Positive Caesareans

For too long, healthcare providers have been concentrating on optimum caesarean rates, this despite the fact that nearly 10 years ago the World Health Organisation retracted their recommendations as there was “no empirical evidence for an optimum percentage”.

Now the Clinical Director for NHS England – Matthew Jolly – joined the fight by stating that caesarean rates should not have targets set as these can lead to “all sorts of unfortunate consequences.”

Attempting to artificially driving down the caesarean rate is dangerous. Over half the litigation costs in the NHS are still in obstetrics many of which relate to birth outcomes which could have been avoided if a woman’s concerns or wishes had been respected.

• 47% of maternity units set target rates
• 50%+ are graded on whether they encourage natural births

Cost is the major factor driving these targets and where cost is considered above a mother and/or baby’s safety, bad decision are going to be made and bad advice is going to be given to mothers.

NICE guidelines clearly state women should be able to make an informed choice about how they give birth. But targets like these are reducing options and we are regularly contacted by women at their wits end, wanting to know how they can challenge the advice given by their carers which they believe to be compromised.

But, is the tide turning? We are working with the Care Quality Commission to understand more about women’s caesarean experience, feeding into the development of this year’s Care survey. Watch this space to see whether such statements are actually reflecting a change in the behaviour of our Trusts.

Some women seem to be taking matters into their own hands when attempting to address the issue of whether or not a caesarean birth places babies at a disadvantage in the development of their microbiome (the colonisation of their gut with health bacteria).

In recent years there has been a lot of talk in the press linking caesarean born children with a higher incidence of obesity or asthma. Such media scaremongering is not helpful for those mothers whose medical situation has meant a caesarean has been a necessity and whose recovery has already been hampered by emotional trauma.

A recent study looking specifically at birth mode and a baby’s microbiome found there to be no lasting difference even as early as 4-8 weeks after birth, particularly if they are also breastfed. Chu 2017

Similarly, while some studies suggest there is a moderate risk of obesity in children born by caesarean, most fail to acknowldge that maternal BMI during pregnancy as well as maternal and paternal BMI post birth are also found to have an noticeable effect. A study attempting to evaluate a collection of studies on this issue still only found moderate risk and could not rule out the above confounding variables. Li 2013

And on the issue of asthma, studies are also contradictory and inconclusive, at best finding either no link, Maitra 2004, or include significant additional factors such as prematurity, maternal asthma, allergic parents, being born with respiratory difficulties etc. rendering the results unreliable. Debley 2005, Roduit 2008, Smith 2004

Despite this, the media continue to propogate such stories, despite the fact that even the research papers themselves rarely say anything more concrete than for example: “It could be that C-section physically prevents newborns from acquiring microbes they would during vaginal births”.

Instead women are putting their babies at risk through inadvertent exposure to dangerous STIs including HIV, chlamydia, herpes and gonorrhoea.

Dr Patrick O’Brien, from the Royal College of Obstetricians and Gynaecologists states: there is “no robust evidence” that vaginal seeding actually has any health benefits to a baby. And a colleague leading the review of studies looking at vaginal seeding, Dr Tine Dalsgaard Clausen, Consultant obstetrician at Nordsjaellands Hospital, Denmark adds “Currently, there is no evidence to show that the potential long-term benefits of vaginal seeding outweigh the risks or costs associated,…it’s important that healthcare professionals promote other factors that are known to improve a baby’s colony of bacteria, such as early skin-to-skin contact, breastfeeding and a healthy diet.”

Until there is robust evidence that this technique is both safe and effective, parents could be well advised to evaluate the megre information presented in media stories and review current research for themselves.

