Category: csections commentary

The surprising results of a recent study suggests they don’t want to know.

The study looked at women with low risk pregnancies who were planning a vaginal birth the majority of whom did not want a caesarean delivery if there was no medical need.

• When asked whether they had checked out the caesarean rate in the hospital they planned to give birth in, the majority had not
• 55% did not believe that their choice of hospital might affect their chances of having a caesarean
• When asked whether a high caesarean rate would lead them to change hospital 75% said no, they would rather stay with practitioners they had developed relationship with

The truely surprising result suggested that when women were told that whether or not they had a caesarean could actually depend more upon administration issues and hospital policies than whether they actually needed one or not, they still preferred to stay with the hospital.

Dr. Neel Shah, of Boston’s Beth Israel Deaconess Medical Center, one of the researchers said:

“If [women] see a hospital with a 50 percent C-section rate, they don’t see their own chances of having a C-section as being 50 percent. Our research suggests they see it as an abstraction.”

It is unfortunately the case, in the current cost cutting climate, that medical need is not the only factor influencing practitioner decisions about caesarean birth. Ironically while there appear to be women having unnecessary caesareans in some cases, there are also those who want to make an informed choice in favour of a planned caesarean who are being refused that option.

If you have a preference of one birth mode over another it is fundamentally important to arm yourself with enough information to support your choice. Being able to demonstrate an informed opinion and knowing what really constitutes a medical need can significantly affect your birth experience.

The NCT and WI commissioned a survey in 2013 to understand women’s perception of their birth and postnatal experiences. As a result of that survey they have launched a national campaign for 2017 targetting ‘red flag events’ called ‘Support Overdue’

Red flag events are instances where levels of staff support for women is so low it is considered dangerous. The survey found that half the women surveyed (nearly 3,000) had experienced a red flag event during their birth. E.g. no one-to-one care during established labour, waiting for more than an hour to be stitched following vaginal injuries.

“The aftercare was awful, I was alone and in a lot of pain” (a quote from the survey)

Another key finding highlighted adequacies in postnatal care. E.g. 1 in 5 women unable to see a midwife postnatally as frequently as they felt necessary and for some leading to a notable delay in the diagnosis of health problems for either Mum or baby.

In a climate of policies driven by cost cutting, the results from the survey are no great surprise. E.g.

• 79% of Trusts did not meet recommended staffing levels
• 88% of women had never met the midwife that attended them for their birth

Elizabeth Duff (Senior Policy Advisor at the NCT) commenting on Woman’s Hour (Jan 2017) stated that understaffing was a significant problem and despite increases in the number of students training to be midwives their research is finding that many trusts simply  “do not have the money to employ the midwives that they know they need.”

The first step for ‘Support Overdue’ is to present the survey findings to the Health Select Committee in Parliament requesting:

• Review staffing with a view to fulfilling the standard, set by the four medical and midwifery royal colleges, of a midwife-to-birth ratio of 1:28 per year;
• Take action to ensure continuity of care: NICE postnatal guidelines are robust, but seem to be implemented inconsistently across different areas. One trust in London reported it offered women three postnatal visits as standard, a neighbouring trust offered women just one – yet both reported they were delivering in line with the guidance. Poor data and recording hampers proper analysis and means it is difficult to get a comprehensive picture of care standards and service provision.
• Enable women to build and maintain a relationship with their midwife: many women give birth in locations chosen by them and known to providers months beforehand; facilitating a relationship between midwives and women in their care would help provide much valued continuity of care from the antenatal period into labour and postnatal care. NCT Press release Jan 17th 2017
  

What is incredible is the inability of decision makers to connect astronomical maternity litigation costs with the radical cost cutting experienced by the NHS. How many deaths and near misses (never mind the cases of PTSD) do there have to be before they ‘get it’.

This destructive habit can cause significant problems between couples. Both feel that their daily life is the most difficult and that the other just doesn’t understand. It is easy to then let resentment fester under the surface and spend valuable time and energy arguing about who has the worse deal.

