Two years ago my eldest daughter gave birth to a baby boy (her third child). It was a classic home birth. She woke up just after 2am. in a pool of water — the waters had broken while she was asleep. She got up, made a cup of tea for herself and her sister, breathed through a few contractions, called the midwife, and then, about 3.15am, said, “I think I’ll go and have this baby now.”
By 3.55 she was holding the baby in her arms. Apart from the fact that it took less than two hours, there’s nothing remarkable in all this, you might be thinking; but my daughter is no wide-hipped Venustype creature – indeed, she could be said to be rather on the petite side of womanhood – and the baby she gave birth to in this wonderfully straightforward way weighed in at four and a half (4.5) kilos! That’s well above average.
She didn’t tear, she had no complications; in fact, the whole thing was an object lesson in the fact that the female organism is perfectly designed to perform the task of giving birth, and will do so harmoniously, if given the chance. But if my daughter had been registered with a gynaecologist or obstetrician in Cape Town, she would probably not have been given the chance to give birth in the way she did. Regular scans would have registered the large size of the baby, and she would have been told, with due, fearinducing solemnity, that in view of the large size of her baby, she would probably not be able to give birth vaginally and that she had better start preparing herself for a caesarean section (CS).
“Your baby is rather large” seems to be one of the main reasons given by gynaecologists for the need to cut a woman open. It’s not the only one, but it seems to be the main one, even though the woman is not unlikely to find herself, after the operation, holding a baby of around three kilos – i.e. below average. It would seem that it is not baby size, but the size of the number of women this is happening to that is unacceptably large.
For instance, in March last year one of the major private hospitals in Cape Town had an 89.8% caesarean rate (I cannot be more specific about these figures for fear of jeopardising the job of the person who revealed them – why should this be, one wonders?) Now, this hospital does not specialise in high risk cases, but even allowing for special circumstances obtaining in this country, there is no possibility of there being medical reasons for all these caesareans. We’re talking here about a hospital where “first world” conditions apply.
In most “first world” countries one would expect a very much lower rate. Holland, Denmark, Sweden all have CS rates of 10% or lower, and the lowest maternal and infant mortality rates in the world. The 89.8% rate of this Cape Town hospital is, of course, way above our national average, but such figures from our “first world” hospitals inflate our figures to such an extent that we currently have the highest caesarean rate in the world (even higher than Brazil where there are private hospitals with 100% CS rate).
The interesting thing is that in our public hospitals, where “first world” conditions seldom apply, the CS rate is very much lower (19.6%)1; it is in our “first world” that the rate soars, whereas in the first world generally the rate is closer to what should be medically expected, i.e. a 7-10% rate2. This means that in some of our major hospitals up to 80% of the caesarean sections performed are most probably unnecessary.
Why is this happening?
Apart from our sharing with urban Brazil, USA and Canada the simple fact that high CS rates are directly correlated with the presence of obstetricians in delivery rooms, there are, I believe, two main factors involved. One is that there is in this country no generally agreed code of medical practice surrounding the birth process. This means that doctors are free to set up whatever regimens they like, whether they conform to generally recognised standards or not.
For example, doctors in Cape Town are likely to set much stricter time limits on certain key stages of labour, and thus will start making worried faces sooner than their counterparts in other countries. The worried face of your obstetrician induces fear, fear produces adrenaline, adrenaline inhibits the birth process, an inhibited birth process is on track for……. need I say more?
The other factor is that in this country there is no law against caesareans of convenience. In other words, a woman can decide to have a caesarean for entirely non-medical reasons. It is considered one of the viable birth options in this country (if you have the money), and has recently become very fashionable. The pressure, as would be expected, comes mainly from America, whereas in Britain, for instance, it is illegal for a doctor to perform a caesarean for non-medical reasons. These two factors mutually re-enforce each other.
On the one hand, doctors are free to “manage” pregnancy and birth so that they culminate in a caesarean section. (There is also something of a financial incentive in this, for although they are paid just about the same for a caesarean as for a real birth, the former takes about an hour, while the latter could take all day – and all night.)
On the other hand, they are only too happy to oblige women who voluntarily seek the scalpel, thinking that it will prevent their vagina from losing its tone. (It is worth pointing out here that research has found that by the age of 65 even nuns, who presumably have never had a sex life, let alone a baby, have pelvic floors in exactly the same condition as women who have experienced childbirth, whether vaginally or by CS!3)
But what’s the big deal, you might be wondering?
