A battle for control of women's bodies

Hi-tech procedures have led to a rise in Caesareans.Sheila Kitzinger argues for less surgery and more sense

Last week a judge threw out the case of Ms S, the woman who was compulsorily "sectioned" under the Mental Health Act and then had a court- enforced Caesarean. He dismissed it on a technicality. She should have started the action within three months of the birth. In fact, she failed to do this because, after rejecting her baby at first, she had had to fight social services for custody.

Women often do not know that they must act quickly if they want to sue a hospital trust, and have to consider the pros and cons while in the hazy, exhausting and emotionally topsy-turvy first 12 weeks of motherhood, when those who have been traumatised by labour may have conflicting feelings about their babies, replay what was done to them over and over again in their minds, and find it impossible to make decisions.

Incredibly, the judge did not seem to see that to detain in a psychiatric hospital a woman who wants a home birth, and then perform a compulsory Caesarean section on her, might be a matter of public interest. If he had, he might have decided that the important issues raised when a woman is operated on against her will should outweigh late application. Ms S will appeal, of course, and there are six other cases in the pipeline.

The Caesarean section rate was 10 per cent in the early Eighties in England, and 15 per cent in 1994/5. No one yet knows what it was last year.

Few obstetricians do Caesareans because they want to be free to get to the golf course. There are many, however, who are not prepared to wait for a baby to be born and who lay down strict time limits. They turn birth into a race to the finishing-post, with operative delivery the penalty when labour does not meet their norm. Women are grateful that their babies have been "saved" by a Caesarean, not realising that the way labour was "managed", starting with induction, followed by interventions that screwed up the normal physiology of labour, resulted in a need for Caesarean section when the cervix did not dilate.

Epidurals, especially if given before 5cm dilatation, double the Caesarean rate. But the main culprit is electronic foetal monitoring. That can increase the chance of Caesarean section by an astonishing 160 per cent. A costly technology that has become routine in most hospitals, without any evidence that it makes birth safer, leads to costly surgery.

Obstetricians often say that the rise in Caesareans is due to the threat of litigation. If something bad happens to a baby, it is safer to show that you did something rather than nothing, and getting the knife out is an obvious way to demonstrate concern.

But a major reason why the Caesarean rate is shooting up is that obstetricians have become deskilled. Older ones know how to deliver a breech baby vaginally. Midwives in traditional cultures massage and coax babies into more favourable positions through the mother's abdominal wall. Younger obstetricians are not experienced enough to do this, and think it is not worth the bother. Yet six randomised, controlled trials have shown that two out of three babies can be turned, and will stay head down. This halves the rate of Caesareans.

Even if a baby stays in the breech position there is no evidence that a Caesarean is safer, and around half of all mothers of breech babies can give birth vaginally if they have the chance. Two randomised trials have shown that breech babies do not benefit from Caesarean section, and their mothers are much more likely to suffer pelvic infection.

Some Caesareans are life-saving. Others aren't, but the decision is often imposed on the mother. She feels relief, and only later questions whether it was necessary. Many women become distressed a couple of months after an emergency Caesarean, feel cheated, lose self-esteem and suffer flashbacks and panic attacks.

Not a week passes but I listen to women's accounts of horrendous experiences of obstetric management. They describe being made to lie on their backs for hours harpooned to electronic machines, intravenous drips and catheters, often being subjected to failed forceps and ending up with an emergency Caesarean section. It is reasonable for women who have been through an experience like that to prefer an operation under controlled conditions with guaranteed pain relief. Modern obstetric management has made the birth room a torture chamber, and offers release from it with elective Caesarean section.

But it is not only deeply traumatised women who opt for Caesareans. Most women, if told by an obstetrician that a Caesarean is best for the baby, go along with professional advice. Obstetricians see operative delivery as a quick-fix solution to ever-widening problems.

An obstetrician once snapped at me that he couldn't stand back seat drivers. He meant women who had ideas about what they wanted in childbirth. He had to be in control of that wayward womb, that feckless woman who puts the foetus at risk. He, and only he, must manage the potentially pathological process of labour and delivery. Many obstetricians think like this, though they may be willing to make concessions, and, like Nick Fisk, an obstetrician at Queen Charlotte's, where one woman in four has a Caesarean, spend time talking to women - though they find it more difficult to listen to them. Professor Fisk claims that there is "increasing maternal input into childbirth". It is not clear what he means by this. Women have always had a lot of "maternal input". Doctors could not produce babies without them. The debate about Caesarean section is about control over territory. And the disputed territory is a woman's body in pregnancy and childbirth.

Women seek Caesareans not just because they can't face pain, or want to keep their vaginas "honeymoon fresh" (one way Caesareans have been promoted in the US) but because they hope they can maintain some control over what is done to them. When they describe horrific birth experiences we should listen to them, give accurate information, and, I believe, support them in getting an elective Caesarean with the next birth if that is what they want.