why the drive to reduce cs rates in nhs trusts?

(340 Posts)
cakebaby Tue 19-Feb-13 08:28:38

Hello ladies
Long time shadow dweller, after 12 week scan its definitely a real baby and not just cake, so I've ventured into the light.
l'm 39 & have had to delay pregnancy for a number of reasons, one of them being a total horror of all things birth related. I have no idea where this has come from & cannot rationalise it. I hate hospitals & have to visit them fairly regularly for work. I get light headed, sweaty, spots before eyes, the works. I suspect this is related to my mothers slow death in hospital when I was in my teens.

At my booking in appt the MW briefly mentioned the b word & gave some options like hospital, birthing unit, home birth, completely ignoring elcs. My pack from the MW with hospital leaflet also completely ignores elcs but states they are proud to be reducing the cs rate. She laughed off talk of an elcs as if I was bonkers and gave the old line 'women have been giving birth for millions of years.... body designed for it' blah...
This was not a great start for me, in one sentence she has compounded my suspicion I will not be in control of my body and what happens to me when it comes to birth, that I won't be listened to or have any say in things. This is not just about requesting an elcs, but about being treated with respect & being listened to.

So, why are NHS trusts so keen to reduce the number of cs, to the point of seemingly aggressively campaigning against them or at least cheerfully ignoring the possibility of one?
Sorry for long post, this is causing me increasing anxiety already.

blueshoes Fri 22-Feb-13 11:14:13

Wise posts from Sioda, Herethere and cakebaby.

If I were to give birth on the NHS today, I would opt for an elcs simply because midwide-led maternity services on the NHS are understaffed and can be substandard. The hospital I gave birth to ds at was in the news today for having turned away a labouring mother. That same scenario was played out when I was there 6 years ago. However, because I opted for an elcs, the hospital had to give me a fully staffed theatre to perform my elcs. My elcs birth was absolutely uneventful whilst unbeknownst around me, women were being turned away from the hospital and those that were there were giving birth (not just labouring) 4 in one screened off room.

Until the NHS properly supports women who go in for a natural birth, I would be absolutely selfish and put my safety and the baby’s foremost. I got the option of an elcs because my first was an emcs. Generally speaking, an elcs is the safest for baby but more risky for the mother. I see it as taking the risk onto myself, and paying a small premium as insurance for a more certain result. Natural birth can work wonderfully for mother and baby but when it goes wrong, can be highly unpredictable and escalate quickly with grave consequences. In terms of the hierarchy of risk, emcs is the most risky. So rather than take the risk of a natural birth going wrong and ending up as an emcs, an elcs is a more predictable outcome.

If you are not planning a big family, elcs is a choice worth considering.

I don’t understand the need to address any fears of natural childbirth. Men don’t have to. I don’t see why it is inevitable I have to push a baby out of my vagina just because women since time immemorial have been doing so (and many dying or permanently injured the process). If you can have an elcs and you have made an informed decision about the risks, it is a nice place to be.

HotSoupDumpling Fri 22-Feb-13 11:49:41

Just wanted to thank the OP for starting the thread, and for the contributions. Found it very useful as I'm currently a few weeks away from possibly asking (at my booking appmt) to see a consultant to request an ELCS. From what my unsupportive GP says, the answer will be a resounding no, despite any decision I may have come to myself.

I find the NHS approach to ELCS really inconsistent with the fact that in so many other circumstances, NHS policy gives individuals or their families the freedom to choose treatment options despite different risks and costs (e.g. the decision to operate on cancer, to start certain drug treatments, to keep someone's life support on for a couple more days or not... etc).

I don't believe ELCS is necessarily the best option for everyone, but I do feel that the balance of costs and risks is not so one-sided that an ELCS should be denied to someone who requests one. We, as a society, should to be heading in a direction where women can (within reason) choose what risks they take for their body and for their unborn babies.

Posterofapombear Fri 22-Feb-13 12:03:28

I think you maybe haven't considered some of the realities of an ELCS particularly in relation to control.

