Is it so shocking that fear of labor pains may be behind some cesarean deliveries?

In this Sunday's Observer newspaper, Louise Silverton, deputy general-secretary of the Royal College of Midwives (RCM) talks about the issue of rising cesarean rates, and is quoted as saying that "women under 40 are less prepared to undergo the physical trauma of childbirth than their predecessors, a trend that is pushing up the rate of surgical deliveries."

She describes England's current cesarean rate of 24.3% as an "unacceptably high and needlessly high" figure that should be brought closer to the 15% recommended by WHO. The fact that Ms Silverton criticizes cesarean rates is of no surprise to me, but what concerns me far more is some of the views she holds about pregnant women. As someone in a position of great power and influence in the world of maternity services, her attitude towards women whose birth preference she does not share is worrying, and her lack of understanding (or willingness to understand) their differing perspective on pain is equally so.

Silverton's solution to pain: 'suck it up like previous generations of women'
Let's examine what Ms Silverton says in the Observer:
"Society's tolerance of pain and illness has reduced significantly."
"Women are less tolerant of labour pains because they haven't developed tolerance of pain. For example, if they get period pain they will either take Nurofen or go to their GP."
"...women under 40 [are] more likely to have an 'epidural in a way that their predecessors wouldn't'."

Ms Silverton describes labor pain as "unbelievably painful" and yet fails to understand or accept that women may have a genuine fear of such pain or choose to avoid it altogether (whether via an epidural or a planned cesarean delivery). What right does she have to suggest that women be encouraged - or forced - to have a natural birth?

The RCM also proposed fees for unnecessary edipurals
This is not the first time that the RCM has been out of step with what contemporary pregnant women want. Back in February 2006, its education and research committee came up with the highly controversial proposal that epidurals should be "free to women who have a definite need of it [but a fee] levied for all other women who desire" one. At the time, Ms Silverton was quoted as saying: "Epidurals provide effective pain relief but, where there is no clinical indication that they are necessary, they can significantly raise the likelihood of other interventions such as caesarean section occurring. "The UK already has an extremely high Caesarean rate and, as the acknowledged experts in normal pregnancy, labour and birth we midwives need to debate ways in which we might help to bring this rate down. "This is a very serious issue and one that is likely to raise significant debate but also something that needs to be debated if we are to improve the normal birth rate."

An argument that is often used against women who choose a cesarean due to a fear of labor pain or labor itself is that they can simply have an epidural. But it is not that simple. First of all, it is clear from the opinion of the very influential midwife above that epidurals are frowned upon too, and secondly, whether it is coincidence or not, I have been contacted by women whose experience of vaginal delivery was that they were refused an epidural or an epidural was 'not available in time' for the start of their pushing. They suffered a traumatic experience and decided to seek support in trying to schedule a cesarean delivery for their next pregnancy.

Clearly, the RCM wants to reduce cesarean rates, but it must ask itself - at what cost physical and psychological cost to the women it claims to serve?

More of Ms Silverton's comments - and my responses to them
"...caesareans have become too easy to obtain"
Not according to the women I receive emails from; they cite experiences with midwives, doctors and hospitals where their cesarean requests are refused. This leads to enormous stress during their pregnancy.

"Women are trying to remove the symptoms of pregnancy as much as they can. They are seeking to control everything. Choosing to have a caesarean gives you an element of control."
Yes, a planned cesarean does provide an element of control, and this benefit is often cited by women whose birth preference is surgery. Is that such a bad thing? The unpredictability of vaginal delivery is not embraced by all women and we shouldn't expect it to be.

"A caesarean is major abdominal surgery. I don't think women realise that. They see it as just another way of giving birth. They see it as easy. And they think that if they can have an elective caesarean they will have no pain because they haven't been in labour."
Of course they realize that it is major surgery, but they have decided to accept the risks associated with that surgery in preference to the risks associated with a planned vaginal delivery. Speaking for myself, I don't view any birth type as 'easy', and I was fully aware that I would experience some abdominal pain following abdominal surgery. However, I also knew that my postpartum pain would be managed (and it was), and that I would be able to tolerate any abdominal pain far better than any perineal pain.

"Some women, tired after a long labour, were wrongly given a caesarean at 10pm to save doctors operating at 2am, when they should be left longer in case natural labour developed..."
I find this comment so reprehensible that I struggle to find the appropriate words. Is it not feasible that the doctor making this decision is making the right one? How many more hours does Ms Silverton suggest that women already "tired after a long labor" continue to labor before undergoing - in her own words - major surgery? And besides the woman, there may also be a danger to the baby in delaying cesarean delivery.

"She also accused junior doctors of approving or undertaking emergency caesareans too quickly if there were any suggestion of risk to the child's health, because they feared they might be sued if something went wrong."
Litigation fear is a reality whether we like it or not, and we might all ask ourselves what would we do in that doctor's position. But the litigation or ethical debate aside, wouldn't most women 'if there were any suggestion of risk to the child's health' also agree with the doctor's (junior or otherwise) decision to perform a cesarean delivery?

"...one has to question whether the women of this country are physiologically incapable of having normal births, and I don't think they are..."
Then why try to force vaginal delivery on those who don't even want one in the first place?

"She listed a caesarean's main dangers for mothers as 'the risk of infection, the effect on subsequent fertility and the effect on their ability to look after a newborn baby when they are post-operative'. There can also be respiratory complications for the baby, she added."
Yes, there is a risk of infection, and you can read more about that here. There is no association with subsequent fertility following a planned cesarean delivery; a number of studies have found that any reduction in fertility is voluntary. Women's ability to look after a newborn baby following a planned vaginal delivery can also be adversely affected; it is not necessarily any worse following planned surgery ( I personally experienced no such difficulty). Respiratory complications are largely associated with pre-term deliveries and can be mitigated by delivery at 39 weeks confirmed gestation - as advised for healthy women who choose to give birth surgically.