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With all the attention paid to England’s shift in direction on covid-19 last week, you may have missed a change in a different area of healthcare: childbirth services.
Hospitals in England have been told to rip up targets for keeping their rates of Caesarean sections under 20 per cent of all births. It might sound like something that’s only of interest to hospital bureaucrats, but in fact it’s a major reversal in a long-running battle over how we should manage pregnancy and birth.
On one side are those who argue that birth has become “over-medicalised”. Pregnancy isn’t a disease, it’s a natural physiological state and is best managed by letting women give birth with as little interference as possible, say the natural birth advocates.
They claim doctors use too many interventions, often for their own convenience, and encourage people to give birth with as little medical help as possible. On the other side are campaigners who say that approach is unsafe.
The ultimate birth intervention is to have the baby through a C-section rather than the vagina. C-sections were initially done only as a last resort. As they became safer, they were done more and more, both during labour if the baby got stuck or beforehand if the mother had certain health conditions that made a safe birth less likely (called elective C-sections).
The total rate of C-sections, either within births at a hospital or those for a whole country, has come to be seen as a significant measure of how “over-medicalised” childbirth has become. In the UK, hospitals were encouraged to keep their rates down, and a maximum rate of 20 per cent was advised by the Royal College of Obstetricians & Gynaecologists. (The current UK rate is about 30 per cent.)
The most glaring danger of such a target is that if you try to limit access to a medical intervention designed to save lives, then you risk lives being lost. And that is what started to happen. In the past decade, UK maternity services have been beset by several safety scandals over hospitals pushing for natural births so much that babies or labouring women died, as I wrote about in 2016.
Another flaw with C-section targets is that today, people have children later in life. As we get older, our tissues become less stretchy and are more likely to tear, which is one reason why older first-time mothers are more likely to need a C-section and to have more tissue damage even if they have a vaginal birth.
But the third reason why C-section targets should never have been set is that they challenge the very concept of personal autonomy. When doctors are genuinely split on something – as they are about the idea that natural births are better – then people’s own wishes and preferences should take precedence, as long as they are fully informed about the pros and cons of all the options.
There are many areas of medicine where there is real debate among doctors about the best approach. Whether you get any input into such a decision about your health may depend on how much your doctor values patient autonomy.
Take the question of whether someone who is at higher risk of a heart attack (although hasn’t yet had one) should start taking statins, medicines that lower cholesterol. If they are lucky, their doctor will talk over the pros and cons, accounting for how the person feels about the risk of side effects and having to take a pill every day. If they are unlucky, they may just be bulldozed into it.
There are similar questions over cancer screening. Despite what you might have heard, having regular tests for cancer doesn’t necessarily mean you will live longer, and screening has downsides too, like the risk of having surgery for a cancer that would never have grown large enough to harm you.
When it comes to childbirth, the change of heart on C-section targets in England is not the end of the arguments. While hospitals no longer have blanket C-section policies, individual doctors and midwives may still try to keep rates down, and there are debates over other interventions, like how long should a pregnancy go overdue before the birth is medically induced.
I fully accept that not everyone feels like me. I chose two elective C-sections to have my children, having read about the pros and cons of each option and taken into account that, at 34, I was a relatively old first-time mum. I am also short, so I was more likely to have a baby too big for my pelvis. But I have several friends who wanted and succeeded in getting natural births, and they feel very happy and empowered by their choice.
I just think choice is the key word.
OTHER HEALTH STORIES
- Our life may really flash before our eyes when we die, according to data recorded during a freak event in which a man happened to have a heart attack and die while he was having his brain scanned.
- A round-up of what we know about the possible causes of long covid.
- Why everything you thought you knew about good posture may be wrong.
FROM THE ARCHIVE
The power of dreams: they are much more than mystical night-time adventures. Recent research suggests that rapid eye movement (REM) sleep – when we have the most powerful dreams – is vital to learning and creativity and promotes a healthy mind in a variety of ways. It isn’t romantic whimsy to say that if we stifle our dreams, we aren’t going to reach our potential.
NEW SCIENTIST LIVE
There are now only two weeks to go before New Scientist Live, being held in Manchester on 12 and 13 March, with a day just for schools on 14 March. There are loads of great talks on health and nutrition, including ones on
- Why calories don’t count
You can join us in-person and virtually; see the full programme here.
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