Cutting remarks


Rather belatedly (it’s been a very, very busy week), I’ve just watched Monday’s One Born Every Minute, which featured the families of three babies born by caesarean.

There are a lot of people out there who think people like me – a doula, an antenatal educator, running a home birth group – are against caesarean. In fact I even had a meeting with our local head of midwifery yesterday, and I said something about ‘the caesarean rate,’ and was instantly subject to a series of sentences about how caesareans were necessary, they saved lives, and all the rest of it. Despite not looking like a lentil-munching yoghurt weaving natural birth evangelist, sometimes I’m assumed guilty by association.

It’s a difficult one to unpick, actually, and as my career in the perinatal arena develops, I actually become more and more ambivalent about caesarean. To start with I found the idea of major surgery in order to deliver a baby almost chilling, and slowly, as I’ve learned more and more about this increasingly common method of birth, I’m not *in favour* as such, but definitely not *against*.

These days it comes back to two issues, then. The first one is informed choice – as long as a family has an idea of what they’re letting themselves in for by making the decisions they do, that’s fine. And the second is letting the birthing woman – and the rest of her family – do what works for them, both physically and psychologically.

There’s no doubt that a caesarean is a major op, and with that the risk of complications arising from birth is much higher than with a vaginal birth. But if a family understand that, and are happy to take that risk, then all power to them. I might get called ‘anti-caesarean’ if I were to point out some of these risks, but I still feel I need to do that, because it’s a lesser evil than dealing with a shell-shocked ‘why didn’t you tell us x or y or z’ if, God forbid, one of these risks comes to fruition. Most of the time they don’t, and the vast proportion of women bounce back absolutely fine, even pleased with the way they have given birth to their baby.

Doing what works for you is, to my mind, the biggie, though. It’s just not my place to judge how you, or anyone, is going to give birth. It’s not up to me – I haven’t occupied your shoes or your body or your mind, and you know what works for you. Just like these two families, both of whom I felt for. One was expecting her fourth baby, but, as she put it ‘only had one at home’ – she felt so out of control throughout the pregnancy, with deep seated and well founded fears that perhaps her baby would again not survive – that removing the prospect of labour was essential to her emotional wellbeing. Who am I to even comment on the appropriateness of that decision? The other was expecting twins, one of whom had a congenital abnormality that might not fare well in a vaginal birth. Ditto.

Why, then, do I carry around an impression of anti-caesarean with me? I suspect it’s because the vast majority of pregnant women who I come across want a vaginal birth. And I want what they want – an uplifting and empowering experience of birth that leaves them feeling physically and emotionally fit. And if that’s what they tell me they want, then I see it as my job to help them explore how they can achieve it. Part of that has to be building a couple’s confidence in a woman’s ability to birth her baby vaginally IF THAT’S WHAT SHE WANTS, and part of that, alas, is sometimes exploring what decisions might be taken in labour that increase the likelihood of a caesarean happening.

The world heath organisation claims that beyond a caesarean rate of 10% to 15%, we don’t save any more mums or any more babies. Still, in this country we’re looking at a rate of about 25%, and rising, and that means, slightly chillingly, that somewhere between 10% and 15% shouldn’t have been. But you can’t transpose the politics into individual cases, and I suspect that one of the caesareans we saw this week would have fallen into that category – and equally I suspect that everyone who worked with the family would have wholeheartedly accepted that there was a deep-seated need to have that caesarean – it just wasn’t a physical need. And it’s a common story – I can think of at least three families I’ve worked with who were in a similar situation.

And that’s where the WHO stats come unstuck a little bit. Because technology has given us an amazing gift with this wonderful, life-saving operation, and has also offered up with it a poisoned political chalice. An expectation from everyone who works in birth to position themselves on one side of the fence or the other, a perfect opportunity to pigeon-hole: are you in favour or are you against?

For or against? Permission to be both, m'lud?

I don’t care how high that fence is, then, I’m going to do my best to straddle it. I will straddle it by pushing boundaries – by suggesting to women that if they would like to, they request that labour start spontaneously before their elective section. That they have more than one birth partner in the room if they’d like to. That the lights be dim as possible, that the mum be handed her baby almost instantly, that the screen is down, that there is as long a delay as required before the cord is cut.

Professor Nicholas Fisk has been pioneering the ‘natural’ caesarean, which incorporated many of these aspects, as well as an attempt to mimic the second stage of labour with a slow, pushing-like period during which the baby emerges gradually. I would like to see something closer to a ‘mother-and-baby-centred’ caesarean where, instead of routine policy and a passive mother to whom a baby is simply delivered, nothing is taken for granted and the birthing woman is truly given as much scope to make the decisions surrounding the birth of her baby as is possible and feasible given the circumstances. Then, truly, the baby’s arrival is not a caesarean section, but a caesarean birth.

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~ by Kedi Simpson on March 6, 2011.

2 Responses to “Cutting remarks”

  1. I’m happy to join you on the fence. The way I try to explain it in classes is that we are lucky to live in a time and place where birth is safer than it’s ever been, and we’re lucky to have the technology to perform caesareans safely and efficiently and to minimise the very real risks they carry.

    BUT, for whatever reason, we also seem to live in a time and place where birth is feared. Where pain is always seen as something to be fixed instantly, and where the very safety of birth has led to an expectation that everyone always gets a good outcome.

    It’s such a minefield, and it is political. I’m right at the beginning of my midwifery training as you know but I have been so lucky to see normal, midwife-led births – in birth centres *and* in the big consultant led unit – and once you’ve seen the power and beauty of a woman birthing her own baby there’s nothing to beat it.

  2. nce again Kedi you have beauifuuly exprssed what is in my hear and inn thaI find so hard to put into word! Genius! Well said! AndItoo join you atop the fence!!

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