In 2011 the UK National Institution for Clinical Excellence (NICE) recommended that women be allowed to make a request for a caesarean delivery, even in the absence of any recognised medical need. Despite this, a recent Freedom on Information request submitted by the Daily Mail found that:

• 21/91 hospitals do not offer maternal request caesareans
• In four hospitals where Maternal request was supported, bosses rejected requests on cost grounds
• Several hospitals insist on mental health counselling prior to giving agreement for a caesarean (this is unfortunately a recommendation in the 2011 NICE guideline – completely failing to recognise a whole group of women who have made an informed choice to request a caesarean)
• Only four hospitals offer Maternal Request caesareans even though their Clinical Commissioning Group do not fund it

Kim Thomas, of the Birth Trauma Association, says in response to the findings: “Women usually have very good reasons for requesting a planned caesarean. Often they’ve already had one traumatic birth and want a less frightening experience next time round. Denying these women their request is cruel, and goes against Nice guidelines.”

Similarly, campaigner Pauline Hull, said: “Women are increasingly choosing a caesarean birth because they’ve decided it’s safer for their baby and safer for them. The maternal landscape has changed. Women are older, heavier, and having fewer babies; babies are heavier.”

Incredibly, Trusts are still using cost as justification for these rejections and define policies to drive down their overall caesarean rate. Trust managers are failing to join the dots…

The costs associated with a straightforward, uncomplicated planned caesarean are actually less than many medicalised vaginal births. This is because unless a vaginal birth is totally straightforward and natural (i.e. not involving any form of medical intervention or pain relief and Mum and baby leave hospital the same day), the costs immediately begin to creep up. Over 50% of UK births involve some form of intervention (NHS Information Centre statistics). In the USA, 67% of births involve anaesthetic, 30% of women are induced and 13% have an episiotomy (Listening to Mothers – USA). You can see how the cost arguement immediately starts to fall apart.

As far back as 2003, studies revealed that just adding induction using pitocin “nullified any cost differences; if epidural anaesthesia was also used, total costs exceed the cost of elective caesarean delivery by almost 10%. The cost of a failed attempt at vaginal delivery was much higher than elective caesarean delivery.” Bost 2003

“A culture of choice has been promoted in recent years, but contrary to the anticipated demand for less obstetric intervention by those promoting choice, there has been an increase in demand for delivery by caesarean section. With the balance in favour of benefit for the baby from delivery by caesarean section, it is now difficult to sustain the argument favouring vaginal delivery…A critical evaluation of costs indicates that there are probably few grounds for denying women their request for caesarean section for economic reasons”. Morrison 2003

And this is before you start looking at the cost to Trusts of longer term issues arising from vaginal birth. Studies reveal the long-term risk of stress urinary incontinence and pelvic organ prolapse surgery is significantly higher for women giving birth vaginally and of course there are significant costs associated with each repair work.

Come on hosptial pencil pushers – JOIN THE DOTS!

Flexibility is key!

You may have lots of ideas and preferences but they need to be just that – preferences.

“…have a plan A, have a plan B, go down to a plan G or K if you need to.” Elizabeth Duff (Senior Policy Advisor for the NCT)

In reality  no-one knows how things are really going to pan out on the day. Keeping preferences flexible ensures that the team looking after you have a good idea of the direction you hope your birth will go, but have the space to be able to suggest other things if it seems like the plan needs to change.

However, this is where your knowledge becomes most important.

For example: If you are hoping to avoid a caesarean, then it is useful to know that some hospitals place what can seem to be quite arbitrary timescales on 2nd stage labour. Knowing this you can ask very specific questions about your status before making a decision regarding drugs to speed up your labour.

Another example: If you know you want to hold your baby skin-to-skin while still in theatre, then it is important to specify this in your birth guide so your gown can be put on backwards and the screen positioned to make this possible. Both these things need to be agreed in advance. If it is your birth guide, the discussion cannot be forgotten.

Know your facts and if in doubt always ask more questions.

A google search will generate a list of lots websites discussing vaginal birth plans. Caesarean plans are a little more tricky to find, but not impossible and in ‘Caesarean Birth: A positive Approach to Preparation and Recovery’ there is a whole section dedicated to the issue of ‘Birth Guides’, including: possible content, structure and key things to think about.