Delivery by Caesarean section is now touted as the celebrities' choice. Disturbingly, more and more women feel they are being rushed into this, too. Why are they being denied the right to labour pains?

Observer

Those qualities we associate with giving birth - the crescendo of contractions, the growing agony, the necessary endurance, the noisy, messy and primitive struggle to bring a baby into the world - are not here. Pregnancy isn't an illness, but it is increasingly surrounded by doctors and their instruments, and with a Caesarean it is ended by surgery; the drug in the spine, the knife through the flesh. Nature seems absent.

Giving birth used to be a brutal and hazardous business. Graveyards are crowded with young women who died during labour and who would today be saved by medical intervention. Caesarean sections save lives. Without them, many mothers, or babies, or both, would be endangered. Today, the risk of death during pregnancy and birth is tiny and the pain may be assuaged or removed. But according to the latest Department of Health figures, Caesareans are steeply on the increase in this country - as with so many other things, we are following the American trend, which is examined in Naomi Wolf's new book, Misconceptions: Truth, Lies and the Unexpected on the Journey to Motherhood, published here and in the US next month. The book is heavily embargoed but the advance publicity says that Wolf, a mother of two, uses it to take a critical look at what she calls the pregnancy 'business' and explore growing concerns that the medical profession is 'making childbirth faster and faster, often creating complications'.

Nearly 20 per cent of births in the UK are by Caesarean section, and that figure is expected to rise further at the next audit in the autumn. The World Health Organisation has stated that the levels should be no higher than 10-15 per cent. In some hospitals (especially private ones), the figure is a dramatic one in three or even more (in private hospitals in America, the rate is about 40 per cent, compared with 25 per cent in the public sector; in Brazil, it is an astonishing 75 per cent). This is not because risks during birth have suddenly increased. The National Childbirth Trust has expressed concern at the high rates (even calling the figures 'ludicrous').

The Department of Health, alarmed by the pace of the rise, commissioned the Royal College of Obstetricians and Gynaecologists to carry out the first national survey of Caesarean rates involving all 237 maternity units in England and Wales. Detailed information on 125,000 deliveries from 1 May to 31 July this year was collected, and the results are now being analysed. When they are published next year they will show that Caesarean rates have doubled in 20 years.

Newspapers have produced grabby headlines about a new generation of women who are 'too posh to push'. The current clutch of celebrity mothers photographed emerging from private maternity hospitals such as the Portland in London seem more often than not - whether by choice or medical necessity - to have given birth by Caesarean. In the States, there are stories of women who have Caesareans because their husbands demand it, for sexual reasons. Sometimes the argument seems ideological rather than practical: on the one side, Nature and female destiny, on the other, Science and a brave, new world; on one side, suffering and a kind of invoked heroism, on the other a refusal to suffer. One kind of feminism and world view against another.

There are two kinds of Caesarean - emergency ones and elective ones. The former is normally done after a natural birth has failed for some reason. The woman can go through hours and sometimes days of labour before being cut open - the worst of both worlds, you might think, the pain with no gain - yet a recent study of 200 people suggests that for some women it is important to try to do it naturally ('give it a go') before having surgery.

One woman I spoke to who'd had a tormenting 20 hours of trying to give birth naturally, followed by a scary rush to the operating theatre where her abdomen was sliced open, described it as 'hell followed by a nightmare' - and she never wanted to have another child.

Elective Caesareans are planned in advance, usually because of known complications - like the placenta being in the wrong position. Although there is no pain of labour, this is major surgery and women certainly suffer more discomfort and pain afterwards, and may suffer greater complications. The assumption by the press, when the figures were released, that Caesareans are the easy option taken up by middle-class women who want to fit a painless birth into their busy schedule seems simplistic; what women overwhelmingly want is a safe delivery of a healthy baby.

However, there is certainly a rise of 'defensive' Caesareans - to avoid litigation or complaint, to which I shall return later, or to comply with the woman's choice ('customer choice' some health professionals call it now), rather than for good obstetric practice. Caesareans, in other words, not for medical reasons but because that is what the woman wants - because she feels safer, more in control, less in pain - and why, after all, should a woman go through all that pain when there is a way not to?

