New guidance to reduce epidurals and to achieve a CS target rate of 20%

[HmmThinkingAboutIt]

New guidance to reduce epidurals and to achieve a CS target rate of 20% is apparently being issued by the RCM, RCOG and the NCT.

I'm try to find the original source to be able to read exactly what is proposed, but this is my source at the moment (its a pdf) www.electivecesarean.com/images12-aug-24%20rcog%20ccg%20press%20release%20final.pdf

On the face of it, I'm utterly appalled by this. It seems to be in direct opposition to what NICE, NHSLA and others are saying. And the trouble with targets is they completely neglect individual care, and create a conflict of interests for doctors & midwifes - and ultimately put woman last.

Has anyone else heard about this/got a better source to confirm EXACTLY whats been said before I get too upset about it?

I'm damn sure this is going to upset a few people here...

Well, yes. I don't have any better sources, but from this summary....?

It is woman hating vicious nonsense that is TOTALLY dismissive of women, their experiences, their preferences and their right to voice them.

Must have been written by misogynist DM staffers on a day off.

Ok found original source here

It doesn't read as bad as that link, but I do have grave concerns about the implications of the document.

Certainly, targets for CS alarm me.

I am appalled by this - there have been enough posts about women being denied epidurals and this will make it worse.

The target to reduce caesareans is going to result in them delaying some women (probably the less articulate ones with no partner to advocate for them) ..and you know what - it will be more dead babies.

But never mind .. who cares about dead babies - we are 'achieving' more 'normal' births..ARGGGGGHH!

Exactly whose side is the NCT on? It's sure not mine.

Hmm I have just had a look at the original link and I think it is just as bad.

Item 6 says it is important to increase the number of women giving birth without epidural.

You can do that in only one way - exactly how they do it now. When a woman asks for one the midwife says 'too early' followed by 'too late' or 'the anaesthetist is doing caesareans continuously for the next three weeks so no chance' or 'do you really want to be paralysed'

wheres you are right - pure mysogyny

Glad its not just me over reacting about it then.

The other really telling thing I noticed was the midwife led care being the default option for low risk women. And yet the place of birth study said that for a lot of women, even low risk women, felt uncomfortable with this. They needed the reassurance of a CLU. I can't help feel that this is counter productive in some ways; if a woman is anxious being in a MLU then if hormones have that much of an influence on birth experience (which they do) then in some cases women are going to have a worse experience as a direct result?

Women have to be at the centre of care, and every time you put targets in like this, I think it looses sight of that and put pressure on HCP to exert influence to make women behave in the 'correct' fashion not to do what is best for them. That is coercive.

There may be too many CS being carried out unnecessarily, but I do feel strongly that the way to prevent that is not to set a target. If you want to persuade women that MLU are better then do that through education so they make a free choice not by changing the system so it makes it difficult for women who do want a CLU. Same goes for epidurals.

The whole thing only serves to undermine confidence in HCP. Which is an enormous issue and one that is actually a driving force in causing problems in maternity. It creates anxiety and it breaks the trust thats essential.

Well said Hmm

You are right about targets. Once you set targets, the target becomes the focus not the woman and baby.

I think this is one of the most shocking documents I have seen.

Mysogynist dangerous rubbish that will lead to more women having dead babies and being traumatised

How would you go about protesting about this? It almosts makes me want to chain myself to the railings

I don't know Ushy. Support the Birth Trauma Association? Write to people? Talk about it on here? (Which is my approach). Try and get other people to simply think about things in a different way and question things more?

Good ideas Hmm I am going to send a letter to my MP as well.

If a male doctor went on TV or radio and said he planned to reduce epidurals he would probably need police protection.

But the midwives and NCT get away with it. I think people don't associate these dry boring documents with what is going to happen in practice. viz.

If they are climbing the wall in agony and begging for an epidural they are going to have to be 'encouraged' to do without. Women are vulnerable in labour and can't argue forcibly - they will just collapse into silence and be traumatised.

There are countless posts on MN where women have been in this position and it has affected them for months if not years after the birth.

Theres a few things that bother me most

The document is PURELY about maternity care at point of birth. I noted that the costs listed in it, unlike the NICE guidance on CS DO NOT include any interest in downstream costs or care. Which I do feel is a massive failing. It is therefore just about short term costs not long term costs and care.

And yet the very first paragraph reads:
Maternity services have often been called the NHS? shop window. Whether or not a new family has a positive experience of pregnancy and childbirth will colour their future use and interaction with health services.

