Should we think of birth as normal, or as dangerous?


A few weeks ago I gave a talk to a group of health professionals about the impact of a traumatic birth on relationships. At the end of the talk, an obstetrician in the audience took me gently to task for using the phrase “when birth goes wrong”: problems such as retained placenta or postpartum haemorrhage were so commonplace, she said, that they were a routine part of the experience, rather than a sign of something going wrong. She added: “The day she gives birth is – apart from the day she’s born – the most dangerous day of a woman’s life.”

It was a striking comment, and one I’ve been thinking about ever since. There is an alternative view of childbirth, which is that it’s a “normal, physiological process”. It’s a view that’s endorsed by the Royal College of Midwives (RCM), and some NHS trusts have appointed midwives to act as “normal birth leads”, helping women to “achieve” a normal birth. Many midwives believes that an important part of their job is to support women to give birth “normally” – that is, without a caesarean section or intervention such as forceps or Ventouse. Proponents of normal childbirth would argue that an over-cautious approach to risk is in itself damaging, leading to unnecessary interventions that result in a more traumatic experience for mother and baby.

Childbirth is possibly unique amongst medical specialisms in that it is dominated by two professional groups who to some extent have competing views of what the job is about. Obstetricians see risk and danger; their job is to make sure that mother and baby come out of the process alive and, ideally, unharmed. Midwives see their job as supporting women to do what their bodies are designed to do: women have, after all, given birth for the entirety of human existence, and are therefore quite capable of doing so today.

You can see, of course, that both arguments have merit. Lots of women do have straightforward births, with minimal intervention. In the past, certainly, unnecessary medical intervention (the eagerness to induce labour, or speed it up artificially, or to give women episiotomies as a matter of routine, or to force them to give birth lying down) worked against the female body’s ability to do what it is designed to do, which is to push a baby out.

On the other hand, you can’t deny that, left to labour without intervention, things don’t always go according to plan: the baby is in an awkward position, or the birth canal is too narrow, or the baby’s shoulder gets stuck on the way out, or the placenta is retained and the woman haemorrhages.

Are women’s expectations too high? Or too low?

I hesitate to suggest there should be a happy medium, because I don’t know what a happy medium would look like. But what bothers me about all this is that women are caught in the middle of two competing narratives. Obstetricians at the talk I gave expressed the view that the reason some women find birth traumatic is that their expectations are too high: they think that they can give birth “normally”, with minimum intervention, and are then disappointed to find that that isn’t the case.

But where does that expectation come from? Not, surely, from an innate sense of hubris or over-confidence, but from imbibing the message that it’s possible to achieve a normal, problem-free childbirth by taking a positive mental attitude: if you believe in your own body’s capacity to give birth, the argument goes, then you’re much more likely to have the birth you want than if you approach it fearfully.

Thus are women caught in a Catch-22: going into birth in the hope and expectation that your experience will be “normal” means that you are more likely to be traumatised when things don’t work out as planned; going into birth with an awareness of all the potential problems and risks mean potentially that your own feelings of fear and anxiety will make the experience more difficult and painful.

And women get the blame. Women’s choices are mocked: they are “too posh to push”, for example, or they are “selfish” for wanting a home birth, free of intervention. They are naïve or silly for imagining they can give birth naturally; or they are wasting the NHS’s money by demanding a planned caesarean. A woman’s place is in the wrong, James Thurber once wrote: and if we’re talking about giving birth, then Thurber hit the nail squarely on the head.






Traumatic births: women tell their stories

It can be hard for women to speak out about their traumatic birth experiences. There’s a widespread perception that all that matters is a healthy baby, and that women should be grateful for a modern system of medical care that means they are unlikely to die in childbirth.

Of course, it’s great that most of us don’t die in childbirth any more. But not dying is setting the bar pretty low for our expectations for medical care. If we go into hospital for surgery, for example, we do usually expect a bit more from the care we receive than simply “not dying”.

So I welcome it when women are prepared to talk about what happened to them in childbirth and to highlight some of the poor practice that still exists. A new photo series called Exposing the Silence gives a voice to women who have experienced shockingly bad care.

The women in the photos speak of having procedures such as episiotomies or membrane sweeps performed without their consent or of being able to feel themselves being cut during caesarean-sections. A lot of the women speak of the trauma they felt after having their preferences ignored or dismissed.

