The increasing rates of lower segment caesarean sections (LSCS) give rise to the question of whether a caesarean section should be considered a ‘normal’ delivery in the 21st century. If ‘normal’ in relation to childbirth is regarded as physiological spontaneous birth, then an LSCS will never be considered ‘normal’. The two words ‘normal‘ and ‘delivery’ make this a question worth pondering.

The term ‘normal’ in the 21st century is problematic. It is an increasingly elastic term in that it stretches to include more and more of what was once classified as abnormal. Whereas ‘normal birth’ once meant birth without medical intervention, birth at the beginning of the 21st century is spoken
of as ‘normal’, even when it has been induced, augmented, or an epidural has been used. If we accept that ‘normal’ is a word that has its meaning defined and given to us by the culture and times in which we live, then it would appear that births involving intervention are increasingly being framed as ‘normal’. Hence the question: ‘Is LSCS a normal delivery in the 21st century?’ If ‘normal’ indicates the most common form, or the most accepted way of doing something, then LSCS may be on its way to becoming a contender for the title.

In New Zealand, one in four, and in Queensland, Australia, one in three women, are reported as delivering by caesarean section.^7,10 Does this effectively make LSCS the ‘normal’ delivery of the 21st century? In researching this important question, it is of interest to note the following: one in four people in the UK do not believe that the moon landing happened¹; one in four people do not cover their mouth or nose when sneezing²; and one in four people believe that a woman’s place is in the home¹¹. Should these beliefs or behaviours be considered ‘normal’ simply because a quarter of the population espouses such world views or actions? It is clearly absurd to claim that the rate at which something occurs determines its normality. Therefore, a correlation between the rate of caesareans and the claim that they are the ‘normal’ birth of the 21st century could be regarded as absurd.

There is another twist to the question of whether LSCS is a normal delivery in the 21st century and that is the word ‘delivery’. ‘Delivery’, according to Wikionary, the oracle of all knowing in the 21st century, means ‘the act of conveying something – the act of handing something over’. In this sense, ‘delivery’ truly does describe what happens at a caesarean section: the woman is ‘delivered’, the doctor ‘delivers’ the baby, and the woman is very much the passive recipient. In contrast, during physiological natural birth, the woman births her baby and provides true skin-to-skin contact with her baby. This natural contact is known to increase successful breastfeeding and attachment processes, which in turn are protective of the mother and baby’s wellbeing. Language is extremely powerful, so while LSCS may be the ‘normal’ delivery of the 21st century – as they are happening more often than instrumental deliveries – LSCS is not, and never can be, the normal birth of 21st century.

The other important consideration in relation to the framing of LSCS as the ‘normal’ delivery of the 21st century is the underlying belief behind such a claim. The following data comes from research carried out in Auckland, New Zealand, which investigated what shapes the understanding of women and the practice of health professionals in relation to intervention in childbirth.¹⁵ One of the findings of the research was that, in the everyday world of women in the 21st century, there is a normalisation of surgical, pharmacological and technological solutions that correlates with what is offered by intervention and procedures such as caesarean section.¹⁶

Many women’s understanding is shaped by a world in which Trinny and Susannah’s magic knickers and Gok’s slicker knickers, along with such devices as the curvalicious corset, are seen as the solutions for controlling and transforming figures. Tummy tucks, extreme makeovers and other cosmetic surgery that carries the promise of looking ten years younger are hastening the growing acceptance and ‘normalisation’ of technological and surgical procedures.

This was captured by one young woman in the research, who said:

‘Over the next few generations, surgery will become more acceptable, more commonplace. Like extreme makeover is becoming really popular and so it is not the big deal that it once was to Jo Public, even though there are still massive risks associated with surgery. Jo Public still sees it as a quick fix and something they are relaxed about; something that is more acceptable. I am sure that surgery will become more acceptable in our generation.’

This acceptance means that there is, increasingly, a reframing of caesarean section as a ‘normal’ and everyday event. Here is another woman in the same research describing her experience of elective caesarean section.

‘With my second child, when I had the elective caesarean section it was like turning up to a dinner date. You go in there and go up to the room that you are going to come back to after the baby. They put the needle in and then you go on down and meet everyone and get into theatre and have the epidural. Then you have the baby and you get sewn up.’

