Caesarean and vaginal births compared

Posted by in Economics, Feminism, Health, Politics

This is not a simple choice. Much is at stake for medical insurers, practitioners and professionals which colours the information provided to women. Consider the following typical newspaper article:

Headline: One in six NHS trusts do not offer caesareans on request – Birthrights charity suggests blanket bans could be incompatible with human rights law:

Almost one in six NHS trusts in the UK do not offer women caesarean sections on request and many more have inconsistent policies, a charity has said. Official guidance states that women should be offered a planned c-section “if after discussion and offer of support … a vaginal birth is still not an acceptable option”.

But Birthrights found that 22 out of 147 trusts who responded to a freedom of information request did not offer maternal request caesareans (MRCs). A further 70, almost half, had policies that the charity deemed problematic or inconsistent, thereby creating a postcode lottery, Birthrights said.

The organisation’s chief executive, Rebecca Schiller, said: “Maternal request caesareans are the number one reason women contact the Birthrights advice service. The women we support have endured previously traumatic births, physical ill-health, childhood sexual abuse or have carefully examined the evidence available and made informed decisions that planned caesareans will give them and their baby the best chance of an emotionally and physically healthy start”.

Above, we see the articulate and well-paid CEO of a private charity using very carefully chosen words to frame caesarians as an emotionally and physically positive choice.

“It is clear that women requesting caesareans meet judgmental attitudes, barriers and disrespect more often than they find compassion and support. We are concerned that this lack of respect for patient dignity could have profound negative consequences for the emotional and physical safety of women.”

Above, opposition to elective caesareans is characterised as lack of respect for patient dignity.

Of the 22 trusts Birthrights classified as not offering MRCs, some had an explicitly stated policy not to do so, others did not specify whether or not they did so but were found not to have carried out any in 2016-17, and some said they did offer them but sent out information to pregnant women that contradicted this. Some of the trusts with an explicit policy not to offer MRCs still told Birthrights they would do so in exceptional circumstances.

The charity claims that a blanket ban on MRCs could be incompatible with human rights law and lawyers acting for Birthrights wrote to one of the trusts – Oxford University Hospitals NHS trust – last month about what it claimed was such a policy at John Radcliffe hospital.

In response, the trust said its practice in providing MRCs was in line with National Institute for Health and Care Excellence guidance, in that when its obstetricians were unwilling to perform it they referred the woman in question to a neighbouring trust.

Veronica Miller, the trust’s clinical director of women’s services, said: “A caesarean section which is not clinically indicated may have serious consequences for a woman and her baby … All requests are considered on an individual basis and a plan for the woman’s care put in place.”

Almost three-quarters of NHS trusts were found not to have written guidelines clearly committing to a woman’s right to have an MRC and only 39 were found to offer caesareans in line with Nice’s best-practice guidance.

Both the Royal College of Midwives (RCM) and the Royal College of Obstetricians (RCOG) and Gynaecologists said that the rights of women who wanted MRCs needed to be respected. Gill Walton, the RCM chief executive and general secretary, said: “Midwives have an important role in supporting women who request caesarean section and respecting their reasons.”

Dr Alison Wright, the vice-president of RCOG, said she was disappointed by the findings. “This denies women choice about their birthing experience and highlights the importance of trusts updating policies and guidelines to ensure women have access to safe and personalised care,” she said. “We strongly believe that women’s voices and choices should be respected and supported to ensure a good birth.”

Above, we see the professional organisations who should be giving evidence-based advice giving in to political pressure.

Kasia Lech-Hill, 37, is scheduled to have a caesarean on 3 September but it has taken four stressful months to get to that point. The university lecturer, from Canterbury, Kent, said: “It’s happening in two weeks but it took a lot of time and a lot of hours and a lot of pushing.”

Lech-Hill was told by her eye doctor that because she has a thin retina, pushing during a vaginal birth could risk the retina detaching, potentially causing blindness. “I raised this from the beginning with my midwives but they said they didn’t recognise this as a reason,” she said. “I had a doctor from Poland [where Lech-Hill is from originally] and they said it would be better from a British doctor and even better, a doctor from east Kent.”

