Category: News

Talking once again about PCTs intention to ban planned caesareans that have no medical need. TV – a rather nerve-racking but worthwhile experience.

Much of the debate centred around the idea that maternal requests were a selfish choice taking money away from other areas of maternity care. Once again women falling into this category were all assumed to be ‘too posh to push’ but “What we need to think about is the number of women that actually fall into this category, the number is incredibly small. When you actually look at the reasons behind these choices the number that actually make this decision, as a ‘lifestyle’ choice alone, is very, very small.” As discussed in other posts, there is far more to it than lifestyle choice alone.

In answer to whether an elective caesarean is more expensive? In addition to the fact that the figures are based upon flawed data, “The issue of cost is a difficult one because actually the assumption that is being made is that a woman that is refused a planned caesarean is going to go on to have a natural birth. 50% of the women in this country manage to give birth vaginally without any form of intervention…the moment they do [experience intervention] the costs rocket and the actual likelihood of achieving the cost savings that are being talked about is very small.”

Interviewed by BBC Radio York for a debate on PCTs banning planned caesareans where there is no medical need (in at 35 minutes). Useful comments later in the programme from independent midwife Chris Warren.

The majority of the debate centred around the question of whether or not women requesting caesareans really knew what they were doing and if so whether they had the right to make an informed choice in favour of a caesarean in the absence of any medical need.

“A woman ought to have the right to evaluate those risks for the planned side of caesareans and for vaginal birth. One of the reasons I think we are seeing an increase in the number of requests is that women are starting to do this. Women are starting to get access to that information and some women, not all because I agree there is a ‘lifestyle’ choice going on here for some women, but some women are making the choice for a planned caesarean to avoid the risks associated with a vaginal birth that goes wrong.”

“Some obstetricans would say that a prophylactic caesarean in certain situations is far less risky than the risk of giving birth [vaginally]. For example if you look at the twins scenario, that is one of those ‘grey’ areas where some practitioners will say no you shouldn’t try and give birth naturally and others will say ‘yes, go ahead’. The difficulty is you are then down to personal opinon of the practitioner that you are speaking to. Women are not given the information they need in order to make those choices for themselves. The National Institute of Clinical Excellence has spent the last 18 months reviewing the data regarding specifically maternal request caesareans and they have now decided and this is going to come out in the next few weeks…it is a reasonable thing for a woman to choose a caesarean. They have actually stated “If a vaginal birth is still not an acceptable option to the woman, her request for a caesarean should be supported within the health service.” NICE 2011

It was suggested that maternal request caesareans should be banned as proposed by some PCTs in order to save the NHS millions of pounds. This suggestion is born out of the NICE calculation that there is an £800 cost difference between these types of caessarean and vaginal births. However the figures used by NICE are based upon flawed data. The base case cost used for caesareans in the calculation includes ALL caesareans (including those which have medical indications and therefore additional costs due to complications arising). NICE justify this by saying “good quality UK cost data for caesarean section performed solely on the basis of maternal request is not currently available as far as we are aware.” But what this means is that the quoted savings use the cost of caesareans where problems are ALREADY identified, they specifically do NOT use the actual cost of a planned caesarean where there is no medical indicator. Not only this but the savings statements assume that all women refused a maternal request caesarean will go on to have an intervention free birth where they leave the hospital the same day. Given the 50% intervention rate of UK vaginal births, this is highly unlikely.

“They [the PCTs] will find that the guidelines from NICE will shortly say the exact opposite and the PCTs need to take account of the research review that is coming out. The fact that PCTs use this figure, £800, as the cost difference between a natural birth and a planned caesarean does not take account of the fact that many births involve some form of intervention…the chances of achieving an £800 saving by putting more women into the natural birth scenario is unrealistic because actually a lot of women will not achieve a natural birth and so the costs will be much more similar to a planned caesarean.”

I was interviewed by BBC Tees as part of a debate on PCTs banning planned caesareans where there is no medical need (in at 1 hour 40 minutes).

“Women have the right to make an informed choice about they way they give birth…some women would rather plan a caesarean to avoid the risks associated with an emergency caesarean…The National Institute for Clincial Excellence (NICE) have clearly stated, and I quote ‘If a vaginal birth is still not an acceptable option to the woman, her request for a CS should be supported within the health system’.”

Such a recommendation by NICE follows an 18month assessment of research into the benefits and risks of caesarean birth. Assuming that the birth is planned for no earlier than 39 weeks these mothers are NOT requesting something which carries any greater risk to their baby than to those born vaginally at the same stage.

Interesting comments earlier in the programme from independent midwife Chris Warren and later by Pauline McDongagh-Hull Caesarean birth campaigner.

Pauline and I have separately contacted Dr Dixon (Chairman of the NHS Alliance) to discuss some of his material – in particular his implication that the UK still aims for the WHO 15% target rate, when it does not.

An interesting experience if somewhat frustrating. Why have a guest on if the celebrity Dr is going to hold forth and talk over you. You live and learn.

Thankfully I managed to make a few points, which will hopefully help a few more women ask more questions of themselves and their practitioners. Unfortunately the programme is no longer available on ITV Player but here are a few sound bites from the interview:

“Informed choice is something which needs to be at the very forefront of the discussion and women that are making it [a request] purely on a ‘lifestyle’ choice, that are not basing it on the risk assessment that they need to think about, are not the caesareans that I would advocate.”

When asked if celebrity caesareans have influenced more women to favour caesarean birth… “I am sure it has, the unfortunate thing is what we don’t know, when these women make these choices is what the actual reasons are…often it is made as a broadbrush statement that they are ‘too posh to push’ and what we don’t know is the underlying reasons that they have. It is a very complex set of issues that women face when making these decisions and it is not often ‘we want to do this, because we just want to do this’.”