NHS hosptials ban requests for caesareans

A number of Primary Care Trusts (PCTs) have decided to ban all non-medical, planned caesareans in an attempt to save money. This despite the new draft guidelines from NICE stating that maternal request caesareans should be supported.

The sort of figures being quoted by PCT’s attempting to claw back money does not consider that the moment medical intervention becomes involved in a vaginal birth, the costs begin to climb. A study in 2003 found that as soon as induction and epidurals were involved in a vaginal birth the cost exceeded that of a planned caesarean by 10% and this discrepancy was even greater in a failed VBAC attempt. This before we even begin to look at the emotional and physical impact for the woman of such interventions.

With this in mind – some figures PCTs and mothers should be aware of:

  • 50% of births involve some form of intervention (NHS)
  • 33% of women will have an anaesthetic (NHS)
  • 90% of women will fail to achieve a natural birth (according to a UK survey Birth in Britain Today Survey 2001’, Mother and Baby Magazine)

Just how many of these women denied caesareans are going achieve the cheap natural births the PCTs are hoping for? To put this in perspective, the savings expected through disregarding women’s emotional and physical health are a tiny, tiny fraction of the NHS 100 billion budget. Bear in mind too that the country’s maternity budget is blown every year by maternity litigation costs many of which arise from vaginal births that have gone wrong. Women would be far better served if these cost-cutting PCTs looked more closely at their staffing policies and practises than in denying informed choice to a small minority of women.

So why do women request a caesarean in the absence of any medical need?

Contrary to popular belief, rarely is such a decision taken lightly. While a few women do see a caesarean as a ‘lifestyle’ choice most do not (and those who do may use private health care rather than the NHS in any case). There are actually many, many reasons why women reach a decision to request a caesarean but the two most common are fear and previous caesarean.

For many women a significant fear of vaginal birth (tokophobia) actually outweighs their fear of surgery. While NICE guidelines recommend that where counselling fails, women be allowed a planned caesarean we know that for many women not only is this counselling not available but they are not even aware that is should be. Assuming women even know that presenting with tokophobia affords them the right to a caesarean many still find their request denied. It is well known in the profession that fear and anxiety can affect a womans ability to labour effectively. By forcing women with tokophobia to give birth vaginally we are setting these women up to fail. Bans enforced by PCTs simply serve to reinforce the bias of those practitioners who do not believe women should have the right to informed choice and women are likely to increasingly find requests on such grounds denied.

And it is not just tokophobia that drives some women to request a caesarean. Many planned caesareans registered as ‘maternal request’ are actually carried out as a direct result of feedback from practitioners. Borderline cases such as breech babies, repeat caesareans etc. are considered by many practitioners to be valid cases for a planned caesarean based on their own clinical assessment of risk. The information they provide to women therefore encourages some to go on to request a caesarean. However in leaving the final decision up to the mother, this is categorised by many authorities as a ‘maternal request’. Not only does this ban put practitioners in a very difficult position but it is very possible that in those PCTs where a ban is in place such cases will no longer be considered medical and women may find their right to an informed choice after a balanced assessment of risk removed by this cost cutting exercise.

Before PCTs make such life changing decisions on behalf of their poorly informed, poorly supported ‘mothers to be’ they should look at both the immediate and long term costs of increasing the number of women forced to have unwanted vaginal births and look to make savings elsewhere.

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