Lech-Hill went to see a GP, who initially refused to refer her to an eye doctor. “I was very much faced with the ‘too posh to push’ attitude,” she said. She said the GP only agreed to refer her when she said she would pay to see an eye doctor privately, which she was forced to do, but the specialist was unsympathetic. “When I got really upset, he told me to manage my emotions better. It’s extremely sexist. I said: ‘Can you guarantee nothing will happen to my eyes?’ He said: “No. But even if it does, you can’t be sure that’s the cause.’”

It was the obstetrician who eventually agreed to a caesarian. “She approved it straight away on medical grounds but until then everyone was telling us we weren’t going to able to do it, how irresponsible it was, how it would be harming the baby,” said Lech-Hill. “It feels like you’re doing something wrong, you’re not following the maternal route. It’s been extremely stressful, I had panic attacks. I was just blaming pregnancy and hormones but as soon as she said ‘you can have a caesarean’ I felt like something in my stomach had changed.”

Lech-Hill was so worried that she was considering going overseas to have her baby. While she is relieved that she does not have to travel, she said there remained a stigma attached to it. “The judgment is still there,” she said. “The perception is that you’re not prepared to be a proper mother, who’s prepared to push.”

Finally above, here is the sympathetic reinforcing personal case, where a women achieves their choice of elective caesarean against medical opposition. Not included is the sound foundation for that opposition – eye pressure is independent of bodily blood pressure as anyone with knowledge of glaucoma would know.

Below, here is an abbreviated evidence-based summary of the pros and cons for both mother and child (links to full sources at article end):

Pros of vaginal birth for the mother:
A vaginal birth is that it has a shorter hospital stay and recovery time compared with a C-section. Women who undergo vaginal births avoid having major surgery and its associated risks, such as severe bleeding, scarring, infections, reactions to anesthesia and more longer-lasting pain. And because a mother will be less woozy from surgery, she could hold her baby and may begin breastfeeding sooner after she delivers.

Cons of vaginal birth for the mother:
During a vaginal delivery, there is a risk that the skin and tissues around the vagina can stretch and tear while the fetus moves through the birth canal. If stretching and tearing is severe, a woman may need stitches or this could cause weakness or injury to pelvic muscles that control her urine and bowel function.

Some studies have found that women who have delivered vaginally are more likely to have problems with bowel or urinary incontinence than women who have had C-sections. They may also be more prone to leak urine when they cough, sneeze or laugh. After a vaginal delivery, a woman may also experience lingering pain in the perineum, the area between her vagina and anus.

Pros and cons of vaginal birth for the baby:
Some advantages for a baby who is delivered vaginally is that a mother will have more early contact with her newborn than a woman who has undergone surgery, and she can initiate breastfeeding sooner.

During a vaginal delivery, muscles involved in the process are more likely to squeeze out fluid found in a newborn’s lungs, which is beneficial because it makes babies less likely to suffer breathing problems at birth. Babies born vaginally also receive an early dose of good bacteria as they travel through their mother’s birth canal, which may boost their immune systems and protect their intestinal tracts.

If a woman has had a long labor or if the baby is large and delivered vaginally, one of the risks is that the baby may get injured during the birth process itself, resulting in a bruised scalp or a fractured collarbone, according to the Stanford School of Medicine.

Pros of C-section for the mother:
A surgical birth can be scheduled in advance, making it more convenient and predictable than a vaginal birth and going through a long labor.

Cons of C-section for the mother:
A woman who has a C-section typically stays in the hospital longer, two to four days on average, compared with a woman who has a vaginal delivery. Having a C-section also increases a woman’s risk for more physical complaints following delivery, such as pain or infection at the site of the incision and longer-lasting soreness.

Because a woman is undergoing surgery, a C-section involves an increased risk of blood loss and a greater risk of infection. The bowel or bladder can be injured during the operation or a blood clot may form, she said. The recovery period after delivering is also longer because a woman may have more pain and discomfort in her abdomen as the skin and nerves surrounding her surgical scar need time to heal, often at least two months.

A review study has found that women who have had a C-section are less likely to begin early breastfeeding than women who had a vaginal birth.

Once a woman has had her first C-section, she is more likely to have a C-section in her future deliveries. She may also be at greater risk of future pregnancy complications, such as placental abnormalities and uterine rupture, which is when the uterus tears along the scar line from a previous C-section. The risk for placenta problems continues to increase with every C-section a woman undergoes.

Women are three times more likely to die during Caesarean delivery than a vaginal birth, due mostly to blood clots, infections and complications from anesthesia, according to a French study.

