An independent inquiry into maternity care at the Shrewsbury and Telford NHS Trust - where between 2013 and 2016 stillbirths and neonatal deaths were up to 10% higher than the UK average - has found more than 40 babies and a dozen women have died unnecessarily. The Ockenden Review, led by Donna Ockenden, a former senior NHS midwife, found that families were subjected to unsafe care because of a culture that denied women choice. In some cases women were medicated and forced to undergo traumatic forceps deliveries, leaving babies with fractured skulls and broken bones, rather than having emergency C-sections.
So isn't now the time, once and for all, for us to finally abandon any C-section guilt?
In 2020, a group of women were interviewed in a new video for the BBC, who spoke about the guilt they have felt for undergoing a C-section. A survey by the charity Mumsnet and charity Birthrights showed that 74% of respondents say they were given the opportunity to discuss the benefits of a vaginal delivery, but only 42% said they were given the opportunity to discuss the benefits of a caesarean section (even though 1 in 4 births in 2019 was a C-Section according to the NHS).
One woman in the video talks about how she felt like she’d ‘missed the mark’ and the shame she’d felt that her body ‘didn’t know what to do,’ while another talks about how if you manage the full shebang - a natural, vaginal birth with no pain relief then you’re seen as a ‘Goddess in motherland.’ They talk about how C-sections were presented to them as a ‘last resort’ when they were pregnant and the lack of support they received after this major surgery.
The survey found that of 1145 women who have given birth at least once reveals that 14% say their opinions and decisions when planning for giving birth were overruled, and 11% say there was an attempt to overrule their opinions and decisions. In total, 24% of the mothers surveyed say their decisions and opinions about their care were not respected. 30%, say their decisions and opinions were not sought at all.
We are seven years on from the ‘Montgomery ruling’ in March 2015, named after Nadine Montgomery, whose son was born with cerebral palsy as a result of complications during his birth. She raised concerns a number of times about her baby’s size and whether she would be able to give birth vaginally, her concerns were dismissed. The Supreme Court ruled that she should have been told about the increased risk of vaginal delivery in her circumstances (she is diabetic and of short stature), and offered the ‘reasonable alternative’ of a Caesarean section. The court ruled that women cannot give informed consent to decisions about their care if they are not given personalised information, presented in an understandable way, and the opportunity to have a proper discussion with a healthcare professional.
'Our survey with Mumsnet showed a vast difference in the number of discussions about vaginal birth compared to caesarean births and between giving birth on a labour ward and giving birth elsewhere. Midwives and doctors need to lead the way in ensuring that any birth, including caesarean birth, is free of stigma,' Maria Brooker, Birthright's Programme Director told Grazia.
So, seven years on, why are so many women still being made to feel guilty about wanting, asking for, or having a C-Section? And it comes at us from all directions, from the NCT groups where the course leader refuses to discuss them, to the midwives who do everything they can to steer frightened women, with valid medical concerns away from a procedure they’re legally allowed to ask for. And then there’s the idea that if you don’t want to give birth vaginally, because you’re scared, because you’ve got medical concerns, because you just don’t want to because let’s face it, it doesn’t sound like the most fun way to spend a weekend, then you’re ’too posh to push.’
Charlotte, now 43, had elective C-sections with both her sons, but had to fight for it. 'I was possibly influenced by my mother, who had two elective c-sections (the first was recommended to her by her best friend, a respected medic, who said since I was due on Christmas Day when most doctors are drunk in the wards – this was the seventies – then she should have a c-section and get me out early… ) I also wanted one because I was 39, and didn’t want anything to go wrong; lots of medics have c-sections for the same reason but don’t necessarily shout about it. I had to really fight to get the c-section, though, even though I was theoretically legally allowed an elective c-section on the NHS – my initial midwife sent me to the senior midwife, who actually made me cry as she was being quite forceful about me not having one. They initially wanted me to have a home birth, which the NHS were really pushing at the time. It was only when I eventually got referred to a doctor, that it was allowed but even then I had to strike a deal – it was booked in on my due date, and if I went into labour early, I would attempt to give birth naturally.’
And of course, when you plan and hope to give birth naturally, and your body has other ideas, that’s a different matter entirely. Both of Justine’s two children, now aged 12 and nine, were born via emergency c-section, which was a source of regret.
'I had two brilliant pregnancies. The second time I was out dancing a fortnight before my due date. But, when it came to giving birth, my body just wasn't set up for it. It isn't guilt-inducing but it does make you feel like a pretty crap female.
'Today, being able have children is just one of the things we do as women, there are so many other things we can excel in and there are medical advancements that help us give birth, but in the past, if you couldn't give birth naturally, you died as probably did the baby - you couldn't do the one job society expected of you.
