Like it or not, Caesarean birth is a fact of life in our society. So much so, that NSW has already taken steps to limit its further encroachment - and Western Australia seems likely to follow against vocal opposition. But is it women, or the medical profession, or just plain old fear that's driving this new phenomenon? Kirsty Stuart reports.

It's been a widely reported - and hotly debated - topic in the media that Australia's caesarean rate is skyrocketing out of control, with a staggering statistic of less than half of all births at some private hospitals being normal deliveries.

According to a report in the April issue of the Western Australian doctors' magazine Medical Forum that state's caesarean rate is 33 per cent with 53 per cent of babies being born by caesarean at Perth's larger private hospitals. Although the World Health Organisation wants to see the current rate reduced to about 15 per cent in developed countries, in Australia the caesarean rate has increased from 10 per cent in the 1970s to 30 per cent in 2005. In fact, some experts are going as far to predict that it will reach 40 per cent by 2010. Why is it that caesareans increasing so rapidly?

Interestingly, the prime caesarean candidate is a first-time mum in her mid 30s with private health insurance. What's more, women aged between 35 and 39 years having their first baby in a hospital face a caesarean rate of 40.4 per cent. Some commentators point the finger at high flying corporate women booking in caesareans in between board meetings and spa appointments, suggesting that it's all due to women wanting the least disruption to their lives as possible when it comes to childbirth. They say that as a society we have become 'too posh to push' and natural childbirth is no longer in vogue - however, the statistics say otherwise.

First, it must be stated that there are different types of caesareans. In a nutshell these are: planned - where the mother has chosen this type of birth; recommended - where the mother's obstetrician has recommended it; and emergency - when problems occur during the birth or the pregnancy. According to a report given at the Royal Australian and New Zealand College of Obstetricians and Gynaecologists' scientific conference in 2005, only five to ten per cent of Australian women who have caesareans actually choose the surgery. Rebecca Lawther, 32, has four boys aged seven, five, three and nine months. The first was by caesarean, the second by vaginal birth, the third by caesarean and the fourth by vaginal birth.

Rebecca says she felt pushed (perhaps an ironic choice of word) into her second caesarean by medical staff. "My second caesarean came about because I ended up getting a cervical lip and I don't know why but the obstetrician just wanted to take control of the labour and I ended up being wheeled off for a caesarean. I just found out recently that the second one was totally unnecessary because I developed another cervical lip with my fourth son during the birth and my midwife dealt with it calmly and confidently. We stopped pushing and we waited a while and it just disappeared of its own accord and I had a normal birth." Comparing her caesareans to her natural births, Rebecca says: "I didn't like the experience of major surgery and there was also the fact that I knew I could do it myself. I found it very difficult to look after my other children after my second caesarean, so I was very keen not to have another one so I'd be okay after the birth. When you've had major surgery, you need looking after and nurturing yourself. After vaginal birth I felt like I could take on the world - I was so ecstatic."

Having experienced both caesareans and vaginal birth, Rebecca prefers the latter. "I don't think caesareans are the wonderful thing a lot of people make them out to be. I think there is this misconception that they are the easy way out - but there is no easy way to get a baby out of you! In the long run, healthwise for the baby and for me, it was better to have a natural birth."

Sally Westbury is an independent midwife who's been in private practice for 16 years. She says she's seen an increasing number of clients coming to her wanting a Vaginal Birth After Caesarean (VBAC). "In the last five years the growth has been exponential," she says. "Five years ago, I had one or two home births and last year I helped 11 women who were planning to have a home birth after caesarean. This year, I've got 12 women booked in over the next six months wanting vaginal births after caesarean.

"The sentiment of most of them with regard to their caesarean experiences is that most of them feel like there is a high degree of medical impatience and they are put on a timeline that is not reflective of individual variation. They feel deeply traumatised by their experience of caesarean section and are looking for a journey that is more supportive and healing for them. These women go on to have vaginal births then just feel incredibly healed and complete."

Bronwyn Key, a 52 year old registered midwife of 25 years who has delivered hundreds of babies, agrees. She's had one child via natural home birth, a surprisingly quick labour of three hours - drug-free.