Do you know how many people will need to be in the room for it? Have you thought about the catheter after?
Do you have a mega supportive DH who you are happy to let deal with baby?

Control and medicine really don't go hand in hand whatever your choice.

HotSoupDumpling Fri 22-Feb-13 12:18:46

Pombear, I agree with you that the realities of an ELCS can sometimes be awful. As can the realities of a vaginal birth. Statistics feel meaningless if any of the risks actually happen.

I agree that the factors you mention should be taken into consideration when deciding. And that for some women, they will be factors that make them want to plan a vaginal birth.

I also agree that childbirth necessarily means you won't have control over a lot of things that happen to you. It is true that the freedom to decide how you intend to give birth doesn't mean that you can choose how you actually, in real life, end up giving birth (e.g. someone who plans a vaginal birth might end up with an EMCS or someone who plans to have an ELCS might not get to the the hospital in time, for example).

However, giving women the freedom to 'plan' to have an ELCS (after considering the risks, including the factors you mentioned) as well as to 'plan' a vaginal birth, doesn't mean that they don't understand that it is ultimately out of their control. Perhaps they have just looked at all the risks and decided that personally speaking they prefer the risks of planning an ELCS over planning a vaginal birth. Regardless of the fact that anything might happen in the end.

Sioda Fri 22-Feb-13 12:22:46

HotSoup It's because we're women, pregnant ones to make it worse. Medicine reserves a special variety of patronising for us . It's strange because many of us don't really come across much sexism until we get pregnant so we get a bit shocked to be treated like children all of a sudden. Some people find playing up to that and going for the anxiety angle- i.e. breaking down in tears at appointment - works, others find playing the 'I'm rational honest...' card works best - i.e. being able to show you understand the risks and benefits. You could try chopping and changing once you suss out what kind of consultant you seem to have. With either option though it's good to bring your DP if you have one/can who will be assertive and back you up. They find it harder to write them off as hysterical wimmins and their role is crucial if you go for the mental health meltdowny angle.

Unfortunately the public have all kinds of daft beliefs that mean we're nowhere near there being enough public pressure for women to be given choice in childbirth. It's a messy mix of sexism, misogyny, misunderstandings of evolution, the natural fallacy, the natural birth lobby as well as simple lack of knowledge about ELCS vs. VB today. Most people believe myths that originate from EMCS experiences, or experiences 20 years ago, or lobbies like the NCT, or they assume they must at least cost way more as that sounds like common sense. So don't hold your breath for change. But do talk to people about your decision and why you're making it. That's how change eventually happens. Good luck!

RedToothBrush Fri 22-Feb-13 13:11:50

Posterofapombear Fri 22-Feb-13 12:03:28
I think you maybe haven't considered some of the realities of an ELCS particularly in relation to control.

Thats an incredibly patronising view. You are never going to be in control completely, but there are plenty of factors that you do have a choice about and may be more important to you than others.

If you are intelligent enough to research a VB birth and all that involves, why don't you think women are capable of researching what is involved in an ELCS?

blueshoes Fri 22-Feb-13 13:46:55

There is a wide middle space between control freaks and go-with-the-flow earth mothers. I agree with redtooth that nobody expects total control, even elcs sympathisers like myself. There is a world of difference between medics putting in a pre-op catheter and someone sticking forceps into my fanjo whilst I convulse. We can make informed choices even in an environment that is not within our total control.

LeBFG Fri 22-Feb-13 14:20:23

But OP has admitted to a need of control. I would personally feel very vulnerable being at the mercy of some surgeon instead of in control of my own body. It's just a different take on the control aspect. OP has dwelt a lot on the lack of control in VBs and perhaps it would do some good to think about the alternative. Neither one or the other on paper will meet the ideal (does it for anyone?) but hopefully, whatever OP decides, she will be treated with respect and get something close to what she decides she wants.

