There’s No Shame in Being Too Posh to Push

Mention Australia’s caesarean section rate and collective tongues start wagging. Our rate is too high, the experts say, partly because some mothers are too posh to push.

It is true that Australia’s caesarean rate is high and, until recently, climbing. In 1997, 20 per cent of women gave birth by caesarean. By 2007, the rate had climbed to 31 per cent, where it remains. This is at least double the 10 to 15 per cent proportion recommended by the World Health Organisation.

But that ideal is 25 years out of date. Britain’s Parliamentary Office of Science and Technology says that if it repeated the exercise used to arrive at the initial figures, it would come up with a “rather higher range”. This is because the recommendation was derived from caesarean figures in countries that had the lowest mortality rates at the time and, today, few countries have caesarean rates below 15 per cent.

Caesarean rates follow the money. In Brazil, caesarean rates in the private sector are 80 per cent. In Australia, women giving birth in private hospitals have a caesarean rate of 41 per cent, compared to 28 per cent for those in the public system.

Staff attitudes and institutional culture with regard to women’s choice also play a part. In one Australian study, 62 per cent of women having a caesarean in a private hospital said their healthcare provider had recommended it. This contrasted with the 40 per cent in the public sector.

A comparison of two British hospitals by the Parliamentary Office of Science and Technology found that caesarean rates were lower in the institution where women lacked the “freedom” to “express a preference for caesarean section” and higher where women were “given information about the known relative risks of [caesarean] and vaginal birth”and allowed to make … the final choice".

Such findings should sound alarm bells to anyone interested in the right of women to make free and self-directed choices about their medical care.

The “too posh to push” claim is mostly myth. Anecdotal evidence from Britain suggests that some women request caesareans because they fear the pain of labour. We know from Australian and overseas data that most women want to have their baby the old-fashioned way. Guesstimates of those without medical indicators who choose caesarean are between 3 and 15 per cent. This fits with the observation of the International Federation of Gynaecology and Obstetrics (FIGO) that most women will act to improve their chance of having a normal birth and healthy baby if they have access to the necessary information and support. In other words, most pregnant women will choose the option medical staff tell them is in their and their foetus’s best interest.

But what if they don’t? There is no hard evidence on the relative risks and benefits of caesarean delivery for non-medical reasons compared with vaginal delivery. This makes emphatic assertions by health experts that vaginal birth is safer than elective caesarean for low-risk pregnant women worth less than a hill of beans.

In the absence of definitive data, there are arguments both ways. One study found 31 per cent of female obstetricians would chose a caesarean over vaginal delivery because of risks of stress incontinence, anal sphincter damage and compromised sexual function following vaginal delivery.

Even if medicos had the evidence on which to base an agreed recommendation about elective caesarean, women would still have the right to decide differently. The freedom to review and evaluate the risk/benefit profile of all available medical options and to make a decision based on one’s own needs and values is what informed choice is all about.

The bottom line is that – short of engaging in self or child abuse – women do not have to prove to health professionals that their healthcare choices are good or worthy ones to have the right to decide. This is as true about their choice of delivery method as it is about how they look after themselves while pregnant, and how they mother once the baby is born.

Pregnant women can choose a glass of wine with dinner, to have their baby by caesarean and to feed by bottle instead of breast. As long as they are making the decision freely, and on the basis of a substantial understanding of the issues, the choice belongs to them.

Publication history

There's No Shame in Being Too Posh to Push  The Sunday Age