When Elizabeth Chloe Romanis first considered the ethics of chosen caesarean sections, she was listening to a radio programme her husband had sent her. The programme was about how some NHS trusts refused to give medically unnecessary C-sections to people who wanted them. “He sent it to me like: ‘Have you heard this?’ and obviously I got very annoyed,” says the biolaw researcher at Durham University.
Someone phoned in and asked, why should the NHS offer the choice when childbirth is natural and surgery costs money? Irritated, Romanis thought someone from her field ought to argue for the right to choose. “So that’s what I did,” she says.
It’s a controversial topic. The World Health Organization says that C-sections are associated with risks for both mother and baby, which is why it campaigns to reduce unnecessary C-sections and considers them a last resort, only to be done when medically necessary, a stance with which some NHS trusts seem to agree. On the other hand, the charity Birthrights and the public body providing national healthcare guidance in England and Wales, the National Institute for Health and Care Excellence (Nice), say if people truly want caesareans after carefully considering the facts, they should be given them.
As the debate continues, the pattern in the UK is clear: C-sections are rising, and rapidly. During the 2010s, C-sections rose from 25% to about 30%-35% across England, Scotland and Wales, way above the now abandoned WHO target of 10-15%. Part of that rise comes from growing numbers of elective caesareans, and Nice believes an increasing proportion of those are requested by parents. So should we be worried?
While massive global inequalities in safety and access persist, caesareans are considered major but safe surgery in high-income countries. In the UK, just over half of those conducted are emergency C-sections, performed when a vaginal birth has gone awry. The rest are elective caesareans planned in advance, most commonly because of pre-labour complications, and a smaller proportion for non-medical reasons.
Concerned that denying C-sections caused too much psychological harm, Nice changed its guidance in 2011 to say that if someone requests a C-section – a so-called “maternal request caesarean” (MRC) – they should be offered one with a willing doctor. But Nice guidelines are only recommendations, and reports from Birthrights and Tees Law have shown that many trusts do not offer MRCs in line with guidance. This is while investigations have revealed a culture at some trusts of pressuring people into vaginal births.
This can have tragic results. For example, a 2015 UK Supreme Court case described how a mother with an unusually large baby was purposefully not told about the risks of her delivering vaginally to avoid her requesting a C-section. During the birth, her baby was deprived of oxygen and later developed cerebral palsy. The court ruled that she should have been made aware of the risk and of the alternative of a C-section, in order to give informed consent.
But worries are still sometimes disregarded. Maria Booker, Birthrights’ programmes director, recalls recent contact with a woman whose hospital decided that her heart condition did not justify a C-section, despite her relative dying in labour of the same condition. “I think it would be inhumane to deny people caesareans in those kinds of situations,” she says. On the back of Birthrights’ MRC report and the Supreme Court ruling, Nice strengthened its guidance on MRCs and shared decision-making last year.
However, the issue is complicated. Ana Pilar Betrán, who leads the WHO’s C-section campaign, says the WHO is especially worried by countries such as Brazil and Turkey, which now have rates of over 50%, but the UK’s rate is also considered too high. It is a concern shared by some UK doctors and midwives.
According to Betrán, the high rates are increasingly driven by non-medical factors, such as the convenience to schedule the birth on a known day that can be prepared for and does not clash with work. “The WHO wants and supports and promotes respectful care during vaginal birth, and the use of caesarean section for women in need,” she says. But when there is no medical need, she argues, there is no benefit to the procedure. Fresh evidence on MRCs, however, shows that it might not be as straightforward as that.
When studying childbirth, researchers look at hospital records and note down how often certain outcomes happen after each kind of birth. For two reasons, this makes it difficult to study MRCs properly. First, MRCs are typically recorded as “elective caesareans”. But because most electives are scheduled to mitigate a risky complication, researchers say it is unfair to align their risks with those of MRCs, where everything might be fine.
Second, the risk of vaginal birth is often underestimated, so the comparison is skewed. This is because researchers do not always account for emergency caesareans as an outcome of attempted vaginal births. In fact, many older studies lump in the emergency C-section risk with the risk of all other caesareans, despite the fact that they are clearly more dangerous and almost always the result of a vaginal birth not going to plan. As Nice makes clear, ideally, studies would compare people planning a C-section with those planning a vaginal birth, but this information is rarely available.
