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Making decisions about birth after caesarean

Women's views on choice about birth

National Institute of Health and Care Excellence (N.I.C.E.) guidance to health professionals* is that decisions about how to give birth after a previous caesarean should be guided by the woman's preferences, as long as there are no strong medical reasons why one birth method would be more appropriate than the other. In other words, pregnant women who've had a previous caesarean and do not have specific medical complications should be allowed to choose the way they want their next child to be born. Vaginal birth after caesarean (VBAC) and a second, planned, caesarean carry different kinds of risks. Whilst the majority of women (3 out of 4) who attempt VBAC will have a vaginal birth (who have had a straight forward pregnancy and who go into labour naturally)**, about a quarter will require an emergency caesarean. The risks of emergency caesarean are typically greater than those of a planned section. For this reason, different women are likely to reach different conclusions when weighing up the risks and benefits of different ways of giving birth. 

Many women we talked to felt that they had a choice in how they delivered their next baby. However, several women suggested that the process of making the decision hadn't followed the clinical guidance. They felt that doctors or midwives had tried to push them to have a VBAC or, less often, a caesarean. Even though some of the women had managed to assert their birth preference in the end, they felt that their wishes and concerns had, on occasions, been side-lined in the discussions they had with health professionals (see also 'Women's experience of making the decision'). 

We were interested to find out what women thought about the idea of 'choosing' how they wanted to give birth' Did they think it was a good idea for women to be offered a choice? Or did they think that health professionals should be able to make the final decision, whilst taking into account women's views? How realistic did they think it was to treat method of birth as a real choice?

Not all women had been aware they would be able to decide how they wanted to give birth when they became pregnant again after a previous caesarean. A few had assumed that having one caesarean meant that they would have to have another. A couple of others were surprised to find out that they could actually ask for a caesarean even if it was not medically necessary. 

 

She had not realised that she could refuse to have a VBAC until a midwife told her so, following...

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She had not realised that she could refuse to have a VBAC until a midwife told her so, following...

Age at interview: 31
Sex: Female
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I would say just really try to be open-minded, as open-minded as you can and try not to be influenced by the medical profession if you have a strong feeling or a strong view that you want to go for a trial of labour then make sure that, you know, your opinion is heard, you know, your feelings are heard, and make sure that you express them. Or if you want, you know, if you want to have a section, make sure that you make that absolutely crystal clear as well because I think if you don't make that crystal clear, the opinion is, 'This lady will go for a trial of labour unless she says otherwise'.

Most thought that women should be involved as much as possible in decisions about how to give birth. But they had different views about who should have the final say if women's preferences were at odds with the recommendations of doctors. Several thought that women want to have and should have full choice over how they give birth. However, some of them also said that they personally disagreed with the idea of having a caesarean for the sake of convenience. A couple of women stressed that it was important for women to receive trustworthy and balanced information so they could make a well-informed decision.

 

She feels it was right for her to have full control over the decision to have her second child by...

She feels it was right for her to have full control over the decision to have her second child by...

Age at interview: 38
Sex: Female
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A lot of people wouldn't agree with me, but I really liked the fact that I knew when it was going to happen, I was very, I felt very much in control and, and I avoided all that, you know, all that' yeah all that pain and upset that, that came about before [son's name]'s birth, with the same, with the same results.

How much of a choice do you feel that you had, personally this time?

Oh, a hundred percent. Even though, you know, the consultant maybe tried to talk me out of it, but I knew that in the end I could, you know, I could' I had every right to the elective caesarean.

And how, how realistic do you think it is for us to encourage other women to have a choice?

Oh, it's wonderful, it's great. Every woman should have a choice' definitely. I'm not saying every woman should have a caesarean, at all, but they definitely should be informed, and decide for themselves what they want to go through, absolutely. I feel very strongly about that.

 

She thinks women should be able to have full choice, but they need good quality information to...

She thinks women should be able to have full choice, but they need good quality information to...

Age at interview: 26
Sex: Female
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Well, I mean, obviously at the end of the day it is down to the individual. But, I mean, me personally, I think if you've got all the information available to you, it's up to you what you decide, but obviously if you're only given a certain amount of information you can't really make an informed decision, I feel.