After years of feminist argument that women should be liberated from medical intervention - the stirrups, pessaries, the horizontal iron bed in a white-tiled room - it seems that many have come full circle, to a fully medical birth.

When I was first pregnant, 14 years ago, it was a time of intense prenatal classes (where we were encouraged to knit ourselves a uterus - can this be true or have I made it up? - and talk about our deep fears and desires), breathing lessons, birth plans, massages, birthing pools, riding the pain, doing it yourself without monitors and crochet hooks to break the water, without pain relief, and feeling like a warrior. For my mother's generation, there was an emphasis on fortitude and a denial of pain. My mother and her friends always said that we popped out like peas from a pod, but I've never heard women of my generation saying that kind of thing - we bond instead over shared stories of suffering and blood and guts and indignity and endurance.

For us, there was an emphasis on labour and birth as a ritual (an important book was Spiritual Midwifery by Ina May Gaskin; Sheila Kitzinger taught us that birth was better than sex). I remember feeling morally, or even religiously, obliged to do it without even a whiff of gas and air - as if I had to earn the right to my baby, fight for it. As if pain was something to be proud of. Now, the climate has changed, and there's something laughable about the idea of vaginas opening like flowers.

In America, Caesarean rates soared in the Seventies because of the introduction of monitoring during labour and because there was a rule of 'once a Caesar, always a Caesar', In the UK, it has risen more slowly (here, we have a rule that twice a Caesar is always a Caesar). But Wendy Savage, the gynaecologist and obstetrician once controversial for her anti-interventionist views, fears we are going to catch up with the US soon. 'We can't set targets because we haven't got the proper data. We have no proper criteria for doing Caesarean sections. We have criteria for appendicectomies or mastectomies, but not for the most common major operation in the country. Why? If you know the indications of Caesarean sections and add them up, then you can say what the rate should be. Has no one added up the indications? I ask. 'I have. I have estimated that in a healthy population, it should be 6 to 8 per cent.' This is three times less than current figures.

The NCT is a well-known supporter of natural birth, but chief executive Belinda Phipps insists on the pragmatism of this, saying that it is 'not because natural birth is our religion or anything. It's because a straightforward birth leads to the quickest recovery, both for the family and for the newborn. And the huge high and sense of achievement that a woman feels after a natural birth is a good place to start with the new baby, whereas major abdominal surgery is not the world's best start.'

She thinks the new figures are 'worrying. Thank goodness for Caesareans. They save women, they save babies. They are not unsafe, as they once were. But they are being used where there is no medical benefit - and perhaps that wouldn't matter if there were no medical downsides, but there are.'

She thinks that a major cause of the rise is the shortage of midwives (which is especially acute in London, where a midwife's weekly wage - often less than £250 after tax - stretches to about Tuesday). Naomi Wolf agrees and laments the decline of midwifery as a profession in Misconceptions . Phipps says: 'If a midwife is with the woman throughout the whole of labour, supporting her and giving her confidence, then that woman is far more likely to have an easier time and to have less intervention. Midwives are the best prevention of Caesareans. We are too ready with the knife, not ready enough with the midwife. It's easier to get knives out.'

Without a midwife, and in the bleak hospital room, it is too easy to go, step by step, towards an emergency Caesarean. 'Let's say a woman arrives at hospital in the first stages of labour,' says Phipps. 'She has perhaps arrived too early - a midwife could have told her to spend the first stages at home. A doctor might look at her, then leave her alone, rather than tell her to go home, relax, have sex, have a curry, have a walk. She is there for 12 hours, lying down, waiting, feeling scared and abandoned. She's sick of waiting, so the doctor decides, because nothing seems to be happening, she should be induced. It's much more likely, because the experience this far has not been positive, that she will have an epidural or pethidine - which will then increase the risk of further intervention.