If British law prohibits caesareans for convenience, that is surely only because they are much more expensive than natural birth, so it’s just an economy measure. Also, if women in our 5-star hospitals can afford the luxury of avoiding the mess and pain of birth, why shouldn’t they? Well, these might be valid arguments if we were talking about some marketable commodity, but we’re not. We’re talking about the coming into this world of living human beings.
As is very often the case, Shakespeare has the relevant words here. They come late on in “the Scottish Play”. Macbeth has been told that he can only be defeated by one “not of woman born”. It is only when he comes face to face with Nemesis in the person of Macduff that he hears the answer to the riddle: “Macduff was from his mother’s womb untimely ripp’d.” In other words, he was a caesarean baby, and thus “not of woman born”.
This defines the essence of the problem, and to get at what this implies we have to look at the situation from the baby’s point of view. By the time it is approaching the end of its term in the womb, the baby has long made itself at home. It reposes in a cushioned world of partial weightlessness, removed from the harsh realities of air and external light. It is an integrated system of expectations, an omni-potential universe, poised on the brink of their multiple realisation. It exists in a sleep-world that is alive with the tension of as-yet-untried possibilities. No one knows the moment when it is going to cross from the potential to the actual – except the baby itself.
It is an embryological fact – although it is not understood how it happens – that the baby initiates the birth process. The baby determines its own birth moment. Neither mother nor father nor doctor knows it – only the baby. It is, after all, the baby’s birth. A caesarean operation, especially a caesarean of convenience, sweeps into this situation like a preemptive strike. The military metaphor is entirely appropriate. For the baby it must be like going to sleep in a peaceful village with all its familiarly comforting sounds, only to be wrenched from slumber by an invading army. (This is almost literally true – in this country it takes about eleven people to do a caesarean).
The mother, due to the anaesthetic, feels nothing – but the baby is not so lucky. It does not have the “comfort” of being fully drugged (although it may be to some extent). One minute it is reposing at peace, the next the wall of its world is cut, then torn, open, and it finds itself being “untimely ripp’d” from the womb. The only cold comfort is that in the following days it will be slightly doped by substances in its mother’s milk – usually pethidine, given to her to still the pain following the operation. Only some time later will it come alive to the fact that something drastic has happened. The baby will have some dim, visceral, whole-organism awareness of the fact that it has been “robbed of its birthday”.
Now, a full-term baby is a legal person, and in its last days in the womb this legal person is, as a whole, the living expectation of the fact that he or she is the one to begin the birth process and thus decide4 the moment of birth. Surely an act which takes this decision out of this legal person’s hands must be seen as a violation of its personhood and consequently of its human rights. An unnecessary caesarean, performed early, or, as Shakespeare says, untimely, is just such a violation. While there can sometimes be good medical reasons for a planned caesarean, to decide to have one for no medical reason is effectively to license a high-powered professional medical technologist to disempower your baby.
To persuade a woman to have an unnecessary caesarean operation is to perform a similar act of disempowerment. Both these actions show a callous disrespect for the personhood of the baby. There are disquieting statistics about the consequences, for baby and mother, of this disrespect, but before I come to those there is a general point to be made. There is a conflict of attitude that plays a large role in this state of affairs. It is between the analytical intellect and what I would call a more holistic-intuitive approach.
The training of doctors is based squarely on analytical intellect, but the problem is that birth as a process cannot be encompassed as a whole by this mode of approach. In basic terms the eyes of analytical intellect are likely to see in the birth process only a physical object (the baby), which is inside another physical object (the mother) and needs to be got out somehow. Obviously if one sees these as the basic facts of the situation then it is fair to assume that the method used is not going to make any difference to the “objects” involved.
It only needs to be technically practical. Clearly, this requirement is fulfilled much more readily by cutting a hole in the outer object and lifting out the inner one, than by trying to coax it through a narrow tube with a bend in it (the birth canal). Cutting and lifting replaces true birth (in which the baby is permitted to go through the birth canal) with a mechanical operation, and thus represents the ultimate mechanisation of birth. It is very convenient. You can time the moment the baby is to be lifted from the womb almost to the minute. This fits into hospital routines very well.
Of course, real birth, being an entirely individualised process, cannot be quantified in this way. Now, I’m sure gynecologists and obstetricians do not regard babies as mere physical objects, but they certainly behave as if they did. How else is one to account for an 89.8% caesarean rate? What of the holistic-intuitive approach? This is the mode in which midwives are likely to be proficient. It will seek to empathise with the baby as a person on a momentous journey from one state of being into another. It will have a feel for the fact that birth is a delicately attuned, integrated, organic process, any one phase or part of which will be intimately bound up with all the others.
