This view is well known to AIMS (Association for improvements in the maternity services - www.aims.org.uk) members working with mothers who wish to book a home delivery, water birth or a natural, active birth in a hospital setting.
On the whole, these mothers are well informed and are usually fighting for their rights from a positive position of inner self-confidence, strength and health. VBAC mothers, however, are less able to fend off such accusations since many have had their personal confidence shattered or at least severely undermined. They may feel they have 'failed' once already and in many cases they have fallen victim to the current medical model of maternity care along with its debilitating aftermath and, of course, they have the uncertain handicap of a uterine scar.
The abundance of outdated and unsubstantiated opinion regarding VBAC makes it relatively easy to frighten and subdue those women who do have enough strength left to broach the subject. Especially since good, reliable, evidence based information to help them defend what is often, at first, an instinctual desire, is not commonly available.
I personally do not believe that a normal, healthy women carrying a healthy, wanted baby is capable of putting that baby at risk. A mother will do anything for her unborn baby and “For the sake of the baby” is one of the most common reasons why mothers consent to caesarean operations. As Sarah Clement says in her book THE CEASAREAN EXPERIENCE it is a supreme sacrifice of love1
I know, therefore, when I’m talking to a mother who has already undergone a caesarean operation and who has expressed a strong need to avoid a further operative delivery, that she will NOT persist with her wishes to the detriment of her baby. She will not be capable of doing so.
In the many birth stories I have heard mothers who have gone against medical advice are always labelled as ‘lucky. Either that or they have had religious beliefs which influenced their decision. Rather unfairly, these stories, even if they have good outcomes, are used to browbeat other mothers into towing the line.
Sadly tragedies do occur. Thankfully these are rare but nonetheless they make a huge impact on us all. However, in all my dealings with childbirth affairs in the last eight years, I have never heard of a tragedy where the mother was actually responsible, or brought in on herself. In all the tragic cases which have come to my attention, the mother’s basic instincts have been overruled. Often the mothers crisis expressed deep concern, severe misgiving or feelings of distress or fear before the tragedy occurred. In such cases the mother and as a result her baby, are both victims, not only of substandard care, but also of the mother’s loss of control. One fact is clear: All the while the mother is control, the safety of her baby is assured.So why are mother’s instincts and their inner knowledge ignored and given so little respect? Why does the medical profession take over the birth process again and again, to the proven detriment of mothers and their babies? Perhaps more importantly, why do mothers let them take over?
We live in a society that is fearful of childbirth. It is also a very segregated society where mothers with young babies and children live apart from rest of society, moving in their own social circles. Rarely do they come into close contact with anyone who is not part of their immediate family or who is not another mother.
In theory, ante-natal care monitors the medical well-being of women, but for many the emphasis on checks for abnormality adds further to the subtle message that childbirth is a dangerous process. There is also a widespread belief in our society that current medical practices save women from the pain and ordeal of childbirth and guarantee a healthy baby.
Indeed the belief that a caesarean will always produce a healthy baby leads to many court cases each year where undue delays in implementing a caesarean delivery are alleged. Settlement figures are high, there is no time limit to bringing a case and since 1990, all children qualify for legal aid. The threat posed by the birth of a handicapped child is there for the whole of a doctor’s career.
Doctors find court cases, and the even greater numbers of hospital complaints, confrontatbonal, adversarial and bewildering. Often they feel their professional competence is being called into mothers question. The reality for doctors is that to be seen to be taking action is less likely to lead to criticism and is easier to defend. Many doctors also lack faith in the natural birth process and their day-to-day experience with the small percentage of births where problems and do arise does not promote a balanced picture of birth. Many doctors, therefore, feel forced to practice defensive medicine.
At a recent conference, Mr. Boylan, a consultant at the National Maternity Hospital, Dublin, said of the obstetric profession with regard to the current 15% plus caesarean operation rate: “We are sending out a strong, subtle message that women are not able to deliver their own children safely in our care.” He emphasised that the women on the receiving end of this message were all perfectly healthy.
Women who wish to have a VBAC are generally unaware of the underlying concerns affecting obstetric practice. The direction of a woman’s decisions will be determined by her instincts and her the knowledge of her individual, personal situation. However, her ability to make firm decisions will be dependent on finding sufficient information to support her instinctual feelings and assure her of the safety of her desired course of action. She will not be prepared to risk her child.
All the available evidence supports the safety and desirability of VBAC. Two reports using computer analysis to compare VBAC against elective repeat caesarean, both came out very strongly in favour of VBAC.2 The highly respected GUIDE TO EFFECTIVE CARE IN PREGNANCY AND CHIILBIRTH supports VBAC and states that "The likelihood of vaginal birth is not significantly altered by the indication for the first caesarean (including ‘cephalopelvic disproportion’ and 'failure to progress") nor by a history of more than one previous caesarean.”3 However, despite the evidence of the safety of VBAC, hospitals have appallingly low VBAC rates. Although some hospitals report rates for VBAC of around 60%, and many over 80%, these figures are based on numbers where those deemed ‘unsuitable’ for VBAC have already been weeded out. It is much more enlightening to find out how many caesarean booked with a particular hospital go on to have vaginal deliveries. One hospital I know has a VBAC rate of only 11% and a very large proportion of those are delivered by forceps.
In order to avoid a caesarean delivery, VBAC mothers have to do one of three things
Clearly each of these options. presents its own particular problems.
If hospitals can learn to listen to mothers, particularly caesarean mothers who wish to avoid a repeat operation, they will discover how to increase their VBAC rates (if this is, in fact, one of their goals). Hospitals with good VBAC rates will also have a system of care which is woman-centred and will be likely to have low primary section rates.
The barriers to listening to VBAC mothers are an unfounded fear of ‘scar rupture’ and an underlying belief that mothers are willing to put their babies at risk to achieve their own aims of a natural birth. This is a ludicrous, terribly insulting and overwhelmingly unacceptable view. How many mothers do you know who would risk a single hair on their baby’s head?
Mothers will go to extraordinary lengths to keep their babies safe - when are the maternity services going to respect this simple, ageless and enduring fact and stop using it to pressgang mothers into unwanted and unnecessary operative deliveries?
First published in the AIMS Journal, Vol 8, No 1, 1996