Who says C sections are bad for you?

Everyone from the Royal College of Midwives to the NHS Institute for Innovation and Improvement — the NHS body that enforces best practice — trots out this target. It is, in fact, hard to overestimate the pressure that doctors, hospital chief executives and midwives are under to get women to push out their babies naturally. An emergency Caesarean saved my life, yet when I became pregnant again, it seemed as if NHS staff mobilised so that I could avoid another operation — whether I liked it or not. It made me wonder whether something more than mere medical concern was at work — perhaps political or financial. And when I started to investigate, I discovered that the scale of the problem was greater than I imagined.

No one apart from the World Health Organisation has dared to put a target on the safe level of Caesareans — that’s why everyone uses its statistic. So where is the evidence that halving our C-section rate would be safe? Answer: there isn’t any.

I discovered that the World Health Organisation (WHO) quietly withdrew its target last year. No one noticed, which must have been a relief, because its reason for doing so is embarrassing. In its handbook Monitoring Emergency Obstetric Care, it states that its figure was not based on solid evidence. “Although the WHO has recommended since 1985 that the rate not exceed 10-15 per cent, there is no empirical evidence for an optimum percentage . . . the optimum rate is unknown,” it says, before concluding: “What matters most is that all women who need Caesarean sections receive them.”

So is our whole healthcare system — and the 130,000 women who have C-sections every year in Britain — labouring under a false premise?

One medical study, Myth of the ideal Caesarean section rate, says: “On the face of it, Caesarean section is just an alternative way of delivering babies. Yet discussion about it is rarely dispassionate.”

No truer words have been said. Most mothers long for an uncomplicated natural birth. Few rave about Caesareans — often for emotional as well as medical reasons. They can feel guilty for letting down themselves and their bean-bagged National Childbirth Trust ante-natal classes. The WHO’s target added to this feeling, with every extra C-section adding to the “bad” statistics.

I spoke to several of Britain’s leading obstetricians in the light of the WHO change of heart, and they wanted a different, less emotive, debate. As Bryan Beattie, consultant in foetal medicine at the University of Wales, says: “The pressure to reduce rates is huge, and a lot of it is cost. I know a number of female obstetricians who had elective Caesareans themselves. But they refuse the opportunity to their patients because of the pressure from the hospital trust to reduce rates. That just says it all.

“I think the issue from an NHS point of view will be less a medical than a political one: can we afford to spend our resources on Caesareans?”

First, how did the WHO get in such a muddle? There have long been arguments over how often Caesareans should be used. Scientific principles are hard to apply, because no one likes to experiment on their babies. A proper trial of the safety of C-sections would allot pregnant women either a normal birth or a Caesarean at random — something that would be hard to swing with mothers. It means the evidence is still less solid than anyone would like. Everyone agrees that a “good” vaginal birth is best, and that C-section are bad for anyone planning a large family. But a complicated natural birth, with tearing or instruments versus a planned Caesarean? Much harder to call.

I tracked down the man who set the target, Marsden Wagner, a retired American paediatrician who was for 15 years the director of women’s and children’s health at the World Health Organisation. Many of the obstetricians that I spoke to said that the 15 per cent statistic “was plucked out of the air”. Wagner denied this, saying that his team looked at the best data available. “Obstetricians hate this recommendation,” says Wagner. “They love C-sections, because it means they get to cut and to make more money.”

Wagner was shocked that the WHO target had been withdrawn. “The authors of this handbook are the WHO physicians who are so damned scared of making physicians angry so they come up with a pathetic waffling statement. There is good international data that going over 15 per cent increases maternal deaths.”

Quite a few beg to differ. Amy Tuteur is an American obstetrician who runs a website that specialises in analysing the safety of Caesareans. She says that WHO figures actually suggest that a Caesarean rate of 15 per cent is “unacceptably low”.

“There are only two countries in the world that have C-section rates under 15 per cent and low rates of maternal and neonatal mortality — Croatia and Kuwait — and neither is known for the accuracy of its data,” says Tuteur. “Even rates up to 32 per cent or more seem to be consistent with excellent outcomes.”