HotSoupDumpling Fri 22-Feb-13 14:51:13

As you say, BFG, every person feels differently, and control has many aspects. Only the OP can know what type and level of control she wants over her birth. And it's great that we on MN can discuss such concepts, and during such discussion we can spend time thinking about what we personally would prefer.

One point, surely, is that NHS policy makes such discussion and thought effectively meaningless. After all, what's the point of brainstorming the personal pros/cons of ELCS v VB when NHS policy is (except in certain circumstances) not to give women the choice between them? The policy after all is that all women have the right to request an ELCS but not to receive one. So sometimes a woman may fall within the NHS's narrow categories of who gets an ELCS, sometimes she will be lucky to have a consultant sympathetic to her right to choose, but most times it appears that in answer to her request (or indeed to any tentative mention of an ELCS) she will encounter a stubborn refusal among healthcare professionals to take her fears seriously and discuss risks in a neutral way to allow her to make her decision herself.

I'm being really 'pontificatey' today, and I'm sorry for over-posting, but two lines of OP's made me really feel for her and resonated with me too:

This is not just about requesting an elcs, but about being treated with respect & being listened to.

So, why are NHS trusts so keen to reduce the number of cs, to the point of seemingly aggressively campaigning against them or at least cheerfully ignoring the possibility of one?

Sioda Fri 22-Feb-13 15:13:38

BFG you're setting up a false dichotomy. You do not have control over your body if you have a VB. You don't control your baby's position, whether and how quickly your cervix dilates, how effective your contractions are, whether your baby gets into distress or not etc. There may be things you can do to influence that process - which might or might not be effective- but ultimately you do not have control over them. Nor do you really have control over whether you end up with an instrumental birth or EMCS. You can of course always refuse but the reality is that if the medical professionals tell you your baby absolutely needs them to survive then you'll almost certainly consent. And then you're in the instruments/surgery scenario where you're completely in the hands of the medics. That's a risk you always run when you plan a VB. Because you can't actually choose a straightforward VB, you can only plan one. I preferred to hand over complete control to surgeons (and a little of course to luck...) than to hand most of it to Mother Nature/luck/midwives/and/or surgeons.

LeBFG Fri 22-Feb-13 15:30:01

You do have more control in a VB than you're making out Sioda - lying down to push rather than squatting for instance can make a huge difference. But point taken that there are many more variables in a VB than a CS. I thought it might help OP to consider that there is also some loss of personal control in a CS (as in any surgical procedure). I'm not trying to disuade her from anything, far from it. I, too, believe that if she is given the right to choose, she should be able to make that choice and be supported by the HCPs rather than patronised/ridiculed.

Sioda Fri 22-Feb-13 15:43:35

In a VB that ends in an EMCS no you don't have more control. And how much effect that kind of active birth stuff has is debatable BFG. Anyway we basically agree on the fundamental issue of choice. I guess the OP needs to consider her issues about control in detail to be prepared for any scenario because one certain thing about any birth is unpredictability.

Interesting thread for me as I too delayed pregnancy to 39 due in part to a horror of child birth. I'm due next week and strangely have gone from being terrified (in early pregnancy) to really quite calm about it. The health visitor says this is largely down to hormones and not unusual. So OP, don't assume that you still feel fearful in a few month's time.

My preference (assuming no complications) is VB, as I have heard some fairly horrifying ELCS stories which balance out the VB stories. It seems to me that things can go wrong either way, and there is no guarantee. One friend got MRSA in her CS wound.

LeBFG Fri 22-Feb-13 15:49:16

I think we're arguing at cross purposes a bit: I'm comparing an uneventful VB with ELCS and you are comparing EMCS with an ELCS. However, I wholeheartedly agree with your last point smile - I don't think we're that far apart.

Sioda Fri 22-Feb-13 16:05:21

Agreed BFG, although I think comparison of planned rather than actual mode of birth is the only relevant one.

OP please don't base your decision on stories you hear as you and worcester describe. Anecdotes are a bad basis for any decision. There is research and statistics and professional advice you can base it on instead.

