A new report on NHS maternity care has revealed divisions between midwives and obstetricians. One of the disputes ... is over the best way to give birth. While midwives, and the government, advocate natural birth, many female obstetricians opt for a caesarean when they have their own children. Do they know something we don't?
... Sher, 38, chose an elective caesarean ... because she decided it was the safest method ... Sher makes decisions on delivery and surgery every day, and she understands the consequences more than most - she is a consultant obstetrician.
One London study ... reported that 31% of female obstetricians would personally prefer a caesarean birth. In the US, the figure is almost 50%. Many female surgeons and GPs quietly take this option too - though, as one told me, "to admit as much is still massively un-PC".
In April 2007, the then health secretary, Patricia Hewitt, launched her strategy for the future of maternity care. Maternity Matters trumpeted "choice", promising better access to "normal" deliveries via home births and midwife units. Her plans chimed with recent guidelines from the National Institute for Clinical Excellence (Nice) drawn up to reduce caesareans - currently 23% of all births - by advising obstetricians against granting them without medical justification. The official disapproval of elective C-sections means Sher daren't talk under her real name; Stephanie Sher is a pseudonym.
So while the government promotes "normal" deliveries to the public, its employees are privately planning caesareans. Why do so many obstetricians opt not to push? What do they know that we don't?
It's important to remember that it is the obstetrician's and the surgeon's task to remedy the rarer complications and consequences of childbirth. Unlike midwives, who oversee successful, normal births every day, doctors bear witness to the worst-case scenarios.
Inevitably this difference in experience manifests itself in an ongoing debate on how best to manage childbirth. Midwife groups advocate normal delivery and "natural" births while obstetricians tend to see medical intervention as a benefit rather than a bane. Yesterday, the healthcare commission published a report highlighting several key problems in Britain's maternity services, one of which was an inherent tension between midwives and doctors on maternity wards. Caught up in the middle are the mothers.
Maternity experts across the board believe that a straightforward vaginal delivery is by far the best for both mother and baby. Most women agree: 63% of mothers see childbirth as a natural experience that should not be interfered with unless necessary. In "putting women at the centre of maternity provision", the government's strategy reflects the overwhelming consensus.
Nevertheless, among all the furore that surrounds the issue of childbirth, for Sher and her colleagues, one thing is clear: the government's promotion of delivery "choice" is a promise rarely kept. "There is nothing wrong with hoping for a natural event," Sher says, "and for everything to happen beautifully. But it just isn't like that for a large proportion of women."
Sher's greatest fear was not the pain of spontaneous labour. It was the prospect of emergency intervention, if the birth went wrong. According to the most recent NHS maternity statistics made available (2005-6), just under half (47%) of expectant mothers have a regular, uncomplicated "normal" labour. The rest have interventions ranging from induction, to forceps, to an emergency caesarean. In other words, when a woman tries for a normal birth and the best, safest kind of delivery, she has only a 50% chance of achieving it. For a significant number of others, the birth will be more complex.
I wonder if those women had access to one-to-one midwifery care for their pregnancy, birth and postnatal care? When women are put through a system that sees women having a different midwife at every antenatal visit, shifts of midwives in delivery suite and then shifts of midwives in postnatal, it's no wonder that most women do not experience a natural birth. bur when women are cared for by the same midwife right from the first visit to 6 weeks postnatal, the outcomes are very different. The ability to develop trust, rapport and understanding are paramount to experiencing natural birth.
With odds like this, it is not illogical to consider alternatives, particularly not if your line of work exposes you to the most extreme of cases. Many obstetricians find the second safest solution is a planned caesarean. The National Caesarean Section Audit (2001) revealed half of obstetricians think this is the safest delivery method for the baby - though not for the mother.
The surgical risks of a planned caesarean include haemorrhage, thrombosis and infection. Scarring on the uterus means the more caesareans you have, the more risky later pregnancies become. But Sher knew she only wanted two children and made the choice that suited her best - both were delivered by C-section. The baby's safety was her primary motive - but not, she adds, the only one. "The other issue was the risk of pelvic floor damage. Again small, but to me, just not worth it."