The reason Tuteur thinks that C-sections have risen is because they are safe — one survey found that most UK doctors thought they were safer for the baby (the risks to the mother are more in question). “Our attitude to risk has changed. If you tell doctors that no neo-natal death is acceptable, then the C-section rate is going to go through the roof. No one has thought through the real dimensions of the problem.”

But also, no one has told the leading medical bodies to stop focusing on a target. When the NHS Institute for Innovation and Improvement brought out its “toolkit for reducing Caesarean section rates” last November it added: “There is a general belief amongst clinicians that maternity units applying best practice . . . will have aspirations to reduce that rate to 15 per cent.”

Cathy Warwick, head of the Royal College of Midwives, says that she was not aware that the advice in the WHO handbook had changed. However, she adds that the rate of Caesareans in Britain and other developed countries is “still too high”.

While individual NHS trusts aspire to reduce these rates, there are real costs to women’s lives, says Pauline McDonagh Hull, a campaigner who runs the electivecesearean.com website. She believes that in cases where the risks of a Caesarean are finely balanced, a woman should be allowed to choose. “But some hospitals just point blank refuse.”

Every doctor I spoke to wanted changes that they know will bring down Caesarean rates: one-to-one midwife care and more consultants in the delivery suites. But targets? No.

Professor James Walker, a spokesman for the Royal College of Obstetricians and Gynaecologists, says: “The WHO’s 15 per cent was an arbitrary figure, decided largely under pressure from America. There is no evidence to suggest that a rising Caesarean rate is to be encouraged, but the relative risk of a Caesarean has reduced in the past ten years. The difficulty is if you say it should be lower, that’s just an opinion. There is no evidence to say what it should be.”

Other doctors are concerned that the NHS is not taking into account the risks to women’s health of vaginal birth — because they do not show up until later life. A survey of female obstetricians found that a third would choose a C-section for themselves, mainly to protect their pelvic floor from damage. “ I’ve been doing this for 20 years , and if I was a woman planning only one baby, I’d have a Caesarean,” says Beattie.

Gordon Smith, head of the University of Cambridge Obstetrics & Gynaecology department, says that it is “very plausible” that our Caesarean rate will continue to rise. This may be for good reason: research suggests that older, fatter women find it harder to get the baby out, and there are more of them now. “If you have a biological reason for Caesareans going up, and you try to enforce idealised rates, the potential is that you discourage individuals for whom a Caesarean might be in their best interest,” says Smith.

In October, the National Institute for Clinical Excellence will announce a new edict on when and how often doctors should perform NHS Caesareans. Hopefully, it will notice the WHO’s change of heart. But the big battle will be between two opposing pressures: the rising safety of Caesareans, and the rising cost. Will they make cuts, or make cuts?

Vaginal Birth

Pros

Less risk of maternal haemorrhage, infection, blood clots, damage to internal organs

Less risk of baby having specific respiratory problems immediately after birth

Shorter hospital stay (one to three days) and quicker recuperation In later pregnancies, labour may be shorter

Mother less likely to require C-section in subsequent pregnancies

Cons

Risk of oxygen deprivation to baby from cord compression or problems during delivery

Risk of perineum tear

Risk of additional trauma to baby when passing through birth canal, or from forceps or vacuum extraction

Risk of pelvic organ prolapse after delivery (protruding into the vaginal canal, causing discomfort and possible incontinence)

Elective Caesarean

Pros

Possible decreased risk of incontinence in later life

Reduced risk of oxygen deprivation to baby during delivery

Reduced risk of birth trauma to baby

Cons

Risk of damage to the mother’s bowels and/or bladder Increased maternal blood loss and risk of needing a transfusion

Risk of complications from anesthesia (pneumonia, allergic reactions, low blood pressure)

Higher risk of infection and blood clots for the mother

Longer hospital stay (three to five days) and longer recovery period

Internal scar tissue may cause problems in future C-sections

In later pregnancies, risks to the mother increase, whether she delivers vaginally or by Caesarean