THE National Institute for Clinical Excellence (NICE), the government organisation designed to determine British medical practice, is likely to be disturbed that a woman’s preference for elective Caesarean section is distorting the rate of births by this method. This increased rate must increase NHS costs, and one of NICE’s aims is value for money. The idea that medical discretion should be influenced by finance rather than the welfare of the patient is repugnant to many doctors.

The preference that some women express for a Caesarean is not because they will find it more convenient, and it is certainly not agreed to because it is easier for an obstetrician to fit a Caesarean section into his busy diary than it is to be present at a long labour.

The consequences of the emotions and prejudices encapsulated by the pejorative phrase “too posh to push”, if generally accepted, would be likely to affect the quality of life and intellectual development of countless people who were not fortunate enough to have been delivered by a quick Caesarean section. Too many babies have had to suffer either the battering of a difficult vaginal delivery, asphyxiation as the result of an inadequate placenta over-strained by the delivery or the hazards of a late Caesarean delivery when the conditions of the mother and baby have already been undermined by a long but eventually fruitless labour.

The complications of Caesarean section, about which there is much talk by the anti-Caesar faction, are predominantly found in those women who have laboured unsuccessfully for too long, and not in the elective Caesarean.

There are few, if any, more satisfying moments for a woman than a natural delivery that goes according to plan. Any discomfort AND pain, if not excessive, is forgotten in the elation and outpouring of emotion that accompanies a birth. The moment is so dramatic, the emotions so extreme, that it is tear-jerking in its intensity — and I speak only as a bystander. If this goal can be achieved it is obvious that a woman should be encouraged to go for it, but it would be idle to suppose that in seeking this ideal many women have been put through hours of pain and misery unnecessarily. As a result, when the child is delivered, the only emotion of which the mother may be capable is relief.

When I first qualified, the Caesarean section rate was 3 or 4 per cent. Now it is 15 to 20 per cent. The increase has in part been because the operation has been made safer as anaesthesia has improved, but other factors are also important. There is a greater realisation that a prolonged labour is not only damaging to the baby but that a struggle to deliver the child may not do much for the mother’s vagina, anus and pelvic floor.

For both the mother’s and child’s wellbeing, a difficult forceps delivery should now be replaced by a Caesarean section. Professionals always like to practise and exhibit their skills. Forty years ago I was very proud of my breech deliveries and took pride in performing them. Even while I was doing so, I was aware of the statistics which showed that a breech delivery was neither pleasant for the mother nor conducive to the baby’s future intellectual prowess. It was a huge relief when it became accepted practice for breech presentations to be delivered by an elective Caesarean section.

There are absolute medical indications for elective Caesarean sections. Some are determined by the needs of the baby, others by maternal factors. Only a foolhardy extremist would not do a Caesar in these circumstances. A normal delivery can be described as such only after it is all over; it is not the time for risk-taking. There are also relative indications, and perhaps the thought which underlines these is a desire to make certain that the baby has the very best chance in life. The quality of the baby’s life and its intellectual development may be determined by its birth. The baby’s birthday may be the greatest emotional moment of the mother’s life but she is only the second most important person present. The nature of the delivery, so far as the child is concerned, may determine not only the mother’s feelings, and a pleasant memory that will last for life, but every aspect of the baby’s life. For a girl the consequences are still likely to be important 83 years later, and for a boy for the next 79 years.

One might think that there would be a great deal of research data on the long-term effect which a battering during birth may have on the child’s future life. Surprisingly this is not so. There is evidence about the effect of severe damage to the baby and of prematurity, but very little sophisticated information about the more subtle influences minor damage may inflict.

In many of these cases the difficult delivery may in the opinion of the maternity staff have been successful, but they are not present in the classroom when the child is ten, nor can they judge its social skills as an adult.

I was taught by my mentor in obstetrics that on average the babies who did best in later life were those delivered by an elective Caesarean section at the 38th week. The Caesar removed the possibility of a difficult or prolonged labour, and the 38th week determined that the child would be delivered before the placenta began to deteriorate, or proved for some other reason inadequate during labour.

The last time there was an outcry about the increasing Caesarean rate I telephoned one of London’s better-known obstetricians for his reaction. He suggested that the really interesting question that needed answering was why so many female obstetricians and anaesthetists, who knew about labours and their possible hazards, were more likely to opt for a Caesar than other women. He wanted to know why this information wasn’t shared by the great mass of the general public.

No one would recommend Caesarean section as first choice if every aspect of the woman’s condition made a natural delivery seem likely, but if there are any doubts it is the baby’s future rather than the nation’s treasury which should determine policy.

Are Caesarean section births a good idea? E-mail debate@thetimes.co.uk