As pregnant people with higher BMIs, we’re often told we’re more ‘at risk’ of having a caesarean birth. But what does that mean, exactly? And how does framing it as a ‘risk’ affect people wanting to choose it as their mode of birth? It’s just one type of birth, after all, just as valid as any other. But those who choose caesarean or ‘C-section’ often feel criticised and like they have to justify it. If you’re feeling like it’s something you shouldn’t talk about, how can you prepare for it and make it a positive experience?
Sometimes a caesarean (sometimes spelled cesarean, particularly in the US) isn’t really a choice. Sometimes events mean that a c-section becomes the only real option. But before I go further, I will say this categorically: It is ABSOLUTELY your choice to request a caesarean if you want one, for whatever reason! It is a completely valid mode of birth. We aren’t all the same, and we have different attitudes to risk and what makes us feel safe. Just because it was or wasn’t the right decision for me, doesn’t mean it is or isn’t right for you.
As with any decision in pregnancy, you should look at the available evidence. Maybe use the BRAIN acronym to help, and choose what feels right for you, your baby, and your family. A good healthcare provider should respect this (as with any choices about your care!) and work with you to try to give you the best experience possible for your circumstances.
What is a Caesarean Birth?
A caesarean is when your baby is born through an incision (cut) in your abdomen (tummy) and uterus (womb). It can be planned (elective) or unplanned (emergency), depending on the circumstances.
It is supposedly named after Julius Caesar. But academics are now pretty much agreed that it’s unlikely he was born by the procedure that bears his name! Raju TN. The birth of Caesar and the cesarean misnomer. Am J Perinatol. 2007
Around 1 in 4 pregnant women in the UK has a caesarean birth, according to the NHS choices website. But there are definite variations in the caesarean rate between different areas and different trusts. Some hospitals and obstetricians are more pro-caesarean, and others less so. Hospitals who handle more complicated pregnancies are likely to have a higher caesarean rate, for obvious reasons. You can find data about the caesarean rate at your local NHS Trust and compare it with others using the NHS Maternity Services Dashboard here (best attempted on a laptop/desktop PC as it’s a pretty big and complicated Power BI interface!):
Why Might You Choose/Be Recommended A Caesarean Birth?
There are some circumstances where complications in pregnancy or labour mean that vaginal birth is seen as too risky. If there are concerns that the baby isn’t getting enough oxygen, your placenta is low lying and potentially blocking the baby’s exit, or you were bleeding excessively in labour – these (and others) are all circumstances where an emergency caesarean would be recommended, and likely performed very quickly, with not a lot of time to think about it.
In some circumstances, if there are concerns about siting a suitable local anaesthetic (often called a ‘spinal block’) swiftly, the recommendation may be to perform the operation under general anaesthetic. In this scenario you would be asleep for the procedure. It would be unlikely that your partner or birth supporter would be present. A general anaesthetic carries greater risk than being awake throughout, but in some circumstances, it is seen as the better option as it means the baby can be born more quickly.
No-one can predict these events, and they happen to people of all sizes and weights. So it’s best to consider that it could be you – even if you’re planning a vaginal birth! People who have had emergency caesarean births can report that it felt quite scary, and fast, and they felt unprepared. It might be helpful to look into what happens and to consider what sort of caesarean birth you’d like beforehand. Even in emergencies there can be choices! This may help you to feel more comfortable with the situation in case it arises.
Non-emergency caesarean recommendation
Different clinicians also have different opinions on when they would recommend caesarean birth. If you have a medical condition which might make vaginal birth more unpredictable or risky, a consultant is likely to suggest a planned, non-emergency, caesarean birth as a way to mitigate that risk.
But you don’t have to agree! As with all aspects of care, it is your choice to look at the available evidence and decide for yourself.
You don’t have to have a caesarean because your BMI is higher than they’d like. You don’t have to have one because you have gestational diabetes. Even if your baby is measuring large for dates, or because you haven’t gone into labour by a particular date, you don’t have to have one! These are all reasons some clinicians may push for a caesarean birth. But there are plenty of clinicians who feel differently! Don’t be afraid to question, ask for a second opinion, or request a meeting with a senior midwife to discuss/ support you with your birth choices.
‘Maternal request’ caesarean birth
Lastly, YOU can CHOOSE a caesarean, and you don’t need to disclose any reason other than you want one.
This isn’t terribly well-publicised, as caesareans can be more expensive (but not necessarily!) and can be seen as more risky (but not necessarily!), but the option is there and should be respected. Your care givers should listen to you and support your request, but not all do… Birthrights have a handy leaflet explaining this:
Again, meeting with a senior midwife can be very helpful. They should listen, explain your options, and can help you advocate for the birth you want, if needed.
NICE Guidance is clear that if you’re making an informed choice of a caesarean birth, the hospital should support this. Clinicians need to have a VERY good reason to ignore NICE Guidance.
