The announcement that women may be routinely warned of the risks of “normal” vaginal birth, along with those of caesarean section, has sparked some fascinating debates, specifically about what “informed choice” means. A recent article on The Conversation argued that it may be worth informing at least those with particular risks from vaginal birth, such as older women, about the different options.
But there are different scenarios linked to having vaginal birth – and they each come with different risks and benefits. For example, there are risks associated with being exposed to unexpected interventions such as drugs to speed labour up, forceps or emergency cesarean section during labour. These may lead to a greater need for stitches, or to higher infection rates. However, these interventions are not inevitable.
An audit by the Royal College of Obstetrics and Gynaecology (RCOG) showed that rates of interventions in labour differed widely between hospitals. It suggested that on average only 44.9% of women have a normal birth without interventions, and that the rate varied between 39.5% and 51.8% across the UK. Many of these procedures may have been unnecessary – according to the World Health Organisation, up to 80% of all women should be able to give birth without them, and women who give birth in places where vaginal birth happens with lower levels of interventions have lower risks of negative outcomes.
The information given to expectant mothers can only ever be partial. As the RCOG data showed, current evidence on “vaginal birth” is generated in settings where most women do not experience a normal birth without interventions – about a third of all women have induced labours. Others will have a drip to speed their labour up, though it isn’t clear how often this happens, as this information isn’t collected routinely. This is at the heart of the problem.
Not an express delivery
According to one study, most women around the world – even those who have had a caesarean or complications – would choose a vaginal birth if they could. But a recent Guardian article in support of women who choose elective caesarean section on demand stated that “if you want an experience go to Disneyland”. This version of childbirth as a procedure to be done as quickly as possible, with no value beyond survival, is a reflection of how labour and birth are managed in many places. In contrast, a recent review of research worldwide, undertaken for the WHO, demonstrated that women around the world want and expect far more from pregnancy and birth than just getting it over with, and not being ill.
The time limits that are used to decide when women should have their labour accelerated have also come in for strong criticism from the American College of Obstetricians and Gynaecologists for being too restrictive. Speeding up labour is based on findings from older studies that very long labours might harm the mother and/or baby. However, current evidence suggests that if progress is steady and mother and baby are well, longer labours are not more harmful than shorter ones.
Most women are confined to bed during labour, despite the strong evidence for the benefits of being mobile. About a third have an episiotomy (a surgical cut), but most of this is associated with forceps or vacuum births. When outcomes are reported for vaginal birth, as detailed in the previous Conversation piece, they tend to include births with all these interventions, which in turn are linked to longer-term problems for mothers (and, sometimes, babies). So the assumption is made – by the media, health service and women – that these negative effects are what they are likely to experience if they plan for vaginal birth. Some then (understandably)choose an elective casearean, despite the increased (though rare) short-term risks of hysterectomy, cardiac arrest, and increased need for neonatal unit care for the baby.
Outcomes of the option that should be available for most women – physiological vaginal birth without routine interventions – are rarely examined separately, and so women can’t be informed about the benefits and risks of this. And even if they were properly informed it’s still unlikely that they will get the option of a natural birth that is allowed to take its time, at least in a hospital setting.
From a certain feminist perspective, the reduction of childbirth to a “choice” between a surgical birth and a vaginal birth with routine interventions is a consequence of assumptions about the fundamental failure of the female body. Choice becomes analogous to the Henry Ford offer that “you can have any colour [car] as long as it is black”.
Opportunity for change
The recent case in which a woman was awarded US$16m in compensation by a US judge showed how unnecessary interference is not always the best option.
Pregnant women, babies, families and societies deserve more than a passive acceptance of unnecessary routine intervention and non-evidence based care. Debates about how informed choice can and should be put into practice are a chance to ensure that service provision offers genuine choice for all women and families.
Health professionals and service providers must learn from hospitals where the philosophy of labour and birth supports what women really want, rather than what risk-averse, litigation-sensitive maternity organisations choose to provide. Once this is achieved, women will have more complete information about the outcomes of physiological vaginal birth, and a higher assurance of achieving it if that is what they want to aim for. Crucially, whatever interventions are needed and wanted (including elective caesarean section), it is essential to ensure that childbirth is a positive experience for all mothers, babies, and families, in both the short and longer term.
But let’s not make any assumptions about women’s “informed choice” until they can choose what they actually want and need.
Soo Downe receives funding from WHO, NIHR, and the EU (COST programme) . She is employed by the University of Central Lancashire, affiliated with the MotherBaby Friendly Initiative and the White Ribbon Respectful Care inititive, and has worked with ICM, FIGO, RCM, and the RCOG.