Is a natural birth really best?

Unless obstetric policy changes, women may be better off with Caesareans. Jane Feinmann reports

You'd think that the natural childbirth pioneer Michel Odent would be over the moon. The French obstetrician has devoted his life as a practitioner, lecturer, researcher and prolific author to campaigning to end unnecessary intervention in childbirth. And now the NHS, widely accused of promoting such intervention, is being kicked into line. A two-year government investigation to settle the long-simmering row over whether Caesarean sections should be used more widely looks set to recommend that they shouldn't. New guidelines from the National Institute for Clinical Excellence (Nice), due out in April, will instead put pressure on obstetricians to ensure that tomorrow's newborns take the vaginal route wherever possible. And the so-called "too posh to push" brigade of women asking for Caesareans will be encouraged to think again.

Yet, far from celebrating, Dr Odent is deeply concerned about the Government's plans. His new book, The Caesarean, due out in April to coincide with the Nice report, will warn that a policy of reducing Caesarean sections within obstetric care as it stands today (an important rider, as explained below) will be a major disaster.

Surprisingly, Dr Odent says that, given the conditions in modern hospitals, a Caesarean can be one of the better options. His arguments are likely to enrage the natural-childbirth movement as much as they will challenge mainstream obstetrics.

With the guidelines already semi-public, Dr Odent says he has heard many reports of deliveries during which the obstetric team tried "everything" in order to avoid a Caesarean, which too often ended in either a forceps delivery with episiotomy or a Caesarean after trying forceps. "Forceps have their place only in museums," he says with a Gallic shrug. And pro-Caesarean obstetricians are right to argue that long, potentially dangerous labour cannot be justified in the 21st century when Caesareans are extremely safe - and in many ways safer than vaginal delivery.

The book will provide horrifying details that explain why one in three female obstetricians in London, faced with an uncomplicated pregnancy, have chosen, or would choose, a scheduled Caesarean delivery. Four out of five of them would make such a choice because of the increased risks of tears to their perineum or anus and the consequent risk of incontinence following a vaginal delivery. These risks, says Dr Odent, are "real and well-documented" - and not an inevitable part of natural childbirth, but largely a result of intervention.

Such respect for the truth, no matter how inconvenient, should come as no surprise to Odent-watchers. Sometimes miscast as being a natural-childbirth zealot, he is increasingly recognised as one of childbirth's most scrupulous scientists. Take the study published in the British Medical Journal in January, showing the pain-relieving benefits from using the birthing pools that Dr Odent himself pioneered in the 1950s and brought to north London and subsequent international fame in the 1980s. The study practically provoked dancing in the streets among some sections of the natural-childbirth community. Yet Dr Odent himself is scathing about the scope of the research, which he claims was "too small to have any scientific value".

It is this insistence on scientific integrity, however, that underpins his concerns about Caesareans, which go beyond what he calls the 20th-century preoccupations around the safety of the mother and baby.

"If we focus on simple safety issues, a policy of scheduled Caesarean at term may be considered well-founded," he explains. "But there are other factors." His book will draw on the Primal Health Data Bank (www.birthworks.org/primalhealth), a unique database that he has established single-handedly containing every piece of research linking pregnancy and childbirth with the long-term emotional or physical health of the child. It's an area that clinical research has largely ignored. Yet there is unequivocal evidence that children born by planned Caesarean have a higher risk of asthma and other respiratory problems. A handful of smaller studies suggest a link between Caesarean birth and autism - sufficient evidence, he believes, to provoke concern about the emotional consequences of birth without the hormonal and physical impact of labour.

He argues, controversially, that Caesareans may actually impair children's ability to love - an impairment that may be scarcely noticeable at an individual level but which could wreak havoc at a population level. "Look at the cultural differences between Amsterdam, which has a 10 per cent Caesarean rate, and Sao Paulo in Brazil, where eight out of 10 babies are born by Caesarean. Anyone can walk at night in the streets of Amsterdam. It would be suicidal to do so in Sao Paulo. A conclusion may be premature, but such an observation has to be of epidemiological interest," he says.

All of which brings Dr Odent back to the choice facing a pregnant women in today's NHS and the Nice recommendations. The choice, he believes, should not be between a Caesarean birth and the kind of vaginal delivery that occurs routinely in hospitals today. "Reducing Caesarean births is impossible without a rediscovery of the basic needs of the woman in labour: her need for privacy, for feeling unobserved, unmonitored and undirected," he says.

Only these conditions permit the "fetus ejection reflex", a short series of irresistible, uncontrollable contractions that shuts down the thinking brain and brings about the release of a complex hormonal cocktail, including a high peak of oxytocin, also known as "love hormones". It's a natural reflex, he says, like falling asleep or sneezing or reaching orgasm. And one of the key benefits of experiencing the reflex is that women's bodies do not get torn.

"Many midwives today do have a deep-rooted understanding of birth physiology, but they are prisoners of protocol," claims Dr Odent. As a result, most women today do not fully release these hormones or experience the reflex. In hospitals they are beset by epidurals or pharmacological interventions or lights, or interfering hospital staff or even husbands. But the same inhibition can occur in home births where a midwife might be constantly handing out advice, telling the woman what to do, or asking her questions. Such interference is not simply irritating; it's dangerous to the woman's long-term health.

Dr Odent has done his best to give women the best chance of this dark, secret labour - promoting the training of doulas: experienced older women who provide "the kind of protection offered by the presence of a mother watching over her daughter as she falls asleep". Research showing that the presence of a doula can improve the outcome of labour and reduce the need for interventions is sufficiently impressive for the phenomenon to be increasingly available throughout the world - including in NHS hospitals.

Meanwhile, Dr Odent is preparing for the publication of his latest book and the forthcoming battle with Nice and the clinical experts, on behalf of the labouring women he has seen himself as representing for 50 years. "I really believe that it should be possible for women to give birth without bright lights and without being told what to do. Women themselves should understand why this is important and insist upon these conditions," he says. "As for the NHS, it's now or never for it to face up to women's birthing needs. Without truly sensitive obstetric care being available, women are fully justified in insisting on safe, surgical childbirth - whatever Nice says."

Michel Odent's 'The Caesarean' is published on 1 April by Free Association Books (Fabooks.com, £14.95)

MOTHERS SPEAK OUT

Sophie Snell, 39, a non-executive director of a building society, from Quarndon nr Derby

This is my third baby, my first at home. I had a boy, 9lb 2oz, all naturally, in water. It was quite a fast delivery - the only complication was that we had a power cut just as I went into labour. But half an hour later it was back on, so we could fill the pool in time. I'd definitely have another home birth - it was so much more relaxed. I could go to my own bed afterwards, and wasn't separated from my husband and children.

Natalie Smith, 33, a part-time bank clerk, from Bromley, Kent

I had my first child naturally, in hospital, but everything went wrong. There were no hospital beds, no pain relief, no nurses, nothing. When I was stitched up afterwards, the nurses did a really bad job of it. Afterwards, I was told I would have to have a Caesarean for the next birth. I went private, and it was fine. But if I had the chance, I would not go for a Caesarean again. The pain was horrendous. You can't do anything for six weeks. Even now, if it's cold, I feel pain in the scar.

Caroline Limb, 42, a translator, from Kingston-Upon-Thames, Surrey

I've had three Caesareans. The first I had to have because I had placenta previa and I was losing a lot of blood. I was anaemic afterwards, shell-shocked and crying with post-natal depression. It was the worst pain I'd ever had. The other births were elective Caesareans for cogent medical reasons. They went well from a medical point of view. The second was the most straightforward, and it was a relief that everything went OK after the trauma of the first.

Dominic Bates