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We need to reduce number of Caesareans

For labour suite read battleground.

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Since long before Macduff was “from his mother’s womb unkindly ripped”, childbirth has provoked endless argument. Caesareans are back in the news this week after the National Institute for Health and Clinical Excellence (Nice) decreed that women in England and Wales who ask for one should get their wish, even if there is no clinical need. It is hard to frame this as anything other than Caesareans on demand, though the Nice people stressed that mums would be offered counselling first.

Marvellous, isn’t it? This Government does its level best to chain women back to the kitchen sink with policies that have left more than a million of them out of work and threaten many thousands more by cutting help with childcare, freezing child benefit and the rest. Then, having realised that women are deserting them in droves, they come up with a great offer: “OK girls. Got the message. Tell you what. How about Caesareans on demand? Whenever you like, you too can have your stomach slashed open in an operation comparable to a hysterectomy that will leave you unable to stand up straight for six weeks. And, by the way, here’s a baby to look after at the same time.”

Of course, I jest but only a little. In fact, Nice is essentially merely admitting to the situation that has existed in practice for years. Reducing the number of C-sections has been a key recommendation of successive health strategies on both sides of the Border but the percentage of women who end up having one continues to rise. At 25.4% it is even higher in Scotland than England.

Exactly how we got here and where one stands in this debate almost invariably involves individuals generalising from their own experience. In the past week we’ve heard from one who nearly died after a Caesarean and another whose friend lost her baby when a vaginal birth went wrong. Feminists fall into two camps: those who see Caesars as an extension of a “woman’s right to choose” and those who see them as symptomatic of the mechanisation of a natural process, largely for the convenience of (predominantly male) consultants. After three natural births, I guess I’m in the latter camp. Two decades ago I avoided one particular consultant after discovering that most babies in my village were born on a Monday (to fit in between his private clinics). His production-line approach inevitably resulted in a disproportionate number of both inductions and C-sections.

The rise and rise of Caesars has less to do with what every woman wants as what doctors decide. It’s partly out of fear of litigation. This story isn’t about mums-to-be being “too posh to push” (or too scared) but consultants practising defensive medicine. That almost invariably means Caesareans for twins, babies in the breach position or when the mother has had a previous Caesar. The rising number of both older and obese mums offers a handy pretext to push the intervention rate up further.

There is nothing inevitable about Scotland’s one in four Caesarean rate when it’s one in seven in Sweden. What I do know is that professional intervention early on with women worried about a vaginal delivery can make a huge difference. Scandinavian research shows that once a woman understands the various risks and benefits, she is unlikely to volunteer for such major surgery. In that context the demographic crisis facing Scottish midwifery - there’s been a 50% rise in midwives over 50 while the student midwife intake has been cut - is very worrying. Without more midwives, my bet is that C-sections will continue to grow, whatever government guidelines say.

Nice expects the Caesarean rate in England and Wales to decline, provided maternity services meet the extra cost of counselling. It would be sadly ironic if what appeared to be Caesars on demand in England resulted in less intervention there, while it continued to rise in Scotland. Make no mistake. Caesareans save lives but in general, if God had intended us to give birth like this, I think he would have supplied a handy zip.

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