If you take into consideration the number of posts on MN and how many women feel unable to say anything at the time, you start to realise, just how much comes after the fact and it takes a while for women to take in everything thats happened.

By failing to consider longer term complications aren't they just completely contradicting themselves if they make decisions on finance on a maternity department basis only? And missing a very important part of the puzzle... both in terms of finances, but also about trust and satisfaction with care.

I find the wording really bothers me in places. Its too paternalistic and too much about influencing women to make a 'good' choice.

"GPs have a strong influence over their patients? choices and can help them make good decisions about where and how they want to give birth, if they are informed about local options."

"Women must receive consistent, positive information and advice from their health professionals if they are to have confidence in a normal birth."

"If a trusted GP advices a low risk woman that her care pathway will be midwife led, or suggests to a woman after a caesarean section that VBAC is a good option to explore, she is likely to be more confident about achieving a normal birth outcome."

So what happens to giving full UNBIASED information? Shouldn't Health Professionals give FULL advice which includes information about problems and the full range of alternatives depending on their circumstances?

There is informed consent before giving treatment, but not the other way round - you don't get informed if treatment is withheld or not discussed. But that means you could already on course for treatment that you may need to consent to...

Which to my mind goes against the "no decision about me, without me" and just generally women's rights. The focus is more about getting women to almost comply with the wishes of the HCP rather than be free to make properly informed decisions of her own with out this judgement of 'good/bad'.

At best I find it patronising. At worst... well yeah coercive and about factory production and compliance.

Lastly, if one to one care improves outcomes and satisfaction, why the need to have a target at all? Especially when one to one care isn't available everywhere. The problem is that this will never be taken into account and places where it isn't available will still be expected to match those that do with their targets.

At whose expense?

Hmm At whose expense?

Women's, babies and their familes.

Every word you say is true. It is appalling

Why aren't MNers reacting more?

All about the ££££

This makes me glad I've never done any NCT stuff. I wouldn't want to be paying this organisation for anything; they do not represent women well with these statements IMO.

Why is it that "normal" birth excludes caesareans and epidurals but includes forceps and ventouse? Do women think forceps and ventouse are normal? They do not get the best outcomes so why on earth is it desirable to increase them?

I don't think you are overreacting. I think this is very mysogynistic too and totally ignores any preferences or concerns of the woman herself. I'm quite surprised RCOG are signed up to this. I will tell my consultant what I think about it next week! I am very high risk (previous fulminating pre-eclampsia at 26 weeks which killed my daughter and almost me too) so I know most of this doesn't apply to me and I am confident I will get the repeat CS I want ... but that is besides the point.

NICE guidelines would have been produced with significant input from health economists who are trained to explicitly value women's preferences (I am married to one). No-one from these three organisations involved in this document has placed any such value on these preferences. The language is all about influencing and persuading rather than listening, sharing or collaborating. I guess its a reaction against the NICE guidelines, particularly from the RCM?

Jules I thought you must have read it wrong about forceps but no.. you are completely right. They actually say they want to increase vaginal birth including forceps.

WTF? What planet are they on? Given a choice between forceps and elective c/s quite a few of us would like to be involved in the decision since it is our bodies that can get wrecked.

RCM NCT RCOG have lost all credibility with this.

The problem here is that the targets (to reduce CS to 20%) are about process not outcomes. Targets to improve outcomes (e.g. redcing maternity, neonatal mortality and stillbirth; reducing complication rates) I think are great. Targets to affect process (reducing CS) with no evidence that this would improve outcomes are at best distractions (and at worst dangerous)

Thank you Hmm for these links.
I have read them both carefully, and am almost speechless with anger at the condescension.

I read in one of the articles that the RCM lobbied a few years ago for a £500 fee for so-called "unnecessary" epidurals. Who are they to judge whether a woman is in unbearable pain? It's too subjective for such arbitrary targets to be imposed from above by faceless idealogues.

On a lighter note, before I explode with rage here is an article from the Daily Mash:

Sorry - I will redo that link:

www.thedailymash.co.uk/news/health/women-to-force-hat-stand-into-anus-of-male-midwife-200907131899

Why such an arbitrary figure (20%) without looking at why it's higher? And if it's "just" maternal request (which personally I believe is just as valid as any other choice, but that might be another thread!) then why are more women requesting sections? Or are there more sections because the hospitals are fucking up the 'normal' birth for so many women, e.g. lack of staff/1-1 care/etc? This needs to be explored before setting any target, if they're still hell-bent on target setting. :(

Far from thinking you are over reacting. This terrifies me. Ds had shoulder dystocia at birth. I came off a bit worse for wear but have thankfully healed ok. The tear consultant said I could have a cs if that's what I wanted if we were to have any more. If that cs was no longer a guarantee I am not sure I could go through it again.

