Giving birth by caesarean section has long been seen as the "too posh to push" option for expectant mums. Either dismissed as "the easy way out" (which it isn't; it's major surgery!), or criticised for not being the "natural" or "maternal" way of bringing your child into the world, the C-section generally gets a pretty bad rap.
But for some women and their babies it is the best option – either in the form of an emergency caesarean following labour complications, or as a birth plan in its own right. Sadly, women pursuing the latter continue to face stigma and obstacles at what's already a challenging and emotionally charged time.
Research published on Tuesday by maternal human rights charity Birthrights found that: "the majority of NHS Trusts in the UK make the process of requesting a caesarean lengthy, difficult or inconsistent, adding anxiety and distress to women at a vulnerable time."
According to the charity's director, Rebecca Schiller, maternal request caesareans are the number one reason women contact the Birthrights advice service. Their reasons for wanting a C-section are varied, but most couldn't be further removed from the "too posh to push" stereotype.
"The women we support have endured previously traumatic births, physical ill-health, childhood sexual abuse, or have carefully examined the evidence available and made informed decisions that planned caesareans will give them and their baby the best chance of an emotionally and physically healthy start," Schiller explains.
"It is clear that women requesting caesareans meet judgemental attitudes, barriers and disrespect more often than they find compassion and support," she adds. "We are concerned that this lack of respect for patient dignity could have profound negative consequences for the emotional and physical safety of women.”
Mumsnetspokeswoman and mum-of-two Anna Cook endured a difficult labour with her first son four years ago, ultimately ending in an emergency caesarean two agonising days after being induced.
"We were fine, but it was an incredibly long, drawn out, difficult process. I was exhausted and tired, and it was all quite traumatic, so I didn't want to repeat that," she says. "I needed to know, before I even got pregnant again, that a caesarean would be an option."
And it should be. Guidelines from the National Institute for Health and Care Excellencestate that: "For women requesting a caesarean section, if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, [hospitals should] offer a planned caesarean section."
Despite this, Birthrights found that: "15% of Trusts have policies or processes that explicitly do not support maternal request caesarean, while 47% of Trusts have policies or processes that are problematic or inconsistent. Only 26% of Trusts offer caesareans in line with NICE best-practice guidance."
For women like Chloe*, who had her first child ten months ago, the struggle for a planned caesarean was "a shadow hanging over my whole pregnancy". Having heard a few too many horror stories about the worst-case scenarios, Chloe was clear from the start that she didn't want a vaginal delivery.
"I don't think I have tokophobia (fear of childbirth), but I didn't relish the prospect of any of the things that have gone wrong for many of the people I've spoken to," she explains. "I wanted to protect my pelvic floor and avoid everything that can go wrong with vaginal deliveries – the third and fourth degree tearing, the pelvic organ prolapse, the pain and the trauma – and I'd researched enough about the pros and cons of caesareans to make an informed decision."
Initially, Chloe says, both her GP and midwife were supportive and "falsely reassuring" of her decision. "I was strung along for 6 or 7 weeks until I realised of my own accord that the John Radcliffe hospital in Oxford has a policy of no maternal request caesareans, so it was never going to happen," she says.
By that point she was 20 weeks pregnant, and it would be another 16 weeks before she finally found a hospital that would agree to the operation – an hour and a half's drive from her home. "I probably rang in excess of nine hospitals, and trawled Mumsnet and Facebook groups in desperation," Chloe recalls.
"The reasoning given by everyone I spoke to was basically that it's not in the maternal interest – if you can give birth vaginally, that's what you should do, because it's lower risk," she explains.
"And that is true. If everything goes to plan, you are better off having a straightforward vaginal delivery. The problem is that you cannot guarantee that!" Chloe adds.
"I was so frustrated because I'd read up on all the risks – I knew there were risks of bleeding and infection, but those are much lower with a planned surgery, and it was my risk to take."
Likewise, Chloe highlights, there are risks associated with vaginal birth. "People are injured giving birth all the time, but no one ever speaks to you about the risks of a vaginal delivery, ever," Chloe says.
"It's totally fair enough if people want to take those risks – the experience of childbirth is important for some people – but I felt my choice was just as valid," she adds. "In fact, the obstetrician who did agree to the caesarean told me it was a completely rational and reasonable decision. I couldn't understand why he was so on board with it, and everyone else was kicking up an enormous stink."
Anna too, faced a difficult interrogation to justify her decision, despite a different doctor already having agreed to her C-section. "I had a very confrontational appointment when I was 34 weeks pregnant. I thought I'd already jumped through all the hoops the NICE guidelines had told me to jump through, but the doctor started from the point of 'why do you want a caesarean?' and I felt like we were going right back to the beginning," she says.
"I became incredibly emotional, started to shake and cry, and she was asking me to relive the birth again, which I wasn't prepared to do. I wasn't psyched up, I wasn't articulate, and she just kept repeating again and again 'we don't give them for maternal request'," Anna adds.
Although the doctor did eventually agree to an elective caesarean, it cast a shadow over the rest of Anna's pregnancy. "I spent the remaining five weeks worrying that it might be taken away from me," she says. "I didn't want to go through all that again, I'd made my choice, and the fact they put this extra hurdle in right at the end just didn't seem fair. Having seen the posts on Mumsnet though, there are a lot of women going through a lot worse."
After Birthrights' research was launched on Tuesday's Victoria Derbyshire show, Schiller told Grazia: "We must prioritise treating women kindly and compassionately at this time, and ensure women are allowed to build trusting relationships, are treated like adults, given personalised information about risks and benefits, and ultimately supported to make the decision that's right for them."
Birthrights operates a free advice servicefor mums-to-be