Pros and cons of C-section for the baby:
Babies born by Caesarean section may be more likely to have breathing problems at birth and even during childhood, such as asthma. They may also be at greater risk for stillbirth.

During a C-section, there is a small risk that a baby can get nicked during the surgery. For reasons that remain unclear, some studies have also suggested a link between babies delivered by C-section and a greater risk of becoming obese as children and as adults. One possible explanation is that women who are obese or have pregnancy-related diabetes may be more likely to have a C-section.

Below is a personal case illustrating more detail on some of these key C-section risks:

When I hear women debate whether it’s better to have a vaginal birth or a Cesarean section, I’m able to offer a rare perspective: I experienced both—in the same delivery. I popped out my first twin, Toby, the old-fashioned way. But my second little guy, Ian, was delivered by emergency C-section after his umbilical cord dropped down before he did, potentially compromising his oxygen supply.

Needless to say, I’m grateful to have had that C-section; but in the absence of an emergency situation like mine, I’d choose a vaginal delivery any day. It sure beats staples in your belly, a catheter in your bladder, intense gas pains, a longer hospital stay and recovery, and double the risk that you’ll land back in the hospital with an infection.

If you’re having a repeat C-section (you’ll probably need to if your first delivery was via Cesarean) or if your baby is being delivered before 39 weeks, the chance that your baby will have to spend time in the neonatal intensive care unit (NICU) also doubles.

To be sure, C-sections are safer now than in decades past. This is largely because of improved surgical techniques and better antibiotics to protect against post-operative infection, and because regional (local) rather than general anesthesia can usually be used. Yet compared to women who deliver vaginally, those who deliver by planned Cesarean are 2.3 times more likely to be re-hospitalized within 30 days (19.2 out of 1,000 women for Csections, compared with 7.5 for vaginal births).

The risk of death is extremely low for babies who are delivered via planned Cesarean to lowrisk mothers with no labor complications—about 0.75 deaths per 1,000 live births. Yet according to a 2008 study of more than 8 million U.S. births over a three-year period, this rate is 69 percent higher than the neo natal death rate for planned vaginal deliveries.

A much more common concern is respiratory distress. Newborns delivered via Cesarean before 39 weeks gestation (about one-third of all scheduled C-sections) and babies delivered via repeat Cesarean are twice as likely to be admitted to the NICU for breathing problems. C-section babies also have higher rates of childhood asthma. “Being pushed through the birth canal squeezes fluid from their lungs, so babies delivered vaginally tend to have fewer respiratory issues,” explains OB-GYN Bonnie Wise, M.D., an associate professor at the Northwestern University Feinberg School of Medicine in Chicago.

Perhaps the best reason to avoid a nonessential C-section for your first baby is so you aren’t forced to have a second—or third—surgery. The potential risks associated with pregnancy after a C-section and with repeat Cesareans are serious. Uterine scarring from a previous C-section leads to a much higher risk of placenta previa (when the placenta partially or entirely covers the cervix) and placenta accreta (when the placenta burrows into the uterine muscle rather than simply attaching to the lining). Both conditions can trigger lifethreatening hemorrhage in the mother, either during labor or after giving birth.

What the statistics say about the reasons C-section rates are rising in developed countries:

Statistical analysis of a hospital’s recorded reasons for rising C-section rate notes the major recorded medical reasons are relatively subjective, and discusses organisational and policy changes which contributed (link to full story below).

Regression analysis concludes legal liability is positively correlated with (ie statistically likely to influence) choice of delivery method in the influential US health system.

Finally, a cohort study of successive patient groups over time concludes “increase in the prelabour caesarean delivery rate for private patients in private hospitals has been driving the increase in the overall (UK) caesarean section rate.


Evidence-based summary of pros and cons for mother and child:

Personal story on C-section disadvantages which personalises the risks:

Statistical analysis of contributors to rising C-section rate:

Statistical analysis on factors influencing choice of delivery method:

Cohort study on public and private rates of caesarean section:

Medical management article illustrates the difficulty of reducing C-section rates when service providers are articulate and

“Experts have their say” article, reframing the debate as womens choice:

Guardian headline: “One in six NHS trusts do not offer caesareans on request – charity” and “Birthrights suggests blanket bans could be incompatible with human rights law”:

Guardian leading paragraph “Women should formally have the right to choose to give birth by caesarean section”: