Too many women in Britain are having their first baby by caesarean section, fuelling an “incessant increase” in the number of children born using that procedure, the leader of the country’s obstetricians warns today.
Dr David Richmond, the president of the Royal College of Obstetricians and Gynaecologists (RCOG), wants an NHS-wide drive to reduce the number of first-time mothers having C-sections and says that some hospitals are carrying out too many.
In an interview with the Observer, Richmond said he was worried that an unnecessarily high number of women whose first pregnancy had progressed without any problem still ended up giving birth by caesarean.
He called for action because mothers who have the procedure for their first child are highly likely to give birth to any future children by C-section too. Reducing the number of first-time caesareans would also help to counteract the growing number of births that involve medical intervention, he added.
“What we need to do is look at the primary caesarean section rate for first-time mothers who have a normal-term, head-first baby. You will find that the rate of elective and caesarean section has a significant variation, depending on which hospital the woman chooses for the birth,” Richmond said.
“The benefit of reducing the number of first-time mothers having a caesarean would be to reduce the risk of having a caesarean with any later pregnancies.”
Rates of caesarean section have been rising gradually for many years – from about 10% of births 30 years ago to near 25% of births today. Of the 646,904 deliveries in NHS hospitals in England in 2013-14, 164,774 – or 25.5% – were to first-time mothers. And of those, 41,929 (25.4%) were by caesarean section. Most were emergency procedures (31,498) but more than 10,000 were elective.
Richmond, based at Liverpool Women’s Hospital – which delivers about 8,500 babies a year, more than any other hospital in Europe – said the increased rate of C-sections was being fuelled by the rise in maternal obesity, obstetricians’ fear of being hit with a lawsuit if something goes wrong during labour, and a small number of women asking to have the procedure.
His remarks have reopened the debate about whether too many babies are now delivered by medical intervention and whether that affects the health of the mother and child. The number of induced labours, and babies delivered by forceps or ventouse (vacuum), have also been creeping up. Experts say that maternal obesity and the trend towards later motherhood are key factors.
The National Childbirth Trust, the parenting charity, has also voiced concerns about the rising number of caesareans. Evidence shows that, when there are no medical complications, a straightforward birth “is safer for the mother and baby, promoting wellbeing and reducing risks in future pregnancies”, said Elizabeth Duff, the NCT’s senior policy adviser. “When women with low-risk pregnancies give birth in hospital, the chance of having a caesarean is increased. This is because intervention often takes place when labour slows – which can happen, for example, when women are left without one-to-one care.”
Cathy Warwick, the chief executive of the Royal College of Midwives, added: “David Richmond is right. We are worried about too many first-time mothers having caesareans and agree we need to tackle this.
“If we do stop first-time mothers having caesareans, we will certainly reduce the number of second caesareans. That would be a positive way forward for both mothers and babies, and for the NHS, because caesareans take up more resources – operating theatres, surgical teams, women having to stay in longer – than when women give birth normally, with just a midwife there.”
Too many women are scared of a normal birth because they are given too little information during their pregnancy, Warwick added. “We need to reduce the fear that some women have around childbirth. They are fearful of the pain and the process of pushing their baby out. That fear causes hormonal processes in the body that make it harder to deliver the baby and less likely that they end up having a normal birth.”
Professor Alan Cameron, vice-president for clinical quality at RCOG, said that an expansion in the number of midwife-led NHS units would help to reduce the number of first-time caesareans, as would better monitoring of babies’ health during labour and work towards reducing maternal obesity.
The Department of Health and NHS England did not respond to Richmond’s views.
THREE WOMEN’S EXPERIENCES
SARAH RUSE, 39
Had a caesarean with her first child, Chloe, now 10, but chose to have natural births with Liam, now 7, and Oscar, now 2.
I still don’t know why I had a caesarean. They told me it was because I wasn’t progressing enough. I didn’t feel like I had much choice. It was just a horrible experience. Afterwards, I started being sick and I didn’t get to hold Chloe for an hour or two after she was born – I was just lying in a recovery room next to theatre shaking violently. I was discharged after four days and my wound got infected; I got more and more depressed.
With my second pregnancy, with Liam, right from the start they told me I had to go for a caesarean but, because of the experience I’d had before, I was adamant I wanted to do it naturally. Until I moved to a different hospital, where I had my third child, Oscar, I didn’t get much support from doctors.
HANNAH HUDSON, 27
Had a caesarean with Paige, now 17 weeks, because she was breech and – as a result of previous operations – it would have been too painful to turn her around.
Everybody says that when you give birth you get this rush of emotion. I was worried that I wouldn’t get that feeling.
I think I was in theatre for 40 minutes – 10 minutes to get Paige out and then they sew you up for ages. The recovery was really positive. I had her on the Friday and, by Sunday, I went out for a walk with the pram. I’ll be having a C-section next time because the umbilical cord that attaches to the placenta in my case was attached at the side rather than the middle, and so was also attached to her waters and my membranes. If she hadn’t turned and I’d gone into labour, I’d have lost her.
There is a stigma attached to a caesarean [because it is often seen as an easy option], but the recovery is often worse, so it’s harder.
MANDY RYAN, 32
Had an emergency caesarean with Abigail, who is now six months old.
Originally I’d wanted to have a water birth but as long as the baby is healthy it doesn’t matter how they are born. The procedure was fine, but afterwards was definitely more difficult.
By day two the pain started to be really bad and I started to have bad bruising. The whole area was very swollen and black. It was probably six weeks or so before I started to feel better and mobile again.
In any stage of preparing to be a mum there are people who will judge the choice you make, even if things are out of your hands. If people are fully briefed on what a caesarean entails then most will favour a natural birth – but equally for many people it isn’t possible. I don’t think it should be looked at as an easy way out. Rebecca Ratcliffe
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