When you’re pregnant, my mom always said, it seems like the whole world is having babies. And, indeed, it’s been a year of babies around here: all three of my sisters-in-law are currently either pregnant or nursing freshly minted newborns, and I’m expecting a little girl in September.
Interestingly, many of the women around me are also onto their second babies. And it’s also interesting – and a little scary – going through this pregnancy and birth in a health system (private, South African) so vastly different to the one (national, UK) where I gave birth five years ago.
Which brings me to a burning, aching, heartsore issue for me, and one I feel almost disallowed to express. 9 out of 10 women I know have brought their children into the world via surgery, rather than natural childbirth. And 9 out of 10 of the pregnant moms I know consider themselves on the ‘likely to need a C-section’ end of the spectrum. It’s an epidemic of unnecessary surgery, among a privileged, healthy section of a population who have no reason to need these high rates of unnecessary surgery.
Why the hell are the majority of women in the private healthcare system in SA being cut open to have their babies surgically removed? Why is there so much acceptance of the systematic denial of women’s opportunity to give birth naturally?
It isn’t rocket science. A privatised healthcare system is consistently loaded against the interests of the naturally birthing mother. The overriding reason is that Caesarians are more profitable for hospitals. They’re easier to schedule, and they give the doctor an easy quick way to get the birth over and done with. The financial rewards are direct for hospital and doctors. The need for equipment and meds, from anaesthetics to syntocin and painkillers, adds to the profit-fest. And all this can be offered under the guise of a pain-free, quick, controlled, safe procedure. And because they are paid for by medical aids, it’s very easy to persuade the patient (as the mother becomes) that it’s reasonable. The reason that Caesarian rates are lower in countries like the UK and the Netherlands that is motivated towards best possible outcomes for mothers AND keeping healthcare costs reasonable. Not just easiest and most lucrative outcomes for doctors.
But if it’s pain-free, quick, controlled, safe, and cheaply available on your medical aid… why shouldn’t mothers embrace it? Isn’t the outcome the same? Well, yes and no. The ultimate outcome – the safe arrival of the child is paramount. And in the tiny proportion of cases where the Caesar is truly necessary, that outcome overrides the importance of other, softer outcomes. Natural birth offers a lower rate of short-term complications for mother and child . Recovery time is shorter, and doesn’t interrupt the early mother-child bonding process. The natural drugs released by the body – the endorphins and hormones – completely support the production of breastmilk and post-birth bonding, unlike medical drugs and surgical interventions, which may badly interrupt these processes. But mostly (though, with so many C-section moms around, it’s taboo to say so), giving birth – if done in a relaxed, supportive environment – can be an utterly amazing process, a privilege, a once-in-a-lifetime source of joy and personal achievement.
According to a 2010 world health report by the World Health Organisation:
‘[t]he recommended minimum necessary CS rate at population level to avoid death and severe morbidity in the mother lays between 1-5%, according to WHO and others.’ 
This view is echoed by the UK’s National Health Service. In any given population, it’s normal for around 5% of pregnancies to involve ‘birth complications’ that might necessitate Caesarian section or other medical intervention. In other words, around 95 out every 100 pregnant moms is capable and likely to have a successful natural birth – in an environment that actually supports natural birth.
But in South Africa, the rate of C-sections in private hospitals is between 80 and 100%. That’s 75 to 95 unnecessary surgical interventions per 100 births. It’s insane. The problem isn’t the complications. The problem is the environment we’re faced with.
Like I said, I mostly feel this is a view that I should just shut up about. There are so many people I’m likely to offend. Every woman I know who’s undergone a Caesarian section has a detailed narrative about why it was necessary. The baby was too big. The baby hadn’t turned. The placenta was doing something funny. The cord was around the baby’s neck. The uterus was doing something funny. The baby was in distress. A detailed narrative, offered very convincingly – and duly frighteningly – by the medical fraternity, and taken up by mothers, who become patients, patiently accepting what doctors tell them – because what else can they do, when listening to the doctor is the only responsible choice on offer?
But it’s impossible that every one of these C-sections was necessary. We have a situation where private hospitals in this country have a rate of around 80% Caesarian deliveries. Some private hospitals have a 100% rate. There are doctors who are known to refuse to consider natural birth as an option. Without exception, in private hospitals, the labour wards have one, two, maybe three beds. And they’re never full. Because you don’t give birth naturally in this country. You “try for” natural birth. For an hour or two. And of those who labour for 12, 15, 24 hours, most do so under the scrutiny of a medical staff who are mostly waiting for the go-ahead to transfer to surgery and get it over with. I have no idea how natural birth is even remotely possible under those circumstances. When a mom does persist with her natural labour all the way through to birthing, curious nurses pop their heads around the door to get a glimpse of her. It’s that much of an exception, and no wonder.
