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In the late 1990s, the expression “too posh to push” was coined to label women opting for C-sections rather than vaginal births, and has since gained global traction. The expression signals inherent bias and represents a form of shaming women who dare to step outside of convention.
Various studies have highlighted the merits and risks associated with both vaginal and C-section births. The idea of the former is buoyed by the dominant narrative that birth is a natural process that should only be surgically interfered with in the event of complications. This remains the policy preference in most countries. In other words, convention trumps scientific innovation.
Statistics confirm the global trend towards C-sections, most notably in regions such as Latin America and the Caribbean.
In 2015, the World Health Organisation (WHO) cautioned against this trend. It determined that, ideally, only between 10% and 15% of births should be C-sections.
Hours of labour
Several of the major private medical schemes in South Africa have an explicit policy of not covering elective C-sections. However, in the country’s private hospitals, C-sections reportedly take place between 60% and 70% of the time. This has been attributed to medical professionals coercing women into this birth method for the sake of convenience, or to women having supposedly become too spoilt or neurotic to endure hours of labour. This narrative seeks to undermine a woman’s right to bodily autonomy.
Is it not time that policymakers concede that this trend is unlikely to see a reversal in the near future? Instead of trying to arrest the trend, should it not be embraced as the product of scientific progress and changing attitudes towards reproduction? Should resources not be used to empower women to make informed choices about the method of birthing best suited to their (and their babies’) clinical, emotional and social wellbeing? A woman better informed about her birthing options is also less likely to be coerced into any decision.
In most countries, the prevailing attitude is eons away from the concept of informed choice. This is because the global narrative, while advocating the right of women to decide when to have children and how many they would like, stops short of promoting the right to decide how the child should be born. At best, the WHO calls for access to appropriate health services to allow women to go safely through pregnancy and childbirth.
Social wellness
As is often the case when it comes to women’s bodies, what is deemed appropriate and how much to spend on such appropriate care is too often a decision made by others on behalf of women, including those who are not dependent on the public purse for their health needs. This paradigm undermines the concept of sexual and reproductive rights that have become the global standard. Internationally, health is defined as encompassing complete physical, mental and social wellbeing. However, by these same standards, women’s emotional and social wellness are deliberately excluded when it comes to how they give birth.
Concerns that nonmedically motivated C-sections may divert skilled health workers away from where they are most needed are not justified as there is no evidence that such professionals would be drawn towards resource-constrained settings in the public health sector, for example, in the event of fewer C-sections.
We have witnessed this in the persistent human resource disparities between the public and private health sectors in South Africa, as well as the brain drain from developing to developed countries. Policies aimed at achieving a more equitable distribution of resources should target health workers instead of straitjacketing women.
Informed choice about childbirth is not such an alien concept, and is likely to become more commonplace as we begin to change the birthing narrative.
In 2011, the UK published new guidelines that introduced the concept of planned C-sections for nonmedical reasons. This empowers women to make an informed choice, subsequent to counselling on the benefits and risks associated with the procedure. The UK’s C-section rate is about 25% of births. However, the guidelines include an opting-out clause for obstetricians, who could refer the woman to a practitioner who is willing to perform the procedure. Despite this shortcoming, the provision for maternal request for a C-section initiated a move away from conventional policy options.
Human rights
A global paradigm shift is needed from prescriptive attitudes about what are acceptable or appropriate choices for women, to those that embrace a woman’s right to choose, and that prioritise resources that will support that choice.
The narrative that investment in maternal health will reap long-term developmental benefits for a nation is also not helpful because it reinforces the notion that women are only worth investing in if the collective benefits. Considerations of costs and the potential societal benefits should no longer be yardsticks to determine what appropriate or worthwhile investments for women are. Women’s sexual and reproductive rights should not be subject to qualification or a cost-benefit analysis because sexual and reproductive rights are essentially human rights that must not be compromised.
Paulse works as a researcher and has an interest in social justice. She writes in her personal capacity.
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