When LSCS is framed in such ways it is possible to understand the increasingly common claim that it is the ‘normal’ delivery of the 21st century. However, such a claim needs to be balanced by the fact that, in spite of all the progress in medicine and anaesthesiology, there remains significant risk associated with caesarean sections.

• Maternal death is higher (three-fold) after caesarean section (in labour) than vaginal delivery.^4,6,12
• Risk of maternal mortality and morbidity is increased for all types of caesarean section, including elective and repeat caesarean sections.^9,14
• Higher rates of placenta praevia, accreta, abruption and hysterectomy correlate with increasing numbers of repeat caesareans.^19,20
• Risk of uterine rupture/dehiscence is naturally higher in women planning vaginal birth after a caesarean than women who plan an elective repeat caesarean section. However, this is offset by a reduction in maternal morbidity, uterine rupture/dehiscence and hysterectomy when vaginal birth after caesarean (VBAC) is successful. Outcomes are more favourable in successful VBAC than elective repeat caesarean section.¹⁸
• Increased risk of maternal rehospitalisation after a caesarean section.⁵

In light of these facts, it is unlikely that the question of LSCS being seen as a ‘normal’ delivery in the 21st century would even arise if there were not multiple influences and interests creating a milieu in which such a sentiment can exist.

This milieu is reflected in the following statements from women interviewed in McAra-Couper’s research, 2007.¹⁵

‘Choosing a caesarean – well it is convenience. That is the thing you do now and fit it in here like this.’

‘I think a lot of intervention happens because women are older and they don’t want to be inconvenienced. They are only going to have one child and so why bother with natural birth.’

‘I just think of this woman who lives in the inner city, eats out, runs a business, has the Palm Pilot, the company car and so has a certain mindset, as do the people she is mixing with and who have influence in her life, telling her she does not have to go through all the stuff and mess of birth. Just have a clean cut.’

It has been argued that the normalisation of caesarean section is less about the caesarean section itself, but rather about what it facilitates. There appears to be a correlation between the perception of what is offered by interventions such as caesarean section and the everyday world with its social and cultural values such as control and convenience.¹⁶ This is what shapes understanding and practice in ways that lead to increased acceptance and utilisation of hitherto ‘abnormal’ interventions such as caesarean section.

It is important to note that while there is a framing of LSCS by some women as convenient, this convenience lasts only up until the procedure itself. There is nothing convenient or ‘normal’ about lying in hospital with a catheter and a pain pump, being confined to a bed and having limited mobility, and suffering the inconvenience of not being able to drive or lift for weeks.

The other issue that is often cited as a reason for LSCS to be considered the ‘normal’ delivery style of the 21st century is in relation to prolapse, incontinence and preservation of the pelvic floor. Larsson and colleagues¹³ showed in a large study (1.4 million women) that caesarean section was significantly associated with a lower risk of pelvic organ prolapse. However, only one per cent of women in the study who delivered vaginally developed pelvic organ prolapse before they were 60 years of age. The authors point out that this issue is a multifactorial problem, and has to be offset by the risks of the uterine scar and complications of a caesarean section.¹³ The effect of the mode of delivery on incontinence has been researched from a number of angles. Boyles and colleagues³ used a survey to look at the incidence of urinary incontinence in primiparous women at three months and six months postpartum. They showed that in the short term, vaginal delivery can be seen to increase the risk of incontinence. However, another multicentred prospective observational study, showed that pregnancy increases the risk of urinary and faecal incontinence and that caesarean section was in fact no more successful in decreasing the risk than vaginal delivery.¹⁷ This issue alone does not provide sufficient evidence to consider LSCS as the ‘normal’ delivery of the 21st century.

It is the milieu of intervention supported by cultural and social values that has given rise to this question of LSCS being the ‘normal’ birth of the 21st century. This milieu is calling into question those things that have always been at the heart of childbirth: the ability of the woman to birth and the clinical skills of the health professional to assist this process.^16,8 It is time to challenge this milieu of intervention of the 21st century. It is time for women to reclaim their birthing power and for health professionals to reclaim their clinical skills in relation to birth.

The first step in this reclaiming is to disassociate the word ‘normal’ (no matter how elastic its use in everyday life) from a procedure such as LSCS, and for LSCS to be described exactly as it was in the 20th century and remains in the 21st century: an operative delivery.