'She's proceeding down the road towards a Caesarean. The labour isn't progressing; she's exhausted - so off she goes. That's a very common and typical picture which, with a midwife, could be a different and far happier one.'

She also says that women feel increasingly fearful about birth. 'This is anecdotal still, but there are some teenagers who worry themselves sick about it, so that it is almost a phobia. They sit in classrooms and see films of a baby being born and it's not really a good introduction.'

Another reason for the rise in intervention is the fear among doctors of medical litigation; again, America is ahead of us on this. A lawyer who specialises in medical litigation and wished to remain anonymous felt this was a contributing factor. 'But you'd be hard-put to get a doctor to admit to it. It has to be the case. If there are signs of foetal distress, a doctor will opt for intervention like a dose of salts.' We are less tolerant of risk now, he says. After all, Who's going to take a small risk - and small often means minimal, not 1 per cent but a fraction of a per cent - when the life or health of their child is at risk? And, he adds, we live in a culture of blame- we are forever in search of someone whose fault it is.

James Drife, professor of obstetrics and gynaecology at Leeds University, says the Caesarean rate has been going up since as long as he can remember. In the Fifties, it rose from 2 to 3 per cent; 20 years ago, it was said that there would be a cause for concern if it rose above 6 per cent. Now it's 20 per cent. There's a graph in the British Medical Journal of the past 30 years which shows a 'steady, relentless increase' both in elective and emergency Caesareans.

Drife points out that in private practice, the rates of Caesarean sections tend to be much higher - after all, the doctor will earn substantially more for one than for a natural birth. He agrees that the shortage of midwives and the fear of medical litigation are among the reasons for opting for a Caesarean delivery, as well as women being more assertive about what they want, and scare stories about labour being more abundant. But above all, he says - reiterating what the lawyer says - we are less and less accepting of risk, any risk, however small. 'If there may be a chance of something going wrong, the risk is unacceptable. If a monitor reading is not perfect, neither the woman, nor her partner, nor the doctor, are willing to take a chance,' he says.

And assessment of risk is also about frame of mind. I ask him if he would perform a Caesarean for a woman if she wanted one, even if there was absolutely no obstetric reason for it. 'You've got to give a woman all the facts,' he says. 'Sometimes a woman may only know one side of the argument. But if a woman is well-informed, then yes, I would go along with her wishes. In the end, it would be the woman's choice.'

Wendy Savage, however, would not have delivered a baby by Caesarean without a medical reason. 'As someone who has spent years fighting for women's right to choose an abortion, I now find myself in the difficult position of saying I don't think they have a right to choose a Caesarean section. Why? Well, with a termination, especially before 20 weeks when almost all of them are done, the risk of death is extremely small - one in 100,000. The consequences of having a baby are long-lasting and the woman is the one who knows what these consequences will be - she has to balance the risks. She is the expert. With a Caesarean section I am the expert, and one of the things I know is that there is a measurable medical risk.'

Women are between two and five times more likely to die through a Caesarean operation than in a vaginal delivery. 'Of course, the risk is still small; say one in 3,000 or 5,000, compared with the one in 25,000 of a natural birth. It is nevertheless a risk - it is not as safe. What's more, women don't recover nearly as quickly, and there is a greater chance of infections developing. Doctors are not, on the whole, very good at talking about side-effects to the women, and they are certainly not very good at talking about dying.' Savage agrees that there's been a profound shift in attitudes towards Caesareans, especially among young, middle-class, professional women. 'It's as if among certain groups of women, a baby by Caesarean section is the normal, natural way of doing it.'

Normal and natural: the needle in the spine, the knife through the flesh. A woman's right to choose?

Nicci Gerrard will be on sabbatical from The Observer for the next 12 months. Naomi Wolf's Misconceptions: Truth, Lies and the Unexpected on the Journey to Motherhood is published next month by Chatto and Windus, £12.99. To order a copy in advance for £10.99, call Observer CultureShop on 0870 066 7989. The NCT can be contacted on 0870 444 8707