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.

Leigh East talks on ITV’s Daybreak – Caesarean bans

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’.”

Leigh East interviewed by Sunday Times – Some PCTs ban planned caesareans

The Sunday Times reveal that a number of PCTs are now formally banning all planned caesareans that have no medical justication. (Linking to Daily Mail copy of the article because the Sunday Times is behind a subscription page).

As an advocate for informed choice I am disappointed PCTs are taking this huge step backwards in women’s birth rights all in the name of cost cutting. What is being forgotten is that the number of women falling into this category is not only incredibly small but that only a fraction of them, should they be made to have a vaginal birth instead, would achieve the totally natural birth. (e.g. no intervention of any sort and no over night stay) necessary to achieve the levels of cost savings being talked about. We know that over 50% of UK vaginal births currently involve intervention. The emotional trauma suffered by women forced to labour when they so clearly wanted a caesarean is akin to that experienced by many women wanting a vaginal birth but ending up with an emergency caesarean.

Attempting to save costs by banning all those planned caesareans where there are no recognised medical grounds totally fails to address the many, many reasons why women make these requests. It is certainly not all about ‘lifestyle’ for many of them and this ban removes the ability for women to make informed choices based on sound risk assessment.

‘Natural’ Caesareans

This wonderful video gives a thorough and sensitive description of a ‘natural’ caesarean. It is exactly the sort of thing that should be shown in all antenatal classes. Women should be told more about caesarean births not less. There seems to be a fear that by telling women more, more will choose a caesarean. I sincerely doubt that, but even were that the case, is this any reason to leave the majority of women in the dark given that 1 in 4 will experience one.

NICE update their caesarean guideline

NICE are updating their guidance on caesarean sections. The draft document has been reviewed by stakeholders (of which I am one) and a new version is due out in Septemer 2011.

At first glance the draft is a marked improvement on the previous version, particularly now that it includes assessment of maternal request caesareans, this following active lobbying by members of the CCA – of which I am a founding member. However there are still many gaps.

Of particular interest to me is how practitioners handle caesarean requests from women whose request does not fit in with any formally recognised medical reason. With regards tokophobia (fear of childbirth) improvements have been made – counselling is to continue to be available and now, where a woman continues to request a caesarean after this, her request should be granted. However, significant hurdles face those women who wish to discuss the possibility of a caesarean where the medical reasons are not clearcut or tokophobia cannot be proven. This is despite clear evidence that many requests originate from previous trauma and pregnancy complications.

The decision to request a caesarean is rarely taken lightly yet NICE currently continue to recommend that women undertake counselling. While balanced, comprehensive information and support during the decision-making process is of course crucial the guideline, as it currently stands in draft, implies that the role of this counselling is to change the minds of these women. It does not recognise that for some the most appropriate option is still a caesarean. These women will not be able to gain agreement for a caesarean till they near the end of their pregnancy, if at all. Resulting fear and distress may significantly impair their pregnancy experience, affect their emotional wellbeing and critically, in a small number of cases, may cause them to abort their baby.

The UK health service needs to be clearer in its recognition that women have the right to make informed decisions about the way they give birth. They need to be more prescriptive about the information that is provided to ensure that it is truly balanced, discussing the risks of both caesarean birth and vaginal birth. Failure to do so leaves many women poorly prepared for their birth creating extra unnecessary trauma for those unprepared for a caesarean outcome (after all, 1 in 4 will experience a caesarean – many in emergency situations) .

The NICE draft is a step in the right direction but there are still some major issues with it.