BeCool Fri 22-Feb-13 16:11:33

cakebaby I have no opinion on ECS that hasn't already been covered.

However I was very anxious during my first PG (for non PG reasons) and I had hypnotherapy recommended to me. This led me to self hypnotherapy/relaxation for the birth which I used and was great for me, though not everyone's cup of tea.

You sound incredibly anxious, and you might find hypnotherapy sessions a really useful tool in enabling you to reduce your anxiety levels re the birth process.

BecAndAlex Fri 22-Feb-13 16:18:04

There is some great advice on here and glad that you are still looking into your options.

I hope you come to a decision you are happy with and get the support you need.

I have 2 children and they were both by c-section. DS was EMCS and DD was ELCS. I recovered pysically from both sections fine, but found the EMCS very hard mentally. Both my children were healthy although DS did end up in SCBU for a short time due to his delivery. This led to me opting for an ELCS 2nd time round. I was nervous that I had made the wrong decision as a c-section is major surgery and there are risks, but ultimately I wanted my baby here safely. My ELCS was fantastic. Calm painless and completely unregrettable. Its hard afterwards as you can't get out of bed to see to your baby and need to rely on midwives to help, but its a small price to pay. I recovered very quickly and was mentally stronger 2nd time round. I had stopped my pain killers after 5 days too. Sometimes C-Sections can be very positive.

Equally unlike yourself, I'm the only one of my friends that have had sections. They have all had very sucessful and uneventful VB(we have 9 children between us). Shut yourself off from other peoples birth stories and focus on your own needs, worries and thoughts. Labour is unpredictable, and no two experiences are the same.

good luck

Shagmundfreud Fri 22-Feb-13 17:12:22

OP -There is a pretty strong case that good, evidence based care reduces the number of emergency c/s. And this is something everyone wants. It really is unnecessary nationally for so many healthy women to be having emergency surgery.

I would never book to have my baby at a hospital with a very high emergency c/s rate if I could possibly help it.

As for not being listened to - I understand what that feels like. It was the reason I booked with a private midwife for my second and third baby. It was worth every penny to know that she was completely on my side.

cakebaby Sat 23-Feb-13 10:42:00

I've been off line for a few days and am stunned to read all the contributions to the thread! Thank you all for your thoughts, very interesting indeed. I have to clarify some points though, my control issues surround being trapped in a 4 day labour, desperate for an alternative, epidural, cs, whatever and being refused, fobbed off etc. I can't exactly throw a hissy fit and walk out to use an alternative service provider, can I? I don't want to be forced into an instrument delivery due to circumstances. I KNOW you cannot legislate for all eventualities, I'm just trying to figure out these best thing for me.
I am still working through the decision process and will continue to do so.

At present, in terms of control and controlled environment, a few planned hours in theatre, surrounded by professionals seems a far more attractive option than an unpredictable labour of undetermined length with no guarantee of staff availability on an understaffed, over crowded unit. Please don't have a meltdown at the way I have described elcs above, it may sound flippant, it's not meant to.

I acknowledge the risks to my health, difficulty post procedure, recovery time. I have no other dc's, fab dh who has done this before (slight grrr) and has 3 weeks off with me, 2 sets of grandparents within 3 miles and am not planning any more dc's.

The child I refer to in my original post is my step grandson, do this topic is an extremely emotive one for me & dh, seeing first hand the life changing effects of supposedly straightforward, natural vb that women have been achieving for millions.....yawn....

I will come to the right decision for me, everyone is different and what is right for me will not necessarily meet others approval. I champion our right to choose and be heard, I may not agree with others views or decisions, but would fight those rights too regardless.

herethereandeverywhere Sat 23-Feb-13 20:56:02

Completely legitimate concerns very well explained Cakebaby. I'd be happy to share more info on my experience of getting an ELCS (albeit for my second birth), if interested, PM me. I loved my ELCS and the wonderful memories it's given me and DH. My 1st birth was traumatic for most of the reasons you fear, although poor staffing and lack of resource wasn't a problem for me.

redplasticspoon Mon 25-Feb-13 22:09:57

Cake baby have you thought about getting talking therapy? It sounds like you have quite a lot of anxiety, and having a cs, even if it is granted, may not be the experience you expect.

rainrainandmorerain Tue 26-Feb-13 22:07:50

Cs rates are a very blunt instrument for measuring maternity care.