 

She thinks that women should have a choice over how they give birth, but that women who are 'too...

She thinks that women should have a choice over how they give birth, but that women who are 'too...

Age at interview: 26
Sex: Female
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Do you think it's realistic for us to encourage women to have a choice?

Yes' This is probably going to make me sound really old-fashioned, but I mean, all these women... like celebrities... who are too posh to push, I think they are missing out really. I mean, obviously if they are told... if you are told, 'It's better if you do have a caesarean than have a natural birth', then by all means, fine, that's the way to go. But if you're just choosing it for vanity then I don't really agree with that.

For some women, their way of thinking about birth choices was influenced by their experience of not getting the birth they had wanted. One woman who had wanted a vaginal birth but had accepted doctors' advice to have a caesarean when she went past her due date, felt it was important to remain realistic about how much control women could actually have over the birthing process. Other women who had not been able to give birth in the way they wanted nevertheless stressed that being involved in decision-making had been very important to them.

 

She thinks it's a good idea to encourage choice as far as possible, but at the same time women...

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She thinks it's a good idea to encourage choice as far as possible, but at the same time women...

Age at interview: 32
Sex: Female
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Nobody really has a choice, do they? What happens, happens. And I had to accept that at the end of the day, there was no choice, it was out of my hands. 'I feel happy that I was allowed to try for a natural birth. 'And I felt happy about the fact that, if I didn't have him naturally that they were going to take me into theatre rather than try to induce me, because basically the 'I don't know if I mentioned to you last time, but the consultant sat with me and looked through my notes and, I think this was before I saw you, and she said to me, 'We won't put you through what you went through last time', and to me that was a huge relief. It meant there wasn't going to be a- you know, an attempt at labour that would end up being a disappointment. It was clear cut. If I didn't have him, I knew I was going to have a caesarean. 'Because last time it was very much as case of my hopes were high that it was going to happen naturally, and then of course I crashed down even harder when I had to have an emergency caesarean so, knowing was better, definitely.

So how realistic do you think it is to encourage women to be involved in their decision-making? 

Very, yeah, but they need to know of all consequences that could occur. 'That, at any time, if you're having a natural labour, at any time things could change and it might not go that way. 
 
 

Because she did not have any control over her first birth, it was all the more important to her...

Because she did not have any control over her first birth, it was all the more important to her...

Age at interview: 19
Sex: Female
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Obviously with the emergency [caesarean] you don't have a choice at all, I felt like I made quite a big' I could have if I wanted to go for a trial of labour I could have. The consultant never said, 'Well you've got to have a caesarean, there's no choice.' That was my decision to have the caesarean. 

And how realistic do you think it is to encourage women to have more of a choice now?

I think, yeah it is' it's not that, it's' women I think now they feel like if they don't' I felt, like I would have felt if I would have not been given the choice, they said, 'Right, you've got to have a caesarean,' I probably would have felt worse because I'd have thought, "Well I got that choice taken away from me the first time, I want the choice the second time."

But obviously they told me now that obviously if I have any more then I've got' they wouldn't give me a choice anymore.

A few thought that giving women complete choice over how they want to give birth could be a problem and that if a woman's preference for birth was questionable for medical reasons, the final decision should rest with medical experts. They felt that 'a little knowledge can be a dangerous thing' and that women might be swayed towards 'wrong decisions' by media stories and other less reliable sources of information. One woman said she just didn't feel she had enough medical knowledge to take an active part in decision-making. 

 

She thinks it is important that health professionals encourage women to make the choice that is...

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She thinks it is important that health professionals encourage women to make the choice that is...

Age at interview: 33
Sex: Female
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To what extents do you think that health service users should be involved in making decisions about healthcare?

[Laughs] as much as they can. Provided they have a clear understanding of exactly what's involved at the end of the day, but, you know' I think there's some occasions where that may need to be taken out of their hands. I suppose it depends on the person's understanding of the situation, but'

'well, that's something as well that's quite important for us to work out. I mean, obviously, choice is a nice idea but you think choice is not for everyone?