'So I couldn't do the one job my physical self was meant to do. Which made me feel awful about myself. I'm rubbish at sports but my body has always done what I needed it to do. But in this case it couldn't. And I couldn't do anything about it (we can always get fitter and faster by exercise, get smarter by studying).
'I couldn't give my babies the benefit of all that good bacteria (microbiomes) they get travelling down the birth canal that helps against obesity, asthma, immune deficiencies and supports good gut health. I couldn't be the first to change their nappy or to bathe them, I couldn't drive them to their first doctor's appointment. For the first time as an adult, I was helpless and at a time when my help was most needed.’
As much as I’m blasé about my own birth experience now, because it all worked out, what Justine says totally resonates. We’re programmed to - and expected to - do anything and sacrifice everything for the good of our children, and when factors that we thought were down to us turn out to be totally out of our control, that’s hard.
'When you are pregnant, you just think of all the ways you can give your children the best life possible,’ she adds. 'Their health is paramount. Because my body wasn't good enough, because it didn't bloody work when I needed it to, I was letting them down. It's probably why, despite having only had two children, I have still spent 5 years of my life breastfeeding. Apart from the fact I loved it, I was trying to make up for the fact I couldn't give birth to them naturally.’
'Everything happens so fast and one is so helpless and in such agony. In that environment that you just say yes to everything, and you feel it is your fault because you can’t walk, you aren’t dilating enough, the pain relief doesn’t seem to work. I felt like an annoyance to everyone (both times) which I have never ever felt in the NHS system before or since.'
Why do we baulk at women making demands about their births and their bodies? Freelance journalist Helen Ochyra had a C-section for medical reasons with her daughter, and is planning on having another with her second child, due next year. 'I always wanted a cesarean. Years before I even decided to have children, I was quite scared of the concept of a vaginal birth. There are so many things that can go wrong. I know so many women who’ve had negative experience - incontinence, episiotomies, infected stitches.
'But when I was first pregnant, I did think that I’d probably end up having a vaginal birth - there’s so much pressure on women to have a ’natural’ birth, but I was pleased when. I found out I had to have the C-section. It’s surgery and shouldn’t be taken lightly, but it took away so much uncertainty.’
For a freelancer like Helen, who’s self employed, this meant she was able to plan in work right up until she was due to give birth. An elective C-Section certainly takes away a lot of the uncertainty around what is one of the biggest moments in anyones’ life. ‘I do like the fact that I’ll be given a date when my next baby will be born and that will be that. We’re supposed to be ok with a week of siting on the sofa, with a cup of tea, waiting for this baby to come along, but last time I worked until the Thursday, and my baby was born on the Friday.'
‘People want to see patience in a pregnant women - we’re supposed to wait around and not complain. There’s something about C-Sections that feels like we’re being more demanding, and it’s often a male consultant who’s the gatekeeper to that decision.'
The idea of what makes for a virtuous mother-to-be, or new mother is interesting. Patience and not complaining are up there, as are not cutting corners (giving your child food in pouches, not exclusively breastfeeding for at least a year or sticking them in front of the tv for 20 minutes, and certainly not taking the ‘easy way out’ by having an epidural or a C-section). It’s all meant to be hard and painful, and a slog. If It isn’t we’re probably not doing it right, or don’t love our children enough, or something.
And these societal expectations make it even harder to unpick what autonomy in pregnancy, childbirth and parenting really mean for women. Statically speaking, the day you’re born will be one of the most dangerous of your life, and as much as a planned C-Section is major surgery, the potential repercussions of an assisted birth, or an emergency C-section are no joke. I knew that, I’d seen all the stats before I gave birth, but I still held on to the hope that I’d be one of the 20% who’d manage to solider on without pain relief, who has a magical birth experience with minimal intervention and then toddle on home eight hours later - even though I literally don’t know a single woman that’s ever happened to.
One of the enduring themes of the report into the Shrewsbury maternity scandal is that women's concerns and fears were simply not listened to, and that needs to change. But we also need to change the dialogue and conversation during pregnancy. NCT groups, midwives and GPs need to spend more time being honest with women about the type of birth they might expect. A ‘good’ outcome is a safe, un-traumatised mother and baby, who don’t face and long-term ill effects from the birth, yet the conversation gets complicated with the idea of a birth being ’natural’ and your body ‘doing what it was designed to do’ (when, as Justine points out, when it didn’t do what it was designed to do 100 years ago, you and your baby probably died). We have so many complex, nuanced conversations these days about what it means to be a woman - so why are we so narrow minded about what a ‘good birth’ means?