On the one hand, where women have poor support during labour (busy mws, lack of continuity of care, etc etc) then the emergency cs rate will be higher than one might reasonably expect. You will get a lot of women who probably didn't need and certainly didn't want emcs's having them.

However - trying to force cs rates down without improving care is beyond stupid. Vaginal birth at any cost means denying those women who DO have good reason for having an elcs one (e.g. primary/secondary birth phobia) - or simply increasing the rate of potentially damaging instrumental vaginal birth rates instead.

Cultural attitude towards cs has a lot to answer for too. I could fill a book with it all - but you can see on pretty much every thread here. CS is often discussed simultaneously as appalling surgery AND as somehow an easy option, or not 'doing it properly'. There are drives to get cs rates down, but not instrumental vaginal births, even though they are expensive and can leave women and babies with severe injuries.

Then the media contribute with a whole load of guff, including telling us we can all have cs 'on demand' now (not true). And the icing on the cake is the nhs post code lottery - you might get great mw care, awful mw care, a pro-vb and vbac hospital, a staunchly anti-cs consultant....

It's all insane. I got lucky with my mws and hcps. I had a much wanted elcs for my first, and will be having another for my 2nd. I am deeply grateful for the care I've had - but it's luck of the draw, frankly.

Ushy Tue 26-Feb-13 23:37:28

Here here rain

redplasticspoon "Cake baby have you thought about getting talking therapy? It sounds like you have quite a lot of anxiety, and having a cs, even if it is granted, may not be the experience you expect."

I know you meant this well but there is a woman on another thread who had multiple risk factors and wanted a home birth. She was getting lots of support and 'go for its' from everyone. No-one suggested that she get help to overcome her anxiety about hospital.

This always happens - women who want c/s are sent for counselling - women who want homebirth despite having risk factors are encouraged.

It is totally bizarre - especially as, from the baby's point of view, the c/s is the safer since it avoids the risk of instrumental delivery and oxygen starvation. Yet it is the caesarean mums who are smeared as 'too posh too push' and selfish.

As rain said, it's all insane.

KatieMiddleton Tue 26-Feb-13 23:59:39

Do you know op I think you are the first person I've read who has summed up most of the risks of birth who hasn't got to the stage of antenatal classes and consultant chats. Very refreshing.

I am also the kind of person who does not deal well with not being in control. This has led to some issues in the past with both my pregnancies. It's only with hindsight I can piece this together but hindsight also shows my labour and birth prep was worth it.

I think where c-sections rates are very high questions need to be asked because the rate on its own doesn't mean much. It's the reasons why those c-sections happened that count. Maternal age and health make a huge difference to birth outcomes, as does poor practice and care (eg leaving a terrified woman on her own and in pain is not going to help her delivery unlike having good care and support and appropriate pain relief).

I think all women deserve respect during labour and birth and to feel listened to. There are other options to c-section but equally op c-section may be the option for you, so investigating lots of options is not going to hurt.

It might be worth exploring doulas, independent midwives, home birth, hypnobirthing and c-section as options (not all of those are things I would go for but an open mind's important).

Feel empowered to choose the birth you want. Get empowered by doing your research and controlling the decision. I did although I chose home birth and I had the right labour and birth for me and my baby.

And then accept you can't control a baby!!

KatieMiddleton Wed 27-Feb-13 00:03:49

By the by, just about every person who learns I had a home birth looks at me like I'm bonkers. I'm not (well not when it comes to birth!) because I made an evidenced based decision but there's stigma everywhere whatever you choose.

So forget the stigmas and make your own evidenced based decision and let the detractors stew in their outraged ire grin

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