I think that sometimes people make a choice, it could be the wrong choice, or it could be the right, you know' I think and, I think there's a lot of, well, on all fronts of healthcare, there's a lot of media influence on what people believe is right for them because they've seen it on TV and it's not, you know, it's not the right, right way to proceed, so'

I think it's essential that people are encouraged to a choice that is the best, maybe not what they think is the best. I think it's important that people actually realise that, like, you know, there is other' there are other options. Just because you've had this as your first, or certainly, I don't know if it makes a difference if it's your first delivery or your second delivery that's a section, I don't know, I don't know the statistics on that, but certainly I think you know, people should be informed, well informed that it's perfectly possible and' Because a couple of people have said to me, 'Oh, goodness, I didn't think it would be, you know, I know you were keen, but I didn't think it would be possible', so I suppose other people want the easy option these days then anyway, but I think, yeah, it should be encouraged. 'I wouldn't necessarily say it's easy having a section but that's what it comes across as, that's sort of perceived like that.
 
 

She thinks women should be involved in decision-making as much as possible but at the same time...

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She thinks women should be involved in decision-making as much as possible but at the same time...

Age at interview: 31
Sex: Female
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I think, you know, in the past there was certainly much more of a tendency to treat doctors as, you know, doctors had the final word, and in fact what they said was gospel and, and obviously, you know, doctors were aware of that as well and, and that had an impact on sort of patient care and respect for the patient and stuff like that. I think there is a possibility that in some cases, we go a bit too far the other way and because people get, can get more information, these days as well, and are aware that they can have more information, I think there is a lot more you know, and because the government talks about patient choice and things like that, I think it must be much more difficult to be a doctor now because, although you may think that you know the best thing for your patient, if your patient has other ideas, you're now duty bound to kind of listen to them and, and to, you know, to take that into consideration. And you may, you may have to do things you don't agree with because the patient wants you to. But in, in a situation like this where, you know, I think, where people can be very badly, well, where women can be very badly affected by the way that they have their babies, and I think because having a baby is different from having an illness, you know, I mean, you're, emotionally you're all over the place before and after and you may not be at your most rational [laughs] and then you've got this little person making huge demands on you as well, I think, you know, if you can have the choice and if you can feel that you're in control of it, I think that probably is, you know, is the best option because I think if you, I think if you've, if you have to cope with the idea that you, you know, you wanted things to happen a certain way and they didn't, you know, you weren't allowed to have things happen that way, I think that must be quite, that must be quite hard actually. 
 

A few women felt burdened by the responsibility of deciding how they should give birth. They worried whether they were making the right decision for their baby and would have liked more guidance from health professionals than they actually got. As one woman put it, 'sometimes people just like to be told'. (See also 'Women's experience of making the decision'). 

 

Making a choice about how to give birth to her second child was difficult because she felt...

Making a choice about how to give birth to her second child was difficult because she felt...

Age at interview: 22
Sex: Female
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I don't know, because the choice was so left to me, I did feel like I had a choice to make, and it was all down to me. But obviously I wasn't quite sure which one was the best choice. So I definitely think now, obviously if it was the third time round, that what the choice I make would be the best choice. 

And how much of a choice do you think women generally have when they're, when they're thinking about how to deliver? I mean, if you think about your friends that you've got around you, how realistic do you think it is for us to encourage women to, to think about having a choice and to make their own plans?

Yeah, I think everyone gets the' the choice and I pretty much, as far as I know, that everyone, the health professionals are prepared to go by your decision. Obviously, if it's down to fears, then I think the only thing they can do is just reassure you, but overall it is down to the woman individually on how they feel and what they want to do.

A few women who were in favour of women having complete choice over how to give birth felt that exercising that choice might be easier for some women than others. One woman thought that as a nurse she had been able to 'play the system' and assert her wish to have a VBAC and stay at home for the first part of her labour even though doctors had advised her against it. Another woman who had decided to go private for a planned caesarean acknowledged that other women might not have the money to do the same if they found it difficult to assert their wishes against the views of their NHS doctors.

 

She thinks as a nurse with an insight into the medical system she was more able to assert her...

