If you ask a hundred mothers about their birth experiences, you will get a hundred different answers. Answers that touch, that polarise, that encourage, that evoke admiration, that cause amazement, that stir up fears. Every birth is unique, no two are the same. And this despite the fact that 30 out of 100 mothers in Germany have given birth in a similar way: namely by Caesarean section (Latin for caesarean section). According to the Federal Statistical Office, the caesarean section rate in 2021 was 30.9 per cent.
How many of these many incisional deliveries were medically indicated for various reasons and how many were "only" at the request of the pregnant woman was and is not recorded. In the absence of a clear definition and often expected billing difficulties for an "elective caesarean section" (more on this below), it may also be difficult to capture the reality in figures. Estimates for "elective caesarean sections" range from 25 % in Europe to 2 % in Germany.
If you would like to know more about general caesarean section rates, the course of a caesarean section, etc., you can find out more on my blog here read more. You can also find out more about how to optimise your Caesarean section scar can maintain.
What does "elective caesarean section" mean?
The term "elective caesarean section" is generally used when there is no medical necessity for the procedure and it is nevertheless performed at the woman's request. However, the term is neither uniformly defined nor used. Sometimes the term "elective caesarean section" is also used in this context. In some specialist circles, the term "elective caesarean section" is also used somewhat disparagingly.
The crux of the matter is the following question: What is "medically necessary"? Only 10 % of the operations performed in Germany are Caesarean sections are medically necessary to save the life of the mother and/or child. This applies, for example, if the child is in a transverse position or suffers from an acute lack of oxygen during birth or the Uterus threatens to tear.
Of course, conversely, we are not dealing with 90 % unnecessary caesarean sections, because the spectrum from "absolutely necessary" to "unnecessary" is correspondingly wide. There are, for example, the many cases of physical indications for which a caesarean section is offered or recommended to a woman. Such a reason may be, for example, a breech presentation of the baby (with the bum in front) or a previous caesarean section. In both cases, however, a caesarean section is not always mandatory, but must be considered on a case-by-case basis. It is therefore very questionable whether a woman who then decides in favour of an elective caesarean section can be considered to have had an elective caesarean section.
Then there are women who, despite an unremarkable pregnancy and an expected uncomplicated labour, wish to have a caesarean section out of fear of a vaginal birth. In such cases, the doctor can certify a psychological indication for a caesarean section - and it would then be "necessary".
We also want to look at those women who shy away from the pain and risks of a spontaneous labour. Because they usually don't want to spare themselves this "just because", these women don't decide in favour of a caesarean section lightly either. I have also looked after mothers who have not made the decision for or against a caesarean section for no medical reason an easy one.
So there is a wide range of reasons and backgrounds in which pregnant women move on the way to an incisional delivery.
Incidentally, the question of medical necessity also determines whether the statutory health insurance fund will cover the costs of a caesarean section (approx. 3,000 to 4,000 euros). However, in the vast majority of cases, the doctor will confirm the necessity of a caesarean section. For a hospital, this procedure is also more profitable than a vaginal birth: a planned caesarean section is easy to organise with duty schedules, means less work and also puts more money in the coffers.
What reasons do women have for an elective caesarean section?
After a Survey by far the most common reason for an "elective caesarean section" is the general fear of vaginal birth. More than a quarter of pregnant women (26 %) are worried about possible injuries and complications. Other reasons include the specific fear of pain or damage to the pelvic floor (13 % each). However, the fear of failing or losing control during labour also plays a role for quite a few women. Others appreciate the fact that it is easier to plan the date of birth. Babies with an expected above-average birth weight (approx. 4,000 grams) and size are also a reason for some women to opt for a caesarean section.
Sometimes events and experiences in a woman's past also lead to a desire for a caesarean section. This can be, for example, a protracted Fertility treatment which has awakened the need for (supposedly) maximum safety during labour. A previous traumatising delivery or a previously experienced miscarriage in the second half of pregnancy (intrauterine foetal death) are also possible motives for an "elective caesarean section". The same can apply if a woman has suffered (sexual) violence.
In all of these cases, the desire for an incisional delivery is understandable and should be taken seriously. However, it would not be professionally sound and appropriate behaviour on the part of obstetricians, midwives and doctors to simply accept this wish without offering to discuss it with the woman concerned.
Of course, every pregnant woman should first be carefully informed about this: If possible, a spontaneous vaginal delivery is still the best way to give birth for mother and child. This is because a caesarean section also harbours risks for both. However, if anxiety, fear or negative previous experiences stand in the way of an spontaneous birth, an empathetic and understanding discussion may be able to overcome such blockages. Depending on the motives of the woman concerned, many questions can be discussed: How can labour pain be noticeably alleviated? What could strengthen the woman's sense of security? And what could increase her confidence in herself and the obstetric support? Where does the woman's fear of failure in labour come from? What could be done to counter her fear beyond an elective caesarean section? Sometimes previous negative birth experiences have to be processed before a pregnant woman can open up to a new decision.
What is important in such discussions, which can be held in confidence with midwives in particular, is that the outcome is open. The aim should not be to "dissuade" the woman from having a caesarean section at all costs or to "persuade" her to have a vaginal birth. Rather, the aim should be to work with her to find out which measures and which route could be a possible alternative to a caesarean section. This requires a great deal of empathy, competence and freedom from prejudice on the part of the counsellor.
