Forum on Maternity and the Newborn

AIMS Journal, 1995/6, Vol 7 No 4

Debate: This house believes that Caesarean section rates in the UK are too high.

This meeting (Tues. 12 Dec 1995) was very well attended and the atmosphere was buzzing. Perhaps it was helped by the number of bright midwifery students who were much in evidence.

Prof. Wendy Savage, Obstetrician, Royal London Hospital was one of the proposers to the motion. She based her arguments on her own practice, comparing her outcomes with those of her colleagues. She felt that, even her own hospital intake which consisted of women with considerable numbers of risk factors could still give birth vaginally. In areas of healthier populations, there could be no valid excuse for the rising numbers of caesareans currently being done in Britain.

Our statistics are not high compared to the USA, Brazil and Canada, 20-25%, but Savage felt that our rate which has risen from around 6% in 1970 to 13-15% in the 1990s was indefensible. She defended her argument using charts and statistics all which proved her point. These dealt with outcomes, deaths and current practice which encouraged surgery.

The other proposer was Linda Howes, of VBAC information and Support. She defended the motion basing her argument on the psychological damage done to women who have unnecessary sections and then must return home unsupported, She felt the section rate was too high and queried why some hospitals have low rates, while others seem to have much higher rates.

She felt that restrictions on the numbers of hours a women was allowed to labour contributed to a tense atmosphere and made women feel failures. She remarked, “all they needed was to be left alone with a midwife and allow nature to run its course." Instead they were sectioned.

She objected to many negative terms used by obstetricians such as ‘trial of scar' and ‘failure to progress‘. These terms are used to beat women into submission.

I found both proposed arguments very persuasive, of course and am only outlining them superficially. The fascinating part of the evening for me was the arguments of the opposers.

Joan Pitkin, Obstetrician, Northwick Park was a dynamic and rapid fire speaker. She flashed up statistics and data to prove her points, just as the proposers did before her. Her main thrust however was, that if we lower our rates, which she felt are as low as they should be, we will then pay a higher price for vaginal births.

Her view is that healthy vaginal births can only be achieved if we use the Dublin model of active management. She never once considered the idea of active, undrugged birth achieving the same thing. She also could show statistically that breech babies did not fare well and that their care, long and short term must be considered in the debate. Another important aspect of our current rate of section is that many women choose them. They are “preferable to vaginal birth as a safe and comfortable way to

avoid the pain of childbirth. Many women, she felt know that the surgery is safe (although Savage had her statistics to prove otherwise). Another important consideration is that vaginal birth often results in urinary incontinence - for the rest of one's life, in some cases. The horrible but rarely spoken of risk of faecal incontinence was also referred to as a sad outcome of vaginal birth.

I was fascinated to hear this debate which pointed out how far away this particular practitioner was from active, healthy women in labour. Her view was how pathological normal labour was and how healthy major surgery was to a new mother! Of, course, these were only the 13-15% who needed intervention.

The last opposer to the motion was Kate Costeloe, Paedietrician, Homerton Hospital. She said she approached this debate from the view of the fetus. I found this view astonishing as women rarely view themselves as separate from their baby but Consultants often do. She also mentioned how harmful complicated births can be to the sphincters, how poorly breech babies seem to do and also how life saving caesareans can be to pre and post term infants.

She made a very good point that perinatal rates are not as significant as infant mortality rates which can change dramatically for these babies. They might survive a poor birth but do they live to healthy childhood?

She also queried how many female obstetricians chose to have sections rather than go through the unnecessary pain of childbirth. This kind of statement puts obstetricians in a very poor light, I felt but nobody jumped up to rebut the implication.

The questions from the floor covered a range of topics. Helen Iewison, NCT, said that section rates are only important when put into the context of how many other interferences a women encountered during her labour. Another mentioned that since Changing Childbirth, more low grade practitioners both on the doctor and midwife side amended births and they might be jumpier than more experienced people. Faith Haddad said that communication during and before the surgery could go a long was in helping women overcome their grief or distress. Gina lowdon of VBAC Information queried the statistics which showed how easy it was for women to achieve a VBAC. Her experiences did not show remotely such a cheery picture.

The last person to speak was our own Annie Francis, a long time AIMS supporter and now a student midwife. Amongst the statistics and data she wished to point out one vital fact. Birth is a journey, both for the mother and baby. This is one of life's major formative events and we are denying it to a large birthing population. She reminded us that there was a high cost to pay for doing so. Much to my surprise and delight, she got huge and sustained applause.

The vote for or against the proposition was taken and most people felt the rate was too high. However there was a substantial number of people who voted against, swayed by the arguments which showed how dangerous birth in our hospitals currently can be.

The evening was good for me, as I need to hear how people think who are comfortable with sections. They do not see it was devastating for women, but useful and life saving. Birth to them is not ‘a Journey’. It is a dangerous and sometimes terrifying ordeal which is best dealt with surgically.

As my friend commented afterwards, “How many women would have any real choice if they had these consultants as their doctors?"

Sandar Warshal