Evaluating the statistics
If considering a caesarean birth, you need weigh up the risks and benefits on all sides. Particularly the risks and benefits relevant to your current pregnancy and situation right now. This is why, unusually, I haven’t included any statistics on this page, because so much is down to personal circumstances.
It can be really hard to find out your own particular situation reflected in the data, as different people’s reasons for choosing caesarean birth can vary greatly. The risks change depending on whether this is your first pregnancy, your first caesarean, and many other factors! Yet research tends to collect all experiences together, making individual comparisons difficult.
That said, things to bear in mind are:
No mode of birth is risk-free
No mode of birth is entirely safe for you or your baby. Complications can arise either way, so be vary wary of anyone who tries to frame caesarean vs vaginal birth as one being ‘safe’ and the other ‘risky’ (in either direction), as it’s just not that simple. Only one thing is certain, the baby can’t stay inside you forever – it’s going to need to come out somehow!
Emergency or planned?
People generally aren’t choosing emergency births! So if you’re considering planned caesarean, you need to know the outcomes for people who also planned one, not all caesarean births. Emergency caesareans are, by definition, more risky. But one way to reduce the likelihood of needing an emergency caesarean is to have a planned caesarean!
If the risk data you’re presented with doesn’t distinguish, then it’s going to give you a biased picture.
Not all ‘elective’ caesareans are equal!
Even having said that, it’s frustratingly difficult to make meaningful comparisons even between elective caesarean vs vaginal birth, particularly with large datasets. Usually larger numbers in data is a good thing, because it can reduce the impact of extremely rare results. However, higher risk pregnancies are more likely to be recommended a planned caesarean, which would be considered ‘elective’ in the data!
In some cases, elective caesarean may have been the only (slim) chance of a favourable outcome, which you’d imagine is then an unfair comparison with a vaginal birth which was almost guaranteed to have the negative outcome. But in a large dataset, where they can’t go into this level of detail in individual cases, nuances like this are likely to have been overlooked.
A self-fulfilling prophecy?
If you’re being recommended a caesarean due to X complication resulting in more caesarean births, you also need to consider whether these were elective or emergency.
It’s meaningless to insist that you need to have a caesarean, simply because everyone else has one, if the only reason the others planned one was because they were told everyone else had!
Relative vs absolute risk
I bang on about this A LOT. But remember to look at the absolute, not just the relative risk data!
A statistic saying something is 3x more likely, or ‘double’ the risk, sounds awful. But when we’re talking about very rare occurrences – e.g. fewer than 1 in 1000, that difference is very very marginal. At a population level, yes it may be statistically significant. On an individual level, however, the risk is so unlikely that it barely makes a difference. Organisations are getting better at presenting data helpfully, but relative risk data still crops up, and can be unnecessarily alarming! So always try to find the absolute numbers to give you a clearer picture.
To get a better grasp of the figures, it can be helpful to think of how many people DON’T have a particular outcome, as well as the overall ‘difference’ in experience:
e.g. if outcome X is 30 in 1000 with birth mode A, and 20 in 1000 with birth mode B, then…
- 970 in 1000 people choosing birth mode A DON’T have outcome X
- 980 in 1000 people choosing birth mode B DON’T have outcome X
- and statistically, 990 people in 1000 have the same experience either way. Only 10 in 1000 people choosing mode A instead of mode B would have a different outcome.
What data is NOT there?
It’s important to consider the flip side. How many people in your situation who did the opposite went on to have perfectly ‘good’ births. How many went on to have ‘troublesome’ births? And what does that even look like?
Some of these will be covered in the commonly recorded outcomes studied by the research – e.g. numbers of cases of shoulder dystocia, instrumental births, wound infection, readmission to hospital, etc. But other complications will likely have been left out – e.g. continence issues, post-natal mental health, sexual dissatisfaction, pain, breastfeeding issues… Either because they’re more difficult to evaluate, long-term follow-up is more complex and expensive, numbers of cases are thought to be low, or the consequences thought less of a concern.
All types of births can have many short-term and long-term consequences. This comprehensive picture is rarely (if ever!) reflected fully in the information we’re given.
Impossible to know what the alternative would have been!
I know people who’ve had caesarean births and wished they’d tried for a vaginal birth. I also know people who’ve had vaginal births and wished they’d requested a caesarean. But undoubtedly, as a statistic, their data probably suggests all was fine in both cases! Statistics rarely account for how people feel/felt, only if a certain pre-specified ‘undesirable’ outcome was recorded. Researchers need to limit and collect together various outcomes to make the analysis of data realistic and manageable. The trouble is, this doesn’t really help when we’re trying to choose between options with such varied experiences!
We don’t have a crystal ball, or a time machine. It’s tricky to evaluate the risks, because there is no way of knowing how many caesareans were truly necessary. Many may have been simply precautionary and perhaps would have been fine if the caesarean hadn’t happened. We don’t what will happen in our own future. All we can do is make the decision we’re comfortable with, after considering the options.
The one thing I can say with certainty is that the choice is YOURS to make. All modes of birth are valid, amazing, life-changing experiences. Good luck, whatever your decision!