"I think if women can have a natural birth it's really to their advantage and the advantage of their baby, the women come out feeling empowered and the babies have gone through the whole process of managing to make their way out into a loving environment so they're coming with a positive attitude as well.

"If you're induced or start interfering with the natural process, you need to interfere more and more and they call it cascading intervention. With more women being induced, the need for more caesareans is happening.

"There is such a culture of fear around childbirth that it predisposes it to being more painful than it needs to be. The fear factor makes labour much more painful and there is a lot of research that proves that you tighten up if you are frightened and then you are working against the force of nature that is going to push the baby out and it's far more painful."

So with only five per cent of women actually choosing to have caesareans - that's 90 to 95 per cent being told they should have them - are doctors pushing the trend and encouraging what is now being called a "caesarean culture"? In Delivery by Appointment, a book that investigates caesarean birth today, author Michelle Hamer questions whether our culture may encourage high intervention births. In other words, asks Michelle, have women lost confidence in their ability to birth naturally?

She writes: "Given the pressure on doctors with the fear - and often experience - of litigation hanging over their heads, the scalpel can usually achieve a more predictable outcome. And that's an important word in this debate - predictable. In this era of globalisation, when we feel comfortable with the familiar brands we eat, wear and furnish our home with, when there is safety in chain restaurants which serve up the same tasting food no matter what country we're in, in this homogenised landscape there is little room for unpredictability - and that is just what labour can present."

And on the concept, which she refers to as McMothering, she writes: "Our society doesn't seem to tolerate risks or manage uncertainty well, but are we in danger of becoming McMums? Of turning birth into a production line, offering much more predictable outcomes - but with a sense that maybe something was lost along the way? Just as we are prone to over-scheduling our children's lives with stimulating, educational activities and thereby squeezing out any room for the vital playing and pondering of childhood, are we also scheduling their births and squeezing out the chance for a 'natural' experience in the quest for perceived control and safety? And by 'we' I mean society as a whole; as well as the doctors and parents making the final decisions."

As noted previously, why are 90 to 95 per cent of mothers having caesareans not by choice?
Theories abound. While Australian rates of caesarean are worryingly high, it's the same story in Britain and the US - the three societies with the highest rates of obesity worldwide. Couple that with the fact that pregnant women are likely to be older first-time mothers and, with increasing IVF rates, having more multiple births. According to the American Journal of Obstetrics and Gynaecology 2002, obese women are six times more likely to have a caesarean than their thinner counterparts. Other reasons touted are that women want to keep their pelvic floor intact and retain sexual sensation and doctors' fear of being sued, not to mention the convenience factor where it's easier to schedule surgery than unpredictable birth times. Then, it seems once women are on the caesarean bandwagon by having their first c-section, a staggering 80 per cent go on to have subsequent caesareans.

On the subject of doctors being sued, Michelle points out that the rate of obstetricians being sued in Australia has tripled since 1991, with more than half of Australian obstetricians having received a "letter of inquiry" from a patient's solicitor - the first stage in the litigation process. On the other hand, she notes, no Australian doctor has ever been sued for performing a caesarean.

It's interesting to note that in the Netherlands, where all pregnant women consult with midwives, the caesarean rate is just 14 per cent. Most Australian women are well versed on the argument that caesareans make it harder for the mother and baby to bond. And that after caesarean, women are at greater risk of bleeding, bladder injury, ongoing pelvic pain, wound infection and that caesarean section leaves a scar in the uterus that can have implications for further pregnancies.

Apart from the fact that natural childbirth is a goddess-like experience that every woman is entitled to experience (with safety in mind, of course) there are wider societal implications at stake. The danger with the situation in Australia, according to some experts, is that it becomes a Catch 22 situation whereby the more caesareans that are done, the more caesareans became normal practice, pushing up the rate even higher.

Michelle summarises it most eloquently: "Somehow the issue of childbirth, surely one of the oldest, most basic processes in life, has become highly politicised, emotive and increasingly medicalised. Naturally we don't want to go back to the days when women laboured in agony for hours and died with their babies still inside them - but what does the future offer? Do we want to head down the path towards completely surgical births?"
Delivery by Appointment: Caesarean birth today by Michelle Hamer is published by New Holland.