Leigh East talking to BBC York – Caesarean ban

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.”

One Show – present inaccurate information on caesarean birth

Dr. Sarah Jarvis speaking on the One Show on Monday 22nd August made two inaccurate statements regarding:

1. the latest status of the NICE guideline on Caesarean Section regarding planning a caesarean in the absence of any medical need

2. the WHO recommendation of a 15% caesarean target rate

Firstly, the NICE guideline has been under review for the last 18 months. The new draft of the guideline, which is publically available, clearly states in 1.3 ‘Maternal Request Algorithm’ “Where there is no identifiable reason, discuss the overall benefits and risks of CS and vaginal birth. Facilitate a discussion with other members of the obstetric team…If a vaginal birth is still not an acceptable option to the woman, her request for a CS should be supported within the health service” (pg. 7 NICE 2011).

In this latest version NICE have validated women’s right to make informed decisions about their own births following clear advice from practitioners. In otherwords NICE recognise that there are many ‘grey’ areas where women have the right to make informed decisions in favour of a prophylactic caesarean over vaginal birth even in the absence of a identifiable medical need. If practitioners are going to talk about this issue then they should at least be up-to-date with the current status of the guidelines they are quoting.

Secondly, the 15% caesarean target rate that has been repeatedly quoted by the media and government for the last 25 years was also quoted to by Dr Jarvis. The WHO target was in fact retracted 2 years ago. WHO removed it from their ‘Monitoring Emergency Obstetric Care: A handbook’ because they finally admitted that there is “no empirical evidence for an optimum percentage”, an “optimum rate is unknown,” and world regions may now “set their own standards.” Not only this but England has NEVER formally stated that they subscribe to the target rate. Once again if practitioners are going to make these statements about caesareans on national television they should do so accurately.

The One Show reaches a significant audience and advisors appearing on the programme have a duty to present information correctly. I believe this is particularly important in the arena of healthcare where lives can be severely impacted by the decisions people take, often as a result of the ideas they have heard in the media. It is great that the One Show has professionals willing to give advice and comment on important issues, but it is imperative that these professionals represent the information accurately and fairly.

WHO retracted their 15% caesarean rate target!

In 2011 the Coalition for Childbirth Autonomy called for the retraction of the World Health Organisation’s recommendation that the caesarean rate should not exceed 15% suggesting that the small number of research papers on which this 1985 recommendation was based have been superceded by a number of large, contemporary studies of caesarean birth. In a subsequent press release by the CCA the WHO retraction was exposed. This was later reported in the press (BBC) (Medical News Today)

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

Despite this, this figure is still being widely quoted in the world press despite having NEVER been a recommended target. And some UK hospitals still refer to it when negotiating with families regarding elective caesareans. There is no ideal rate and alone cannot legitimately be used as an argument to refuse a request for a caesarean delivery.

Leigh East talking to BBC Tees – Caesarean Ban

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.

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.