby. I'd happily do it again."

She now believes the Caesarean option should be open to all women, regardless of whether there are medical grounds. "Why not? If you've got to have your leg amputated, wouldn't you rather have a general anaesthetic? Why suffer all that pain if you don't have to?"

Is Lucy simply a maverick, someone who has been turned off normal labour and delivery by the downside of her job? Not according to Debbie Chippington Derrick, co-author of a book on Caesareans, to be published by the National Childbirth Trust later this month. Some women with perfectly healthy pregnancies, she says, are now opting for Caesareans - the ultimate in "managed care" - for no other reason than fear of childbirth.

"There aren't any figures available," she stresses, "and I suspect it is only happening on a small scale, but some women are choosing Caesareans, either to avoid the pain of labour or because they fear damage to the pelvic floor. Some have had an appalling birth experience the first time around - they just can't face it again."

Over the past decades many countries have seen a relentless rise in Caesarean births. In the US (where Madonna is rumoured to be scheduled for one this month) rates are up from 6 per cent in 1970 to 23 per cent in 1990, while in Brazil more than a third of women have their babies by Caesarean in order to maintain a tight perineum and the "honeymoon freshness" demanded by their husbands.

In Britain one in seven women now has a Caesarean compared with less than one in 100 only 25 years ago. While most of these, whether planned or emergency, are performed on medical grounds - a low-lying placenta and a large baby in a small pelvis are among the most common - a survey carried out in 1994 found that 52 per cent of obstetricians and 46 per cent of midwives believed that requests by women were a driving force behind the increase.

At Queen Charlotte's Hospital in London, where 3 per cent of planned Caesareans are carried out at the woman's request, Professor Nicholas Fisk believes all women should have the right to choose.

"All the discussion about consumer choice in maternity services is taken to mean the right to have natural home births, not the other way round," he says. "But there are a lot of logical arguments why women may be better off with a Caesarean."

Principal among these is the damage that can ensue when babies are born via the normal route. According to Fisk, "a third of women who have a vaginal delivery experience urinary incontinence three months after the birth, and a third sustain injuries to the sphincter that can lead to anal incontinence. Constipation, piles, painful perineum, all these things are common, especially after a forceps or ventouse. It's these things that are changing people's attitudes."

And nowhere faster than among fellow obstetricians, apparently. Fisk's survey of 282 London colleagues, published in The Lancet in March, found that 31 per cent of female obstetricians would request Caesareans for themselves, even if there were no clinical problems. Eighty-eight per cent cited fear of perineal damage, while 58 per cent were concerned about their long-term sexual function.

Fisk is a definite Caesarean enthusiast. He points out that nowadays, with antibiotic cover and drugs to prevent blood clots, Caesarean surgery is extremely safe for the woman and he also claims that, when planned, it presents a lower risk to the baby, given that one in 5,000 full-term babies die and one in 300 suffer oxygen shortage during vaginal birth. "People say labour is natural and God never designed babies to come out this way, but do you find a great demand for natural, home dentistry?" he says. "We should be prepared to take informed choice and client empowerment to its logical conclusion."

But Fisk's views are strongly disputed by other doctors. Dr Marion Hall, a consultant obstetrician in Aberdeen, says there is no hard evidence that high Caesarean rates save lives: "There is no research which shows benefits to the baby and, with the high risk of pulmonary embolism, haemorrhage and infection, Caesareans are certainly more dangerous for the mother than vaginal delivery." She also believes that women have a "wonderfully elastic arrangement for having babies" and that with the right midwifery support, most will come through vaginal birth relatively unscathed. "For women with a really morbid fear of labour, a Caesarean might be justified, but otherwise it would be malpractice to agree to it. You really need to be able to show the outcome will be better to justify such a major medical intervention."

But why should any woman be so terrified of vaginal birth that she would rather opt for major surgery? Chippington Derek says it is a "real indictment" of the way women in labour are treated, while Caroline Flint, head of the Royal College of Midwives, believes many obstetricians are themselves indirectly responsible. "Women are becoming more and more afraid of childbirth," she says. "They are being told, in effect, that labour is devastating, dangerous and painful. It's terrible that women feel it's so awful; for many, birth can be a very positive experience."

The request for a Caesarean can sometimes mask deeper anxieties. Sheila Kitzinger, childbirth writer and researcher, says: "A great many women suffer sexual abuse as children or adults and find it very difficult to accept that that part of their body can work and they can feel positive about it. Vaginal birth, with all the examinations it entails, can feel very threatening." But whatever the reason, she argues that if a woman feels very strongly that she wants a Caesarean, doctors should respect that decision.

What women considering Caesareans may overlook is that, while the operation itself may be safer than it has ever been, it still entails, usually, several days in hospital and six weeks of not being able to drive or even do simple things like walking upstairs holding the baby.

"You miss out on many things people take for granted, like changing your baby's first nappies," points out Gina Lowdon, Caesarean adviser for the National Childbirth Trust and the Association for Improvements in the Maternity Services (AIMS). "It can be a very difficult period, especially if you've already got children."

Having experienced both a Caesarean and a normal labour, Lowdon found the pain of contractions easier to bear than that caused by the surgery. "Labour hurts, but it's like the pain of pushing yourself to your limits, it's something you cope with, like running the London Marathon - you wouldn't thank someone for putting you in a wheelchair for the last 100 yards.

"The pain of a Caesarean is different; it keeps on hurting even after you've had the baby."

Not all those who have had Caesareans feel they are the best thing since sliced bread. Even when the operation is advised on medical grounds, it can leave a woman feeling robbed of a fundamental experience.

Deniece was fit, healthy and looking forward to the birth when she was told at 35 weeks that her baby was breech.

"From then on the pressure was really on to have a Caesarean. The consultant said I could try for a vaginal delivery, but that he would have my legs up in stirrups, would use forceps, and would have to cut me from here to kingdom come."

Despite a "wonderful" operation which she was able to watch, Deniece still has regrets about what happened. "Afterwards I was in agony for six weeks. I could hardly walk and felt like I'd been run over by a bus."

A Caesarean, she says, is not the easy option. "I felt very disappointed not to have had Bethany naturally"