These factors make it very tricky to estimate the risk of choosing a C-section versus planning a vaginal birth, but not impossible. In 2021, a team of Canadian researchers found a hospital database in Ontario that, unusually, had logged MRCs. This allowed them to compare MRCs to other low-risk pregnancies where the plan, but not necessarily the outcome, was a vaginal birth.
The data shocked the study’s head author, Darine El-Chaâr, a perinatal researcher at the Ottawa hospital. In the planned vaginal birth group, there was a higher percentage of negative outcomes compared with the MRC group, driven by serious vaginal tears and babies admitted to intensive care. “I myself am challenged by the data,” she says, underlining that she believes vaginal birth is natural. “I wanted it to be the other way around.”
The study is compelling but not quite perfect – yet. The relatively small amount of MRCs (1,827, as opposed to more than 400,000 planned vaginal births) meant that extremely rare outcomes such as death never materialised in that group. But now they have a database, El-Chaâr expects the evidence to grow over time. This will also allow her to investigate the long-term impact.
In 2018, Sarah Stock, an obstetric researcher at Edinburgh University, led a review of 80 long-term studies of C-sections from high-income countries. The review did not distinguish between MRCs, other elective or emergency caesareans, so it can only say something about the surgery itself, not about the relative risk of choosing it over a vaginal birth.
Stock found a combination of benefits and risks after a C-section, for both parent and baby. For example, parents had a lower risk of incontinence and babies a higher risk of childhood asthma. Effects in either direction were generally small. “There is no right answer here,” says Stock. “Women need to make decisions with their care-givers on what’s important to them.”
The issue of future pregnancies was more one-sided. For example, people with previous C-sections had a small but increased risk of placenta complications in their next pregnancy and generally went on to have fewer kids. And while differences were small, the review found increased risks of later miscarriage and stillbirth. However, Stock says, if you’re just having the one baby, you don’t need to think about that. Having a C-section when you are 24, pregnant with your first child and wanting four more, is a different proposition to when you are 42 and not planning to get pregnant again.
Overall, the argument against MRCs is not that clear-cut. But what about the phone-in radio caller’s worry about surgery costs? This is also less problematic than it first appears. According to a 2011 Nice analysis, the expense of MRCs is only marginally higher than that of planned vaginal births, if treatment for related issues such as incontinence is taken into account. El-Chaâr thinks this might be especially true for parents over 40, who are often induced early but then sit around for a long time, waiting for active labour to start. “I would not be surprised if it’s cheaper to have a planned elective in that group,” she says.
Whether a C-section is a good choice, then, depends on what is important to the individual. There also appears to be little reason to worry much about the population level in the UK, as the high rate does not seem to have negatively affected the most important outcomes: during the same decade that saw caesarean rates reach 30% and above, deaths of parents and babies decreased in both England and Scotland, though stark racial and socioeconomic inequalities remain.
So, can choice advocates find reason to support reducing caesarean rates? For Romanis, the “perplexing” focus on MRCs must be dropped. Instead, numbers could be brought down by tackling the fact that doctors sometimes perform emergency caesareans that are not medically necessary.
That phenomenon is partly due to doctors’ fear of being blamed for not intervening in time if something goes wrong, says Soo Downe, a midwifery researcher at the University of Central Lancashire and a WHO collaborator. It leaves some people with C-sections they never wanted and could have avoided. “I don’t think women who want caesareans get them, and I know for sure that women who want physiological labour and birth don’t get that,” she says.
That rings true for Booker at Birthrights. “If we could support physiological birth in a better way, we would bring the caesarean rate down,” she says, “but I don’t think that translates to individuals being told that they cannot have a caesarean.” So, focusing on reducing caesareans that are both unnecessary and unwanted could be a golden middle way.
In the end, it comes back to choice. “It’s about maximising health by allowing people to make the decisions for themselves,” says Romanis, who points out that a more open conversation about C-sections would also better equip people for giving consent in an emergency.
The goal should be to improve outcomes for everyone, says Downe. “How can we build maternity services where this isn’t a debate any more?” she asks. “Where women have caesareans when they want them, where women have necessary caesareans when they need them and are properly consenting to them, but where women who don’t want any of that stuff have great births as well?”