Is the natural way always the right way? This is the fundamental challenge being posed by some leading obstetricians who are arguing that vaginal birth may present more risk and lead to more complications than Caesarean section.
In a recent in-depth article for the Daily Mail, Dr Mairead Black of the University of Aberdeen made the case that vaginal births should not always be assumed to be the best route to delivery for expectant mothers and that informed patient choice should play a role in the final decision.
Her argument follows an unprecedented 2015 UK Supreme Court ruling (Montgomery vs Lanarkshire Health Board) that changed the legal healthcare landscape in regard to informed consent.
The judgment ruled in favour of a complainant who had not been informed of a childbirth risk they encountered, despite voicing concerns during pregnancy. A baby developed a brain injury due its shoulder getting stuck during delivery, which would not have happened if a pre-labour Caesarean section had been performed instead.
The effect of this has changed the weighting of a consultation discussion in favour of what the ‘reasonable patient’ believes to be the significant risks, rather than just those risks that have been identified by the consulting healthcare professional.
Indeed, the Royal College of Obstetricians and Gynaecologists are currently debating whether vaginal birth should always be deemed to be the default option for childbirth within the UK, as they believe there’s a significant role in routinely discussing the relative risks and benefits of vaginal birth compared with Caesarean section with pregnant women, regardless of what concerns the patient may have themselves.
The discussion has moved on significantly in recent decades due to key changes in childbirth techniques and improvements in healthcare technology, which have resulted in procedures such as Caesarean section becoming safer. In step with these changes in the medical field, there has been a marked move to women opting to have children later in life, which means that the problematic risk for those women during labour and birth is higher.
However, while both Caesarean section and vaginal birth are considered to be relatively safe in high-income countries, each features its own set of risks. What those risks actually are is arguably subjective depending on the healthcare professionals and pregnant women in question. Indeed, studies from high-income countries suggest that risks due to natural birth may be poorly appreciated by women and health professionals.
As a default, most UK hospitals still opt for vaginal birth for most pregnancies, despite the risks and the fact that the National Institute for Health and Care Excellence (NICE) has recommended that there should be some room for choice.
When one looks at some of the statistics cited by Dr Black in the Mail article, it becomes apparent that vaginal birth is not always the best option for pregnant women. Some 21% of women have to have an emergency Caesarean section during labour, which is not as safe or controlled as a planned one; while up to 95% of UK women aim for a vaginal birth in their first pregnancy, only around 75% achieve this.
Vaginal birth can also cause immediate and longer-term complications for mothers. These include an 8% postpartum haemorrhage rate, a 1% blood transfusion rate and a 5-6% third-degree tear rate (40& suffer some degree of tearing). One in six women end up having an operative vaginal birth, such as use of forceps, which is associated with faecal incontinence and pelvic organ prolapse in later life.
Psychologically, vaginal births can be damaging for mothers; long labours, complications and interventions are associated with maternal distress, postnatal depression and intense anxiety in future pregnancies.
All in all, the above means that just over 50% of first-time mothers experience an uncomplicated, spontaneous vaginal birth.
In this light, the alternative of a planned Caesarean section is attractive. While, like any other medical procedure, Caesarean section is not risk-free, the risks attached are akin to those of a planned vaginal birth in the short term and may be even safer for the baby (albeit with a slightly higher risk of respiratory problems at the time of birth).
There are risks, however; Caesarean section scarring will make each future pregnancy riskier as it can affect placenta development. This in turn results in increased risks for the mother in developing major bleeding and even hysterectomy (although this is rare). There are also concerns that babies born by Caesarean could be at higher risk of developing asthma.
Weighing up these risks is subjective since different women will assess these risks differently to each other. However, fully informing expectant mothers of the risks attached to both options will help them decide as to what matters most.
There will be practical consequences for healthcare providers if Caesarean section is put on an equal footing with vaginal birth in the minds of pregnant women. Caesarean section rates in UK hospitals are likely to rise further if potential risks of vaginal birth are discussed as a matter of routine, and this will have an impact on budgets. NICE estimates that vaginal births cost an average of £1,512 each whereas planned Caesareans cost £2,369 (emergency Caesarean sections cost £3,042).
However, shouldering the additional costs is arguably acceptable if women’s informed choices are founded on realistic expectations and result in a lower number of emergency procedures.
The challenge for healthcare professionals is how best to communicate all of the above without causing greater anxiety or concern to the pregnant woman in question, and helping them assess all these risks to their own personal circumstances and expectations. However, being aware of both risks and modern solutions ultimately helps expectant mothers, healthcare professionals and health providers.