Advantages and disadvantages
While around 15 % of children in Germany were born by caesarean section in 1991, today the figure is twice as high (30.9 %). This rapid increase has been discussed in professional circles for some time. The result is a new guideline from the German Society of Gynaecology and Obstetrics (DGGG). According to this guideline, pregnant women should be better informed about caesarean sections. Apparently, many women still underestimate the extent and consequences of a caesarean section. Even though this procedure has become very safe today, it is not without its risks. After all, it involves a so-called major abdominal operation (laparotomy).
A caesarean section undoubtedly has certain advantages - but it also has many disadvantages. I would like to take a brief look at both here:
Although the woman does not experience any labour pain during the procedure, she has to deal with pain for longer afterwards as the wound heals and her Caesarean section scar to do. As a result, the mother's physical capacity is limited for longer after the procedure than after a vaginal delivery. The uterus also recedes more slowly after a caesarean section than after a natural birth. The risk of complications may increase for further pregnancies and births.
In any case, the woman is exposed to the general risks of an operation, such as the risk of anaesthesia, infection, thrombosis, etc.
However, the risks are not only limited to this birth, they also extend to possible subsequent pregnancies. This reduces the chance of becoming pregnant and increases the risk of a miscarriage with the next baby.
On the other hand, a caesarean section spares the woman other possible birth injuries such as an episiotomy/tear and/or further damage to the genital area. In this context, however, I must disagree with the assumption that a caesarean Pelvic floor to take it easy: This is because the pelvic floor is already exposed to heavy strain during pregnancy, especially in the last trimester.
With a caesarean section, the child is not exposed to the risk of suffering oxygen deprivation due to complications. The same applies to possible injuries to the arms or shoulder. However, newborn babies are more likely to have problems breathing on their own after a caesarean section. This is because, unlike a vaginal birth through the narrow birth canal, the amniotic fluid is not completely squeezed out of the small lungs during a caesarean section. As a result, the little ones often need help breathing after the birth. In addition, a vaginal birth provides babies with valuable maternal microorganisms (e.g. certain "good" bacteria), which are important for digestion and the immune system. This is not the case with a caesarean section.
But I can allay one fear: More and more clinics today are making it possible for the mother to have a baby with the so-called Sectio-Bonding, to take their baby to the breast even after a caesarean section - provided that both mothers are in good health and the mother is not under general anaesthetic. Nevertheless, babies born by caesarean section often have difficulties adjusting.
Evil voices that weaken women
Desired caesarean sections in particular are often covered in the cliché of having a baby "just as easily" as it fits into your diary. Or as the saying goes: "Too posh to push" (loosely translated: "Is too posh to push"). And unfortunately, it is often enough women or mothers themselves who are not exactly squeamish in their critical comments towards other mothers with an "elective caesarean section".
Nowadays, many women who have given birth by caesarean section for various reasons - including medically indicated ones - have to listen to harsh criticism. The claim that they miss the "real birth experience" is probably one of the more "harmless" statements. Other voices believe that "real Bonding" is not possible with a caesarean section anyway. A mother whose vaginal birth ended in an emergency caesarean section once told me in tears that she had to listen to how things would certainly have gone differently if only she had made more of an effort.
The term "caesarean section bashing" is making its sad rounds. That's why I appeal to everyone who takes part in it: Stop denigrating other mothers!
Of course, we midwives are particularly keen to encourage and empower women to perceive and experience birth as a natural process. That's why we don't like the fact that birth is increasingly being redefined as a medical procedure. The fact that the caesarean section rate in Germany is consistently high should be criticised - but it's hard to blame the women. And I also don't like the idea that women can choose between vaginal birth and caesarean section like they can choose between pizza and pasta on a menu. Which in reality, of course, no woman does - but which is probably not infrequently offered to her in this way.
My opinion: No one has the right to deny a woman the birth of her child. No one has the right to label one type of birth as "more valuable, more correct, ethically better" and belittle another. An incisional birth is a different birth experience to a vaginal birth. Equally, a vaginal birth with an epidural is also a different birth experience to a spontaneous birth without an epidural. This "series of comparisons" can be continued indefinitely: giving birth with more or less painkillers, with a longer or shorter labour time, etc.
I'll say it again: no woman has "failed" or "done less well" because she gave birth by caesarean section or needed more painkillers! And no woman is better than others because she gave birth "faster" or "more naturally" or didn't experience moments when she "couldn't take any more".
We should all Treat mothers with respect, recognition, more understanding and genuine empathy. Every single one of them deserves that! After all, there is not just one "right" way for everyone, because every woman is unique and brings her own individual circumstances to the birth. In my experience, if you ask a hundred mothers about their caesarean section, you will get a hundred different answers about their experience.
Which decision to make?
The right to a self-determined birth is often cited as an argument in favour of an "elective caesarean section". I am also in favour of self-determination. However, it should not be confused with hoped-for guarantees. Neither with a caesarean section nor with a natural birth is there any guarantee in advance of absolute safety, the best birth experience, the highest recognition or anything else.
In my work, I have seen time and again how much it helps pregnant women when they can talk about their worries and needs and are taken seriously. The better informed women are, the better they can categorise their thoughts and take a differentiated view. In this way, it is not fears that guide a decision, but enlightenment and self-reflection. You can also ask me about this in my online counselling contact.
And in any case, the decision as to whether the birth should be an elective caesarean section, but also for the caesarean section, requires a Birth preparation course necessary. Because every birth requires good and intensive preparation and mastering the breathing technique is also important for a caesarean section. This is because the baby also needs mum's conscious and attentive breathing during this birth.
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