The Fabled 15%

The long held notion of expectant mothers opting for a caesarian as being “too posh to push” should have finally been put to rest two years ago. Research published in the British Medical Journal in October 2010 showed that, by some distance, emergency c-sections outnumbered the elective procedure which was only rarely performed without an underlying clinical need. The researchers who conducted the study commented, “It seems unlikely that maternal request in the absence of any clinical indication contributes substantially to the rates.” However, new concerns have arisen that pregnant women who have a phobia of giving birth are having their requests for a c-section delivery fall on deaf ears .

The UK's Royal College of Midwives have suggested that 10% of women experience tocophobia - the fear of giving birth - at some point during their pregnancy. For a few women this can become an overwhelming phobia and lead them to terminating their pregnancy. In a talk at the 2012 Royal College of Midwives annual conference in Brightonmidwife counsellor, Zara Chamberlain, explains:

It's no good saying to a woman that children have been born through the vagina for thousands of years - they know that. These are intelligent women but it is a phobia, it's a fear and they can't avoid it.

I'll be blunt. The very notion of there not being a medical reason for caesarian is simply preposterous. The alternative to surgery is excruciating pain that can go on for days, the risk of stroke, heart attack, permanent incontinence, incision without pain relief (episiotomy), pelvic dislocation and death. These are just a few of the risks to the mother alone. Some women, after balancing the likely risks and potential outcomes of labour versus caesarian, would choose the somewhat more predictable surgical risks.

In countries like the UK and Canada where health care is largely free at the point of delivery, the cost of a caesarian is compared to the cost of vaginal birth. While an emergency c-section can hike the cost up by around £1,000, a planned section can cost as little as £84 more. Even so, there have been calls for women without recognised medical need opting for surgery to be made to pay for it.

Caesarian is often characterised as the easy option for delivering a baby. It certainly is not. Carried out under a spinal block (epidural anaesthetic), it is one of very few such major operations to be performed this way. Recovery times can be longer than for a straightforward vaginal birth and, as with all surgeries, there are inherent risks such a haemorrhage, thrombosis and infection. Electing for a c-section is a serious decision. In some areas of the UK, caesarian numbers are double the World Health Organisation’s “optimal” of 15%, which has led to politicians suggesting that women who opt for the op should be charged.

The question is, how was that 15% figure was reached? It was reported globally on publication, in 2007 of Rates of Ceasarian Section: Analysis of Global, Regional and National Estimates.Disturbingly, in researching this article, I have discovered that no one, not even the WHO’s Marsden Wenger, one of the report’s authors, really knows how the figure was arrived at. He claims that the team he worked with on the paper used “the best data available.” When asked to produce that same data for Times journalist, Helen Rumbalow, he could not do so. Conveniently, though, the figure of 15% that Wenger et al recommended was the same as the one that, again without substantiating data, the WHO had been touting since 1985.

What Wenger’s report found, when you study it carefully, is that only two countries with caesarian rates as low as the WHO’s golden 15% also have low maternal and neonatal mortality. Those are Croatia and Kuwait: nations not renowned for accurate data gathering. Indeed, the report indicates very clearly that better outcomes for mother and baby are achieved in countries where caesarians are in the 30% area �" just like the UK and Northern Ireland. Unsurprisingly, yet very, very quietly, the WHO withdrew it’s “15% by caesarian” recommendation in 2009. Unfortunately, the fabled 15% is still bandied about in many discussions on the availability of caesarian section surgery.