These stories come from the US, but I’ve heard similar experiences in the UK. The story recounted by one of the women is not, sadly, uncommon:

“‘Do you understand you are doing this without my consent?’ As they are putting needles into my arm, I’m telling them, ‘You are doing this against my will.’ Their response, even as my strong contractions grew faster and I was in active labor, was, ‘I can’t wait all night, and we are doing this now.’ Less than an hour later, he was born, taken from me before I could hold him longer than a minute or two, and not returned until almost three hours later, even though he had no complications. I cried every minute and couldn’t stop thinking, this isn’t supposed to be like this.”

Is it a good idea to reduce the caesarean rate?

Caesarean section rates in western countries have been rising for a long time – but the rate varies widely between different countries. In Sweden, for example, it’s 17%, while in Cyprus it’s 52%.

It’s not at all clear why rates differ so much. Reasons often cited for high caesarean rates include: the increase in older first-time mothers (for whom pregnancy and labour is riskier); the increase in overweight mothers (ditto); the fact that babies are getting bigger; a trend for women to request a planned caesarean section; increased medical management of labour, which sets labour on a path culminating in emergency caesareans; and a cautious approach by doctors who fear litigation.

This is informed speculation, however: the only way to know for sure would be to record and collate the reason for every caesarean section, and that doesn’t seem to happen. I am slightly sceptical of the idea that the increase is down to women requesting the procedure. It provides a handy narrative and another pejorative term for women (“too posh to push”) but the truth is that the majority of caesarean sections are performed as an emergency procedure, and there are often medical reasons for planned sections (breech presentation, placenta praevia).

Does it matter?

This is the interesting question. In Australia, one in three babies is born by caesarean, one of the highest rates in the world. There is pressure to reduce the rate: caesareans, it is argued, pose an increased risk to the mother and baby. An article in the Sydney Morning Herald quotes Andrew Bisits, the medical co-director of maternity services at the Royal Hospital for Women in New South Wales:

“People forget that a caesarean is a relatively major operation. It’s an instant trauma to the body. It’s anything but keyhole surgery. I think that fact sometimes gets lost and people forget that you can get through a normal birth with no scratches or just a few scratches.”

In New South Wales, a policy to reduce the c-section rate and increase the “normal” birth rate has been unsuccessful, with c-section rates remaining fairly static. According to the Herald article, there has even been an increase in the number of women having induced labour and forceps deliveries. More women “are having major haemorrhages after they give birth.”

One obstetrician, Professor Hans Dietz, argues that the “increasing push towards natural birth is having the unintended consequence that more women are having longer, more difficult labours”. He says:

“In the past it was two to three hours of unsuccessful pushing before obstetricians intervened, now it may be six. It has the advantage that some women will push their baby out, but the risk that some will be left with a post-partum haemorrhage.”

The article goes on:

“He estimates that for every 10 caesareans prevented, it is likely that four additional tears to a woman’s levator muscle – which holds the pelvic organs and bowel in place – occur, and four additional sphincter tears.”

Dietz is also sceptical about the oft-cited dangers of caesareans:

“In my entire clinical life, how many women with major later life health problems due to caesarean have I ever seen? I can’t remember a single one. How many after forceps will I see? Several a week, at least 100 a year, maybe 200 a year,” he says.

So, is the drive to push down the caesarean rate misguided?

The short answer is: I don’t know. I suspect that nobody else does either. The Herald article demonstrates that people who work in maternity services have vastly differing views on the subject.

For women, it’s bewildering. Few, I imagine, are delighted at the prospect of surgery to deliver their baby; but even fewer want what Dietz describes as the potential consequences of a difficult vaginal birth: “urinary and fecal incontinence, prolapse, sexual dysfunction, years or decades later.”

What we need is more data: why caesareans are performed; the health consequences for women (and their babies) who deliver this way; whether reducing the caesarean rate results in better outcomes for women and their babies; the particular factors that lead to an assisted delivery; the physical and mental health consequences for women and their babies who have an assisted delivery; the correlation between factors such as age, weight and social class and method of birth.

Until we have that data, women will continue to be the unwitting victims of an argument that rages between professionals without coming to a satisfactory conclusion.