... Michelle Thornton, a colorectal surgeon, sees around 100 women a year suffering from faecal incontinence. "I'm seeing the end result of a traumatic birth," she says. "Very few of my colleagues would opt for a vaginal delivery and, if any of them asked me, then it's an elective C-section."
What about planning for a natural vaginal birth and preparing well for an intact perineum and a short second stage? Private midwives are expert at working with women to achieve these aims. Most women who birth with private midwives do not need stitches and experience a healthy return to normal pelvic floor function.
... Not all experts agree that the risks of a surgical birth outweigh the benefit of protecting the pelvic floor. But calibrating clinical percentages is different from witnessing the lives of women with faecal incontinence, says Thornton. "It's definitely altered the way I think about childbirth. The thought of being faecally incontinent - to have a life like my patients - I don't think I'm strong enough."
... Thornton has half a dozen women in their early 30s. They have "bonding issues with their babies . . . as well as young partners expecting to resume a normal sexual relationship. Two of the couples have split up because of the traumas." She counsels patients both psychologically and physically. "Emotionally it is tough," she says. "Having those patients with you when they get upset is tough." When treatments fail, "it's terrible, because the patient is absolutely gutted". Her patients know a permanent colostomy is the only solution. Imparting this news always makes Thornton anxious. "It's a terrible feeling. It's like giving them a cancer diagnosis."
When it comes to medical matters, we assume that knowledge is a good thing. Looking at the childbirth choices made by some female doctors, we might think their superior professional experience makes them right. But many admit their exposure to complications inevitably taints their personal choices. Is it really better to know what they know? Perhaps it's not that most women don't know enough - but that female doctors, and particularly obstetricians, know too much.
... If you've seen deliveries, she says, "you know the reality." And "maybe that's why doctors go and have caesareans - they know it is quite a risky time".
Interesting, as many midwives opt for homebirths when they have their babies.
Consultant obstetrician Virginia Beckett also puts it plainly: "When I was 14 weeks pregnant I dealt with 12 stillbirths in one 24-hour shift. You can imagine that might skew your view of how to manage your labour." (Beckett has had two caesareans, the first because her baby was breach, the second was elective). On that particular shift, her baby was too small for her to feel any movement. Emotionally drained and anxious, she scanned herself in the middle of the night. She needed to know her own baby was still alive.
Beckett has worked in obstetrics for more than 16 years, but dealing with stillbirths "doesn't get any easier". As the obstetrician, you "go in with the machine and with the patient's eyes boring in to the side of your head, make the diagnosis and break the news".
Every time it happens Beckett finds it "heartbreaking, sometimes I do cry actually, not in front of the patient. You feel terrible . . . But there's nothing you can do." In the middle of a busy shift there is no time to reflect. "You can't spend half an hour coming down from every case," Beckett says, "because there will be another one along in a minute."
Complications include "abruptions, where the placenta separates and mum and baby can bleed to death. We see people having seizures with pre-eclampsia or eclampsia. We see people's uteruses rupturing when they've had a caesarean section in the past. We see acute fetal distress. We see very complicated vaginal deliveries using instruments, at which various degrees of injury can be sustained . . . All life is here as they say."
It is the obstetrician's job to control the less palatable, natural, consequences of childbirth. And they are very good at it. The UK is one of the safest places in the world to have a baby. And of the 1,917 babies born each day in this country, just 11 will be stillborn. "We know that when we work effectively we're able to make a difference and that's why we keep doing the job. When it goes to plan, you feel very positive."
And when things go badly? "You feel absolutely awful: drained and disempowered, really." Choosing a caesarean, admits Beckett, is one way of redressing this because "you realise how out of control things can be sometimes" and ultimately, "how fragile life is".
The medics making this choice are unlikely to find support among their colleagues in the midwife unit or even, in some cases, their employers. Current Nice guidelines discourage obstetricians from offering C-sections on "maternal request". Instead, natural births top the government's maternity "menu", with home births promised alongside other "normal" delivery options by 2009.