As such it must be trusted, responsively read, worked with, co-operated with. It is only such a style of consciousness that can even begin to sense the nature of the baby’s state of being in the womb before the birth process begins; but however difficult this is to grasp, the midwife must identify herself with it, otherwise she will not be able to read the process properly. The baby’s state of being in the womb is not accessible to analytical intellect, and obstetricians, by lifting babies untimely out of this state of being, show either that they are so “intellectual” as to have no feeling for it, or that they are suppressing the feeling.
There is also the possibility, of course, that they genuinely believe they are easing the lot of women, while at the same time smoothing the baby’s path into this world. Does this stand up? What are the consequences of their disempowering babies by by-passing the birth process? Statistics from recent research have increasingly convincingly shown that there is approximately three times higher risk of both infant and maternal mortality, and markedly higher morbidity following Caesarian section performed without adequate medical justification, and these are compounded in subsequent pregnancies.
As well as increased risk to CS babies of asthma later in life, research now shows they have a higher risk of allergies generally and are significantly more likely to suffer gastric disturbances and diarrhoea in the immediate post-natal period. This list could be considerably extended. The interesting thing is that when the labour process has begun spontaneously, particularly in the case of a planned CS, the incidence of the above complications is reduced. Thus experiencing at least part of the natural birth process, even if it ends in CS, would seem to be beneficial. The crawling phase in childhood is regarded as highly significant, since missing it appears to be linked to subsequent dyslexia.
By the same token, deciding the moment of birth and making your way down the birth canal could – I would say should – be seen as a developmental step of equal magnitude. What then could be the effect of depriving a child of this experience? There are many good medical reasons for having to skip this step, both in a planned and unplanned way. In the case of a good reason, could it perhaps be that, although their experience has been that of being “untimely ripp’d” from the womb, a person later in life will have some dim consciousness that it was necessary and for the best? Whereas if the reasons were not good – simply for the convenience of mother or doctor or both – the person will have some deep, latent knowledge that their “birth” was somehow “wrong”? And might this dim knowledge have some serious consequences for their general wellbeing?
What is the significance for a person’s adult emotional integrity of the struggle down the birth canal? Obstetricians might do well to ponder this question. Midwives are likely to have an intuitive understanding of this, though they may not be able to put it into words. The ridiculous thing is that this whole unbalanced situation need not be happening. In spite of their having some suspect birth practices, it doesn’t happen, for instance, in Holland. There women have enough confidence in their ability to give birth naturally, and enough clarity about which professional is appropriate for which task, to know that if you’re pregnant you don’t register with a gynecologist or obstetrician, you go to a midwife. Obstetrics is the study of abnormal childbirth – and that is what obstetricians are practised at. They do so few “normal” births that they are not as skilled or experienced in that field.
For a healthy woman, going to an obstetrician is like using a steamroller to make a pizza, or getting Robert Mugabe to run a playgroup. If a code of practice existed that recommended, or even prescribed, that obstetricians should refer women with uncomplicated pregnancies (which more than 80% are) to midwives, then we would be moving in the right direction. Then women would be with caregivers with the kind of holistic-intuitive expertise they need, and their babies would be honoured instead of disempowered.
The midwives would no longer find themselves reduced to the role of attendants at caesarean operations, feeling as disempowered as the baby, and watching their time-honoured knowledge going down the drain. Obstetricians would be freed for more emergencies and would be available for those areas where they are really needed. However, since the current situation, for lack of a code of practice, is governed by market forces, the obstetricians of the private sector are not likely to enter these other areas.
As a result, it’s disempowerment all round: the babies are disempowered, the mothers are disempowered and the midwives are disempowered, and ultimately the doctors are disempowering themselves.
Instead of fulfilling the imperatives of the noble profession they joined, they are regularly acting in bad faith towards the women who come to them for help, but most of all towards the babies. It is not really all that difficult to grasp the essence of what is at stake here. My daughter put it very well the other day. Speaking about performing CS to fit a hospital schedule rather than when really necessary, she said, “If you’re happily sleeping in there and somebody opens the door and rips you out, you’re going to be upset, whereas if you’re struggling to get out and can’t, and somebody opens the door, then you’ll be very pleased”.
If obstetricians would listen to this voice of female common sense, they might well end up having a much more authentic and satisfying life – and the disempowerment of the unborn would cease.