Birth trauma, rising caesarean rates and what the data misses
Half of all babies born in English NHS hospitals now are extracted via caesarean section. Recent monthly figures put emergency caesareans alone at over a quarter of all births, and yet stillbirth and neonatal mortality rates have not improved at the same pace as intervention rates have risen.
Something is not adding up.
The standard explanations are workforce shortages, litigation fears and the long shadow of maternity safety scandals, all of which are real. But these aren’t the whole picture; they describe institutional pressures without asking what is happening to the women and birthing people inside those institutions. They account for clinical decisions without asking what is driving the quiet, steady loss of confidence in physiological birth that underlies so many of them.
When safety becomes surgery
Requesting a caesarean section is, for most people, primarily an emotional decision. An investigation into decision-making in childbirth within the risk society, positions caesarean section as a social and moral experience shaped by fear, anxiety, uncertainty and the promise of safety (Scamell). It is what happens when someone has watched friends describe frightening, unsupported births and concluded that labour is something to be survived rather than moved through in an empowered way, or when a previous birth has left something unresolved that cannot be faced again. when the system has communicated, through rushed appointments, unfamiliar faces, and decisions made without explanation, that the person's body cannot be trusted, then intervention is the responsible choice.
Maternal request caesareans are rational responses to a system that has progressively withdrawn the conditions that make physiological birth feel possible. When someone does not trust that they will be known, held and supported through labour, they choose certainty, because however significant major abdominal surgery is, it feels more controllable than a system that cannot be relied upon.
This loss of confidence is perfectly rational as it reflects lived experience, of care that changed hands too many times, of being left alone at critical moments, of not being listened to, of interventions that happened without full explanation or propper consent: experiences that do not just affect birth preferences, they become birth trauma.
Birth trauma and the caesarean rate
The connection between birth trauma and rising caesarean rates is rarely made explicitly, though it surely should be.
Research suggests that between 20 and 48% of women and birthing people describe their birth as traumatic (Greenfield et al). Around 4 to 5% of women and birthing people in the UK meet criteria for PTSD following childbirth, roughly 25,000 to 30,000 people every year (Ayers et al). Many more carry difficult experiences that fall below that clinical threshold but profoundly shape their subsequent choices.
A person who experienced a traumatic first birth, who carries intrusive memories, hypervigilance, or a deep sense that their body failed them or was failed by those around them, faces a subsequent pregnancy in a fundamentally different position. The nervous system, still holding an unresolved experience, responds to the prospect of labour as a known threat. Requesting a caesarean is, in that context, a survival response.
This is one of the most significant and least-discussed drivers of rising caesarean rates. Until birth trauma is taken seriously, until people receive real, relational, trauma-informed support after difficult births, those experiences will continue to shape subsequent birth choices in ways the data captures but rarely explains.
The institutional logic of intervention
The forces driving caesarean rates are structural as well as personal. Clinicians in England work within systems shaped by formal inquiries and the ever-present threat of litigation following adverse outcomes. The necessary investigations into maternity failures at Morecambe Bay and East Kent have contributed to a culture in which deviation from protocol feels professionally dangerous, and intervention can seem like the safest institutional choice regardless of its clinical merit. So caesarean section becomes a mechanism for managing uncertainty and distributing responsibility, as much as a clinical decision.
The pressures on individual clinicians and on individual women and birthing people are different expressions of the same broken system. Midwives who cannot practise with continuity, who cannot build the relational trust that enables someone to feel safe in labour, who are managing caseloads that make unhurried person-centred care structurally impossible, are also part of this picture. A system that produces burned-out midwives and traumatised women and birthing people will produce higher caesarean rates.
The cost
Emergency caesareans remain necessary, vital and often life-saving. The question is what do rising rates tell us about the state of the system, and what do they cost.
Physically, recovery is significant and frequently underestimated: symptoms varying from chronic pain, restricted mobility, disrupted bonding and emotional distress in the weeks and months after birth are commonly reported. Much of that recovery is managed by women and families at home, with minimal support.
Emotionally, caesarean birth, both planned and emergency, can itself be a source of birth trauma (Turk et al). The loss of a hoped-for experience, the shock of emergency surgery, the feeling of passivity or absence from one's own birth, the difficulty making sense of what happened are common (Clement ); (Lemola)For many people who have had them, caesarean birth is neither easier nor less traumatic than they expected.
What would actually change things
The 2024 Cochrane systematic review on midwifery continuity of care (Sandall et al.) found that continuity models were associated with fewer caesarean sections, fewer instrumental births, more positive experiences and cost savings. The evidence is clear and consistent that those who feel known and held are less likely to need or request intervention.
Taking birth trauma seriously is the other important piece: providing real, relational, trauma-informed support after difficult births reduces the likelihood that one traumatic birth shapes the next pregnancy, and the choices that follow from it.
Both are straightforward in principle and being dismantled in practice, with birth units closing, community midwifery being reconfigured, and the decimation of postnatal care. The conditions that make physiological birth possible and safe are being withdrawn, and the caesarean rate is rising in direct proportion, surely we can see this is a consequence, not a coincidence? Until it is named as such, at every level where these decisions are made, the caesarean section rate will continue to rise.
References
Scamell, M. Childbirth Within the Risk Society. Sociology Compass, 2014, 8: 917-928.
Greenfield M, Jomeen J, Glover L. What is traumatic birth? A concept analysis and literature review. British Journal of Midwifery. 2016;24(4):254–267.
Ayers S, Bond R, Bertullies S, Wijma K. The aetiology of post-traumatic stress following childbirth: a meta-analysis and theoretical framework. Psychological Medicine. 2016;46(6):1121–1134.
Türk R, Harder U, König-Bachmann M. Post-traumatic stress syndromes following childbirth influenced by birth mode — is an emergency caesarean section worst? Archives of Gynecology and Obstetrics. 2023;308:1117–1125.
Lemola S, Stadlmayr W, Grob A. Maternal adjustment five months after birth: the impact of the subjective experience of childbirth and emotional support from the partner. Journal of Reproductive and Infant Psychology. 2007;25(3):190–202.
Clement S. Psychological aspects of caesarean section. Best Practice and Research Clinical Obstetrics and Gynaecology. 2001;15(1):109–123.
Sandall J, Fernandez Turienzo C, Devane D, Soltani H, Gillespie P, Gates S et al. Midwife continuity of care models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2024, Issue 4. Art. No.: CD004667.