Privately, however, many obstetricians believe women should be able to choose a caesarean, if they are aware of the risks. Consultant obstetrician Sara Paterson-Brown has publicly asserted a woman's right to an informed choice because "mothers must live with the consequences". Her hospital has not since suffered a stampede of women eager for the surgeon's knife. "Women are counselled and fully informed and recommendations are made," she says. "We don't feel threatened by women expressing their choice."
Paterson-Brown won't tell me how her own children were delivered, but resolutely feels "the best way to have a baby is normally with no complications. The trouble is, you don't know if that's going to be you or not."
The vast majority of women want a vaginal birth. Just 3% of women even ask for a caesarean without medical indication. Almost 25% will end up having one anyway - largely in emergency circumstances - and a substantial number find their "normal" delivery will go seriously off plan. "There is a lot of luck involved," says Beckett, "and sometimes the luck isn't there for you." Doctors know this, lay women don't; and when things go wrong, they blame themselves.
Luck? Is it "luck" if we get a uni degree? Is it "luck" if we pull off a dinner party? Is it luck if we get through a very busy week with everything achieved as planned? Or, is it good planning, good information, good support and confidence in our abilities? There is so much a woman can do to achieve a positive, natural birth: she can inform herself, plan for a great birth, increase confidence and engage supportive care providers. Without this, intervention is the most likely result because that is the world we live in today: a world that is fear-ridden and that seeks to control that which we do not fully understand. I believe that most pregnancy and childbirth "complications" are mediated emotionally and mentally. When women are supported, informed, confident, prepared and cared for by a care provider who supports natural birth, she is most likely to birth her baby naturally.
Dr Abigail Fry remembers one birth as a medical student which turned from "calm" to "completely crazy" when a cautious doctor intervened. It became a difficult forceps delivery. Afterwards she remembers "the registrar doing the woman's stitches and saying: 'Do you think this bit, you know, should go there?' And I was like 'I don't know!' It was a mess." Unlike her obstetric colleagues, Fry chose a home birth.
... "I really enjoyed it." ...
A recent study also found a huge polarity between pregnant women's expectations of birth and the reality. Expectant mothers need not be frightened by rare, unlikely risks, but they should be given realistic information about the pain and unpredictability of childbirth.
How is that not frightening women? "It's going to hurt like nothing else ... it'll be excruciating. Oh, and by the way, birth is also unpredictable so don't have any expectations because they'll be shattered". How about, "The sensations of birth can be managed in many ways such as with water, hot packs, movement, position changes (etc). Birth can be unpredictable and so it might be helpful to spend some time going through some of the more likely issues that can come up and to look at how they might be managed at the time." The latter is far more empowering and less fear-provoking than the former.
Instead there exists a misguided, competitive birth culture; where "lucky" or natural "birthers" are praised for their success, while mothers who "succumb" to medical intervention openly admit they've "failed". Elective caesarean births are so low on the league table they can barely be mentioned without fear of acrimony.
"Women need education," says Linda Cardozo, a professor in urogynaecology, who blames the "brand of doing it naturally" for this competitive approach as well as the trend for the "madness" of home births. "Most are perfectly safe," Cardozo admits, "but if something does go wrong you're in the wrong place to deal with it." Childbirth is a natural process, but she thinks we've forgotten it's also "a natural process for far more mothers to be damaged and far more babies to die, and medical intervention is absolutely wonderful because it's prevented that".
But this does not make Cardozo an advocate of elective caesareans. She remembers colleagues choosing them 20 years ago, but personally felt differently. "You see bad experiences in all deliveries, not just vaginal," she says, besides which, "I truly don't believe the risk is worthwhile.
Caesarean section is an operation and all operations carry a complication rate." So Cardozo did what most women in the UK do, and delivered her three children vaginally, in hospital. Two were twins, one delivered by forceps. "And I'm not incontinent - yet," she says ...