This behaviour can occur regardless of the type of birth you have had. Remembering that your birth partner has also gone through huge upheaval and stress is important.

They are sleep deprived, they are anxious, they witnessed their loved one in pain. They may have felt inadequate during the birth blaming themselves for not having prevented unwanted intervention. Then and once back at home they may be taking roles and making decisions on your behalf that they are not used to.

For example, unless discussed in advance your partner will, in the case of a general anaesthetic, be making decisions about feeding and clothing your baby for her first few hours. Unless you have discussed it in advance they are unlikely to know what you are planning to do and may not know the potential impact of giving formula instead of breast milk immediately after birth. Try not to criticise decisions, particularly if you did not discuss such eventualities beforehand – they will have done what they thought was right at the time.

Similarly, while you are recovering, some jobs you have previously done within the home probably now fall to them. Some may relish this, but others may feel the pressure, particularly if you are overly critical. This will all be in addition to their working day so quite quickly they are going to end up as exhausted as you. Appreciate what they are doing and try not to criticise when things are not done your way. Does it matter if the washing is left in the machine for 24 hours before going into the dryer? Probably not. Nor is it the end of the world if they gave the kids the wrong drinks in their lunchbox.

Ask each other for help and support and try to remember that you are both going through a huge learning curve while extremely sleep deprived.

It is only in truly believing the roles are totally different and have extreme and unique pressures of their own that you can hope to remove this barrier to emotional recovery.

A UK hospital has challenged targets handed down by others (in this case their Clinical Commissioning Group – those who set the targets for the hospital). The Royal Berkshire Hospital was told their caesarean rate was too high (27.1%) and they must get it down to 23%. When asked whether it was cost driving this target the interim Medical Director Brian Reid said “That would be the driver.”

Unfortunately this target led approach to hospital care of pregnant women is typcial rather than unusual. Targets are a major factor driving policy and practise in many places. Where targets are based on cost cutting this can only mean that the health and safety of pregnant women and their unborn child cannot take top priority.

The NICE guidelines on Caesarean Section have stated that:

• women wanting to request a caesarean where there is no medical need should engage in a detailed discussion with their practitioners. All the risks and benefits of both vaginal and caesarean birth should be fully discuss but if, after this, the woman still prefers a caesarean this should be granted
• women wanting to request a caesarean on the grounds of fear should be offered perinatal mental health support and if, following this, they continue to want a caesarean, this should be granted

So if more women are making an informed decision in favour of a caesarean birth over an attempted vaginal birth then the targets need to reflect this need.

The World Health Organisation retracted their recommended target 4 years ago when the studies on which they had based their recommendations were found to be flawed. They have now stated:

There is “no empirical evidence for an optimum percentage”, an “optimum rate is unknown,” and world regions may now “set their own standards”. ‘Monitoring Emergency Obstetric Care: a handbook’

Despite this, official bodies continue to use such figures to beat their hospitals into submission with unachievable targets.

And lets be clear many caesarean requests are from women whose circumstances are not clear cut, where a decision in favour of either birth mode is equally justifiable. So simply telling them no when they ask for a caesarean and the press labelling these women as selfish or too posh to push is simplistic and insulting.

Take for example a baby lying in the breech position. A breech birth can be delivered vaginally or by caesarean section. However any woman making an informed decision about her birth will know that a breech position can make for a more protracted birth. Protracted births can increase the need for pain relief and instrumental assistance or ultimately an emergency caesarean. Couple with this, the fact that in the recent past many breech births have been delivered by caesarean, so practitioners are getting less experience with these births and this may justifiably lead some women to choose a planned caesarean over a vaginal attempt. These women are not selfish, they are making informed decisions on behalf of their own bodies and their baby’s.

So if you are planning your birth, read the NICE guideline and arm yourself with the facts prior to requesting a caearean, particularly one where there is no clear medical need. In addition my book “Caesarean Birth: A positive approach to preparation and recovery” provides all sorts of information about both caesarean and vaginal birth so that you can make an informed decision about which way you would prefer to proceed.