She thinks as a nurse with an insight into the medical system she was more able to assert her...

Age at interview: 37
Sex: Female
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I think it was because I am a nurse and so I... I know kind of how to play the system to a certain degree, so I had a relatively good choice. I had full choice, I had full option to do what I wanted to do. 

I think if I hadn't been so strong and adamant then I don't think it would have been' I think I would have been easily taken over, so me personally, I was strong enough to fight the sort of system and say, 'No, I'm not going to go through that', but with other people, I'm not sure. I think they may have been overrun.

That was my next question really, how realistic do you think it is for us to encourage women to have more of a choice? 

I think they should be encouraged to have more of a choice. They did tell me I could have a VBAC and it was a, 'Yes, we definitely hope you can but you know, there's these sort of negative kind of things'. I think it's the negative input that you constantly get in the medical sort of interventions that really turn the idea, or reduce the likelihood that you're going to delivery naturally, unless you're pig-headed like me and say, 'I'm going to do it and there you go'.

 

She is pleased with her decision to go private to have the birth she wanted but she is aware that...

She is pleased with her decision to go private to have the birth she wanted but she is aware that...

Age at interview: 42
Sex: Female
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I feel I was a bit bold with what I did, so you know, some people might think' so, so I feel quite, I suppose I feel quite good about that, because, you know, I'm not always that bold, so, I took things into my own hands and I feel quite good about that, that it all went well.

And how realistic do you think it is that other women will have the level of choice?

That is a, you know, they, they may not be able to. Although I think a lot of people, you know, in England, because we've had the NHS such a long time, people will buy a Mercedes but won't want to spend a penny on their health, you know? [laughs]. Well, I'll drive an old car and' so, you know, it's, it's ways of juggling things, but I do understand there'll be people that will not be able to make any, you know, make a choice like I did at all, under any circumstances. And do you know what I think they should do? They should argue as much as they' argue with the- whoever's talking to them as much as they can [laughs] to get what they want. As has happened a lot recently with these breast cancer drugs, and I mean, people power's coming to the fore. Now I can also see issues for the NHS for this, because they can't possibly afford it, or, but I'm kind of glad there's people power coming, but I also think there's going to have to be a bit of a culture shift in that the NHS can't pay for absolutely everything and that we're going, might have to pay for bits of our healthcare ourselves. And, you know, people will spend twenty thousand on a new kitchen; I wouldn't dream, you see I wouldn't dream of that, but then a lot of those people wouldn't dream of spending anything on their health, so' and they might have to shift because I don't think the NHS can afford it all. I can see that they're, they're a bit strapped.

A couple of women thought that those who don't have a strong preference about how to give birth at the start of their pregnancy might end up being pushed into a particular direction by the views of health professionals. They felt that women generally did have a choice, but only if they were sufficiently vocal and well-informed to argue their case.

 

She thinks women who don't have a strong preference about how to give birth might find it...

She thinks women who don't have a strong preference about how to give birth might find it...

Age at interview: 30
Sex: Female
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I think it is completely your choice, it is completely your decision, but it depends I suppose what kind of person you are; how swayed you are by the professionals. Because somebody like me, I think, being really indecisive, it's, it's going to affect me a lot. But I have known of people that have been like, 'No, I'm having a, a planned caesarean, I'm not messing around with all that.' And you know, they know exactly. And I kind of in a way wish I were like that, or like, 'No, I really want to go natural, you know, because of the achievement and that's what I want to do.' So ultimately, obviously it is completely your decision but I think if you're kind of indecisive and you're not really sure, you are going to be affected by the doctors and the midwives, because they are really, 'You should give it a go and.' 

* The guideline on caesarean section was published in 2011 by the National Institute of Health and Care Excellence (N.I.C.E.). Nice guidance states' ‘Inform women who have had up to and including four CS that the risk of fever, bladder injuries and surgical injuries does not vary with planned mode of birth and that the risk of uterine rupture, although higher for planned vaginal birth, is rare.
**
Birth Options After Previous Caesarean Section; Royal College of Obstetricians and Gynaecologists (July 2016)

Last reviewed August 2018.
Last updated August 2018.

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