Only You're right it is terrifying. What is the point of NICE saying that women wiht fear of childbirth or after previous traumatic birth should be able to have caesarean if the NCT , Royal College of Obstetricians and the RCM are using the backdoor to tell them something different.

It will result in more dead babies and women with 4th degree tears.

Yes...terrifying

God, this makes me feel quite sick.

I'm tempted to link to this in AIBU to get a big of a wider audience given the nature of what they are saying...

What do people think?

One of the most distasteful aspects is the Soviet-style idea that women who follow the RCM guidelines are making "good" decisions.
I agree it's the midwives fighting back after NICE relaxed its guidelines on c-secs.
I'm sorry to see the RCOG are also involved. Some obstetricians seem to feel that their skills and professional judgement (and ego?) are more important than maternal choice.

Here's an article from the BMJ in 1999, in which various doctors discuss Queen Charlotte's obstetrician Sara Paterson-Brown's support for c-sec as a maternal birth choice
"...[c-sec on maternal request] consigns the obstetrician to being little more than a technician in the matter. Our patients expect and professional standards require more of us than that."
ukpmc.ac.uk/articles/PMC1114580/

It troubles me whenever targets are used for healthcare procedures. I don't care if the CS rate is 50% or 5%. What is important is that women are getting the care they need when delivering a baby. It is up to the medical team to decide if a CS is needed or not.

Oh and if women are to be denied epidurals, lets set a goal for men having a colonoscopy. No men are going to be allowed to have any pain relief, anti nausea or sedatives for the procedure. After all, if women can push out a 9lb+ baby without pain relief then men shouldn't have a problem with a small tube being inserted into their intestine.

More disgusting misogyny from the Natural Birth ideologues ably supported by the bean counters (who can't even count apparently - see NICE's calculations on CS v. VB referred to above). One thing ppl can do is use the contact email facility on the 3 organisations websites to let them have a piece of your mind. It'll be ignored and dismissed of course but getting some rage off your chest helps I find. Plus it might at least annoy them (my comments certainly will....) which is the least they deserve.

Then you could look up the organisations who supported Pauline Hull's press release as well as her own elective caesarean blog and support them in whatever way you can. There need to be alternative organisations who can take on the NCT and they need to be able to show they represent the views of a significant community if they're to have an impact at policy level. You could also pass on the press release to anyone you know who might report on it. You could send links to ppl or facebook post on this article:

skepticalob.blogspot.com/2012/08/new-document-on-british-maternity.html

And you could complain to your own obstetrician and/or midwife about it. They are responsible for the behaviour of their representative organisations whether they personally agree with them or not. Out of ideas after that.

It might be worth posting about this in Feminism and Women's Rights, on here - it won't get a lot of traffic but it should be informed and useful comment - AIBU is often full of people looking for a fight, which I don't tend to think helps anything serious.

I've been thinking about this, and I am just stunned and furious. When being advised to choose a MW led unit, will first time mothers be told about the rate of first timers who transfer because of a need for epidural relief? Will they be advised about the time it will take to be blue lighted to a hospital (consultant led) environment where that can happen? And by the way, how much does that cost, if they want to make childbirth as cheap as possible?

What is this guesstimate of a universal 20 percent Cs rate based on? The WHO had good reason for abandoning their prescriptive rate. It was meaningless. Given that CS rate (which is very much an EMCS rate, let's remember) varies so much from hospital to hospital, depending on the demographic for the area served by the hospital (older mothers typically needing more Csections), the stupidity of such a blunt instrument is breathtaking.

Let's face it - why do people 'need? anaesthesia of any kind? The experience of pain iteself doesn't kill you. A broken leg will heal whether or not you take painkillers. Everything from dental surgery to having gallstones cut out or a limb amputated can happen without anaesthesia (although you may have to tie the patient down to carry out the procedure).

So let's do away with anaesthesia altogether. After all, the pain from a broken leg is a GOOD pain, isn't it? It lets you know that each day, with every painful moment, you are getting closer to the bone being mended. If you are in agony, you'll be sure not to use that leg, either, so the rest will be beneficial.

You see, if you overlook the notion that extreme pain can be dehumanising, traumatising and cause severe mental and emotional suffering, then getting rid of epidurals, and all other anaesthesia, makes total sense. Cheaper, isn't it? And that's what matters.