It fills me with resentment – not towards the mothers that get put in this position, or the babies born in this way – but towards the system so unswervingly biased towards removing any real sense of birth choice from an entire population of mothers. Healthily pregnant mothers with healthily gestated babies in healthy uteri, with potentially excellent outcomes for a natural birth. That is what is being denied here. It’s a systematic and it’s endemic robbery of choice, one that wastes money to the tune of billions of dollars internationally, in countries where privatised healthcare is the norm . And, scarily, despite the fact that I have had a completely wonderful, easy, successful natural birth previously, even I hear the same things from doctors. A little detail here or there – “well, we’ll have to keep an eye on this, because if it persists you may need a Caesarian, but not to worry, we’ll just have a look closer to the time.”
I speak to first-time moms who (inevitably) talk about “trying for a natural”, and my heart sinks for them. Not because I care either way what they choose. But it saddens me that they’re not being given much of a real choice. It saddens me that they’re overlooking the astonishing job they’ve already done of conceiving and gently producing a baby.
They’re ignoring the way their body has absolutely reliably built every bone and nerve and blood cell in that baby’s body, painstakingly fed it oxygen and nutrients and a perfect blend of hormones, generated a heartbeat and a blood supply. The placenta has formed and fed and nurtured, the amniotic fluid has bathed and held and protected, the uterus has stretched to accommodate the growing child. For nine whole months, their bodies have done extraordinary things that no doctor could ever attempt. And then, just before the child is ready to arrive, the doctors have the gall to snatch away the once-in-a-lifetime opportunity of the equally extraordinary culmination of this amazing process.
For heaven’s sake, isn’t sex also a strange mix of pain and pleasure? Imagine a world where your friends only shared horror stories about their first sexual encounter, where normal sex was replaced with a 95% IVF rate, or some kind of highly profitable surgical procedure. Imagine a world where you and your partner would be inspected by a doctor, and penis and vagina sizes analysed and compared for potential discomfort. How comfortable and fun would sex be after that? I can think of other, more scatalogical examples, but I’ll spare you. It’s a bizarre enough little picture. Orwellian even. But in the case of childbirth, we’ve gone to that dark world. A world where doctors are allowed to subjugate a normal, natural, messy real-life process and replace it with something clinical, surgical, and dominated by scheduling, equipment and profit.
A normal natural birth is both normal and completely extraordinary. It is a marathon of physical and psychological effort, yes. It is not without discomfort, no. But it is also a physical, loving, primal process – as much as the process of conceiving a child in the first place. It’s a once-in-a-lifetime opportunity, to allow your child to enter the world at a pace and a rhythm determined by his body and yours, in a unison of effort that will bond you like no other experience in your life. I am truly sorry for those who have missed this experience. I don’t judge them or their babies; I do judge the nasty juggernaut of a healthcare system that’s made it impossible for them to trust their bodies. And yes, in some cases - just like in the case of those who need IVF and other interventions – it may be a life-saving, life-creating necessity. I appreciate that, and have no desire to dismiss it. But in most cases, it’s just a terrible pity.
And what angers me most is that I feel myself trapped in the same system, where doctors wield their power to plant these seeds of fear. Even with my own history of a perfectly happy, healthy natural homebirth, I can feel that exercising my real choice involves considerable resistance, to safeguard my own fragile confidence and faith in my own real ability to give birth. I’m a few years older now. The doctors point that out. They point out blurs on a scan, and make little noises of concern, and my throat constricts. And I wonder whether I’m fated to be processed in the same way through the same system, or whether I have it in me to safely navigate my – and my baby’s – way through.
I’ve been writing this article for a while now. I’ve resisted publishing it at various points because I’ve not wanted it to look like a rant directed at any specific person’s choice. It’s not that. If you’re a mom who gave birth by C-section, I’m not saying you did the wrong thing. I’m not talking about you. I’m talking about a system much bigger and more powerful than both of us.
Acknowledgements and further reading
 Arikan I, Barut A, Harma M, Harma IM, Gezer S, Ulubasoglu H. –Clin Exp Obstet Gynecol. 2012;39(3):288-92.PMID: 23157026 [PubMed - indexed for MEDLINE]
There’s tons of reading on this divisive and controversial topic. Here are a few articles and blogs I came across: