EU law on woman's rights during birth

(152 Posts)
cantreachmytoes Mon 17-Dec-12 12:25:49

One World Birth

A film has been made about women's rights to choose the type of birth they want - hospital, home, midwife centre, whatever(!) - and their right to privacy during it, based on an EU law passed following a case brought by a Hungarian woman.

It features the UK, US, Chinese, Aussie presidents of their respective colleges of midwives, as well as human rights lawyers and others.

This is the abridged version (15 mins), the original is 1 hr.

RedToothbrush Mon 17-Dec-12 14:23:27

Given who some of the people who are in the introduction to this piece of work, and their own ideological and vested interest in promoting 'natural' birth over birth choice and some of the things they have said publicly, I've very torn over this. There is a distinct whiff of hypocrisy and opportunism from some, which I find extremely distasteful.

That said the films core does seem to be very positive and the implications of Ternovszky v. Hungary in the court of European Court Human Rights which I hadn't heard of before are brilliant and I'd go as far as saying every woman should know about it, especially if they are facing problems getting a homebirth or indeed getting an ELCS if thats what they choose.

To give people an idea of what the film is about - the ruling of the EUCHR:
^ "is a fundamental principle underlying the interpretation of the guarantees of Article 8 (cf. Pretty, loc. cit.). Therefore the right concerning the decision to become a parent includes the right of choosing the circumstances of becoming a parent. The Court is satisfied that the circumstances of giving birth incontestably form part of one's private life for the purposes of this provision [...]".^

Thats not the entire story as having a bit of a read around the subject, it does seem that actually the situation is a little more complex and there are other rulings which mean that a woman doesn't have a 'right' to choose how she gives birth:

The European Court has ruled a number of times that “the Convention does not guarantee as such a right to free medical care or to specific medical services” (RR v Poland (App No 27617/04)). It has also said that the state’s margin of appreciation is greater when assessing priorities in the allocation of scarce public resources (Sentges v Netherlands (App No 27677/02)).

But given that theres been recent studies in the UK that have put the cost of homebirths as being cheaper than MLU and CLU and that NICE stated in their recent guidelines on CSection that the cost of ELCS were exceptionally difficult to assess and when factoring the long term effects of incontinence alone - and not exploring other issues or factors - stated that the difference was negligible and should not be used as an argument against an ELCS, I'd have to say that theres really a case to be made here, in the event someone had the unfortunate need to or simply the balls to challenge it legally.

Interesting and thought provoking despite some of the individuals who did contribute to the film.

Shagmundfreud Wed 19-Dec-12 10:27:41

"and their own ideological and vested interest in promoting 'natural' birth over birth choice"

What - you mean people like Ina May Gaskin and Michel Odent make it difficult for women to choose a hospital birth?

What rubbish! Do you have any evidence at all that the natural birth advocates in this film have campaigned or argued for a restriction of the right to a hospital birth?

Shagmundfreud Wed 19-Dec-12 10:33:34

Should add - when the normal birth rate has dipped nationally to under half of all births, and where there are HUGE variations in intervention rates between hospitals that can't be explained away by demographics, it's an absolute distortion of the situation to suggest that those who are seeking change in maternity care which they believe would result in an increase the rate of normal physiological birth, are somehow behaving unethically in bringing this sorry state of affairs to public attention.

PeoniesPlease Wed 19-Dec-12 15:04:14

But no reference was made to maternal request ELCS as a valid birth choice was it?

It seems to me that the people involved in the making of that film have just as much of a vested interest in making women have a particular type of birth - a "natural" vaginal birth, as they claim that obstetricians do. After all, if all women decided that they wanted to have an ELCS, then they would be out of a job wouldn't they?

I would love to see more choice for birthing women. But I think that needs to encompass ALL types of birth - from unmedicated homebirth, through hospital birth with any pain relief requests made by the mother immediately responded to, to ELCS, and anything else I haven't thought of!

Wasn't it the RCM who brought out that ridiculous publication recently, about trying to arbitrarily reduce the number of epidurals by 20% in the absence of all evidence? That is why I don't trust the individuals involved in that film. They are only interested in one very specific type of birth.

Hopefully though, people will be able to widen the scope of this movement, and challenge the law if necessary in the way that RedToothbrush suggested, so that this could actually be really useful for women.

RedToothbrush Wed 19-Dec-12 15:19:28

The comments of many involved were and have consistently been against medicalised births. That puts pressure on women, and the way they phrase things frames the argument that medicalised birth = bad, natural birth = good. It means that choice is not free.

If at any point some of these ideologists said "yes if woman want a CS or are happy with one under the guidance of a doctor" AS WELL AS supporting the right to a natural birth then thats fine. But the argument is constantly framed as doctors being the bad guy and interfering and midwives being saintly and doing things in the best interests of woman at all times.

The trouble is, that caught in the middle of this and their evangelical beliefs they actually fail to listen and instead just end up telling us all whats best.

But they don't. Its biased. And they don't represent choice. They represent the natural birth lobby and its agenda which in some cases is extremely damaging to the interests of women as many, many threads in this section and elsewhere on Mum's net will testify to.

Shagmundfreud Wed 19-Dec-12 17:03:10

"It seems to me that the people involved in the making of that film have just as much of a vested interest in making women have a particular type of birth - a "natural" vaginal birth, as they claim that obstetricians do."

You have utterly missed the point of the film and the campaign.

And the language you use says everything about the way you see birth, and the role of health professionals in labour.

They have no interest in making women have any particular type of birth. They simply want a maternity system which enables women who want a physiologically normal birth which doesn't involve emergency surgery or the use of instruments (the type of birth the vast majority of women want) to have one. Our current system simply doesn't optimise women's chance of a healthy, normal birth, which is what it should be doing. In fact it ruins many women's chance of having a straightforward labour. It actively obstructs normal birth.

As far as women's right to have a planned c-section goes where there are no medical indication (including tokophobia) - I agree that this is a problem in our current system in the UK and we need to resolve it. But first we need to resolve the problems that are making our system unsafe and leading to very high rates of emergency surgery, as this is the cause of the greatest amount of emotional trauma and ill health in new mums. And this will only be resolved by increasing the number of midwives and improving access to case-loading midwifery care. If the government decide to increase funding to the point that we can guarantee all women instant access to epidural, and c-section on demand, while ALSO vastly increasing midwife numbers so that women who want a normal birth have a reasonable chance of getting one, then brilliant. But I suspect this isn't going to happen any time soon, and if we have to choose, we need to prioritise safety. Which means that increasing midwife numbers needs to be prioritised ahead of widening access to surgical birth for low risk women.

"I would love to see more choice for birthing women. But I think that needs to encompass ALL types of birth - from unmedicated homebirth, through hospital birth with any pain relief requests made by the mother immediately responded to, to ELCS, and anything else I haven't thought of!"

According to the current evidence (Care Quality Commission (CQC) in 2010) nationally more than 9 out of 10 women 'definitely' (68.9%) or 'to some extent' 27.9%) got the pain relief they wanted. I'm assuming that women who requested an epidural and didn't get one wouldn't answer tick a box that said they 'definitely' or 'to some extent' got the pain relief they wanted. I'm suspect that large number of the women who ticked the 'to some extent' box had pethidine or opioids which didn't work well for them, so perhaps not a situation where they were denied access to pain relief.

And nearly all women in the UK have access to obstetric led births. In fact 9 out of 10 births take place in obstetric led units. It's birth centres which are being shut down, and home birth services (like the one attached to the Homerton) which are being cut. If you want an epidural in a large teaching hospital in the UK you are very likely to get one. On the other hand if you want a birth without the use of instruments, episiotomy or surgery in an environment which supports active birth and water birth - well, bloody tough luck, you're probably not likely to get one!

In other words, the power isn't in the hands of midwives and natural birth advocates. Our current system, even the UK where we have a midwife led system of maternity care, is vastly biased towards medicalised birth, and this is reflected in the ridiculously high rates of emergency surgery that mothers are experiencing in labour.

"medicalised birth = bad, natural birth = good"

Can you explain to me how a birth involving forceps, ventouse, episiotomy and emergency c/s is preferable to a vaginal birth involving none of these things which still ends with a healthy mum and baby? Surgery, augmentation and instrumental birth (which is what we mean by a medicalised birth) ARE bad if they are avoidable!

Shagmundfreud Wed 19-Dec-12 17:06:47

Redtoothbrush - what do you mean by a 'medicalised birth'?

RedToothbrush Wed 19-Dec-12 17:07:30

I didn't understand the point of the film. Ok...

Shagmundfreud Wed 19-Dec-12 17:13:12

"They are only interested in one very specific type of birth."

I think you'll find that the type of birth they are interested in is what ever birth it is that women feel the current system of maternity care (particularly in the US) is denying them.

I honestly don't believe for one minute that women in the USA or across Europe outside of the UK are being denied access to medicalised birth including emergency surgery, induction, augmentation or c/s on demand.

Do you?

But there is clear and unequivocal evidence that women in these countries are not being offered an alternative.

Shagmundfreud Wed 19-Dec-12 17:14:35

What do you mean by a 'medicalised' birth?

RedToothbrush Wed 19-Dec-12 17:15:34

I honestly don't believe for one minute that women in the USA or across Europe outside of the UK are being denied access to medicalised birth including emergency surgery, induction, augmentation or c/s on demand.

Do you?

In a word. Yes.

And they are also being made to feel guilty by not having a natural birth.

Shagmundfreud Wed 19-Dec-12 17:21:46

"In a word. Yes."

There aren't enough emergency c/s being done? Or inductions?

Where are women being denied inductions or emergency surgery? Do you have proof that women are being denied access to these things.

"And they are also being made to feel guilty by not having a natural birth"

By whom? And how?

Two of my three births involved interventions (forceps/augmentation/epidural). Why do I not feel guilty about needing this type of help in labour when I'm a strong advocate for normal birth?

Shagmundfreud Wed 19-Dec-12 17:25:31

And what do you mean by 'medicalised births'?

You clearly feel that women are unfairly denied access to a 'medicalised birth', but that's not what the evidence says. It says that more than half of women in the UK are having interventions and medical input in birth, despite pretty much all doctors and midwives believing that normal birth rates could be much higher.

So the evidence doesn't suggest that women are being denied access to medicalised birth. It suggests that many women who could have uncomplicated births are ending up needing surgery to deliver their babies, because of substandard care.

RedToothbrush Wed 19-Dec-12 17:36:04

Shag, this debate is pointless with someone I consider to be one of the very people who be part of the problem rather than the solution, due to the strength of their feeling about natural birth. You are pro-natural birth, not pro-choice. And I do feel there is a massive and fundamental difference.

I've seen you on MANY occasions upset people on this forum with the language you use and the way you frame your arguments. You have some valid points, but I'm damned if I'm going to get into yet another debate with you on the subject for that reason. You don't get the problems that are a direct result of the preachings of the pro-natural lobby, which can be as damaging as over zealous and pushy and defensive obstetricians. Thats not about choice or the best interests of women. Its about ideological belief. Its a massive missing part of the debate you actively choose to ignore.

Anyway carry on... I know you will.

Phineyj Wed 19-Dec-12 17:41:31

At the same time, I understand that EU legislation on insurance requirements for healthcare practitioners means that independent midwives can't legally deliver babies after September next year, in the UK at least. So that takes that choice away, even for those who can afford it.

Rainbowbabyhope Wed 19-Dec-12 17:58:20

Red I am confused - why would anyone not be pro-natural birth in the first place? Of course there are many situations where medicalisation is necessary, including elective sections and other interventions. But pro-choice means being pro-all choices including natural birth. We can't ignore the fact that the introduction of any intervention, including all forms of pain relief, has side effects and risks which is why you need to consent to them. Why wouldn't we support those trying to make sure we all have access to at least the chance of a natural birth? The whole point is that many of us don't even have that opportunity to be supported in trying for a natural birth which is undeniably the best for our bodies (excluding those who have specific medical issues). For example, if we can eliminate the need for some women to require opiate based pain relief (with the risk factors it comes with for mum and baby), simply by providing access to a pool during labour to encourage the most natural birth possible, why on earth wouldn't we do that?

Shagmundfreud Wed 19-Dec-12 18:00:47

"Shag, this debate is pointless with someone I consider to be one of the very people who be part of the problem rather than the solution, due to the strength of their feeling about natural birth. You are pro-natural birth, not pro-choice."

What makes you think I'm not 'pro-choice'?

True, I do believe that in our current situation of very limited funding in the NHS we need to focus on improving safety first. This might mean not widening access to epidurals and c/s on demand within a context when we can't even guarantee adequate midwifery care in labour or safe postnatal care in the community because of short staffing. But the funding crisis aside, what have I said that makes you think I believe hospital birth, epidurals or c/s on demand should be rationed, even if all the resources were there to widen access while also providing safe care to all mothers across all birth settings? I have no fundamental problem with women having pain relief or c/s on demand and nothing I've said here suggests I do.

I think the problem is RedTooth that the evidence supports my argument, and not yours. It's hard to engage in an adult and reasoned argument when you have so few facts at your disposal.

Which perhaps is why you feel the need to resort to unsupported assertions about my beliefs, and character assassination.

That's a shame.

I'd also like to point out that you need to get your head around the distinction between 'normal' birth and 'natural' birth. The midwives and advocates on this film are making the case that our system of maternity care is denying choice to mothers, and putting their health at risk by exposing them to unnecessary surgery during birth. They are not advocating that women 'should' go without pain relief or that they 'should' give birth in any environment other than the one they feel safest in. They are not advocating that women who need the help of doctors should be denied it. If you are hearing another message it's coming from your own assumptions and beliefs about birth, not from what this film, or the individuals in it are saying.

It's a shame you can't engage like an adult on this topic. We should be able to have a sensible discussion , because it's a damn important subject!

Shagmundfreud Wed 19-Dec-12 18:05:53

"that many of us don't even have that opportunity to be supported in trying for a natural birth which is undeniably the best for our bodies (excluding those who have specific medical issues)"

Actually a natural birth is undeniably best for ALL women who want it and can achieve it safely, including women like myself who are categorised as 'high risk'. In fact you might argue that there are many high risk women who are even more likely to suffer ill effects from surgery than healthy women (diabetics, and morbidly obese women for starters) who have a great deal to gain from having a straightforward delivery.

Rainbowbabyhope Wed 19-Dec-12 18:21:30

Shag yes I agree with you about encouraging natural birth for anyone who can achieve it safely.

The main point is providing allowing everyone to have access to an environment where the normal processes of birth are encouraged rather than hindered, which unfortunately just isn't the case. I understand this is what is being supported here.

I too am in the position where in my current pregnancy I am classed as high risk - totally unnncessarily from a medical perspective. Unfortunately in my local hospital high risk translates to being encouraged to stay on my back in bed like a good girl being monitored constantly (without medical indication). No choice for me - except that thankfully I can afford independent midwives.

Shagmundfreud Wed 19-Dec-12 18:28:48

I hired an IM too because of a lack of support for normal birth for high risk women at my local CLU.

I really think that in about 20 years time they'll have cottoned on to the fact that birth is safest when technology and medicine is incorporated into the care of women in a way which doesn't obstruct the normal physiology of labour.

I honestly think one day it'll be everyone, and not just the natural birth lobby, who'll look back on the way many labours are managed now and feel a sense of disbelief at the sheer dunder-headedness and wastefulness of certain aspects of our system of maternity care.

Ushy Wed 19-Dec-12 21:40:00

shag You said "According to the current evidence (Care Quality Commission (CQC) in 2010) nationally more than 9 out of 10 women 'definitely' (68.9%) or 'to some extent' 27.9%) got the pain relief they wanted. I'm assuming that women who requested an epidural and didn't get one wouldn't answer tick a box that said they 'definitely' or 'to some extent' got the pain relief they wanted."

Actually they would because of the issue of women being told they are 'too early' or the anaesthetist is unavailable. So they are delayed and delayed, end up with a much riskier procedure because they can't keep still and a much higher risk of the epidural not working (late placed epidurals are much more likely to fail).

So basically 8% say they definitely did not get the pain relief they wanted at all and 27.9% only got it to some extent - that's over a third of the 700,000 or so women who give birth every year.

Given that labour pain is one of the severeist you can experience, I'd say that is a flagrant breach of human rights. hmm

Shagmundfreud Wed 19-Dec-12 23:12:01

Have you got access to any evidence regarding women requesting epidurals - the average wait?

Worth considering: 1 in 8 epidurals don't give complete relief of pain.

And many of those who opted for pethidine would have found it ineffectual. This might account for a large proportion of those saying they did not get adequate pain relief in labour.

But yes you are right Ushy - women should have access to the services of an anaesthetist if they want an epidural. They should also have access to one to one care, a midwife they know, access to a pool, access to a birth centre, access to a good home birth service. On current form I very much doubt these things will materialise though, do you? And access to epidurals is no more important than access to one to one care, or a home birth service, or waterbirth is it?

Shagmundfreud Thu 20-Dec-12 08:03:37

Meant to add that women won't usually be admitted to hospital unless they're in active labour and therefore epidurals at 2cm aren't going to happen. I'm not aware of women in active labour being told it's 'too early' for an epidural. And of course some delay is down not to the anaesthetist being unavailable, but to the woman not requesting an epidural until they are in transition or in late first stage.

Of course a lot of this discussion is speculation as we don't have figures - we don't know what percentage of women don't get epidurals following a request for one, or who experience a significant delay in getting one.

rainrainandmorerain Thu 20-Dec-12 09:37:15

shagmund - there have been threads on this board about women requesting cs and being refused. Whether or not you don't 'believe' it is irrelevant (although presumably you think these women are lying, which is a bit repulsive). It happens. This is women who have had traumatic births previously as well as those who are requesting them for other reasons. If you believe you can just get cs 'on demand' in this country you are very badly informed - or perhaps being wilfully ignorant, because the actual facts don't suit your views or argument.

PeoniesPlease Thu 20-Dec-12 09:57:36

I also think this discussion is getting a bit derailed. Both imposing interventions on birthing women that they do not want and have not consented to, AND refusing ELCS at maternal request are human rights violations. They both involve refusing the woman in question agency over her own body. There is no point in playing women off against each other because their ideal births look different.

Thankfully, it seems that the ECHR is waking up to this, and I hope that we will see more cases which will clarify and strengthen the position.

Also Shagmundfreud, re my use of language - surely if fewer than 50% of women are doing it, then it is no longer the norm? Perhaps you should consider your own language too.

Shagmundfreud Thu 20-Dec-12 11:43:28

Re: norm - what is meant by 'normal' in regard to medical matters is the physiological norm.

Rain - I haven't implied that women wanting ELCS aren't being thwarted in their choice in the NHS. Just that it's hard to know exactly how often requests are being made and how often they are being denied.

Would like to add - I think it's really important in relation to this issue to acknowledge the likelihood that choices are and will have to continue to be made about how to allocate maternity spending. IMO higher rates of elective surgical birth and wider availability of epidural shouldn't be prioritised over increasing midwife numbers. Just saying - if choices have to be made, and I think they do......

PeoniesPlease Thu 20-Dec-12 12:26:51

But that is prioritising the rights of only one group of women - those who want a midwife-led vaginal delivery, at the expense of another - those who want a consultant-led vaginal or ELCS delivery. It is exactly what I think we should be avoiding. Playing one set of women off against another because they make different choices about how best to bring their baby into the world.

It is no less of a human rights violation to be denied ELCS/epidural than it is to have CFM/induction/episiotomy without consent. Both involve denying women choice over what happens to their own bodies.

Shagmundfreud Thu 20-Dec-12 13:07:42

"But that is prioritising the rights of only one group of women"

No - it's about optimising health outcomes.

At the moment many women are being left on their own for long periods in labour in some hospitals because of the shortage of midwives.

This is leading to higher rates of emergency c/s, birth trauma and ill-health.

It's also not safe for babies.

Safety has to come first in any system of health care surely?

Shagmundfreud Thu 20-Dec-12 13:12:55

"It is no less of a human rights violation to be denied ELCS/epidural than it is to have CFM/induction/episiotomy without consent. Both involve denying women choice over what happens to their own bodies."

I don't agree with you.

If you inflict medical treatments on a woman without her consent then it's classed as an assault.

There are many, many, many people in the UK who are not getting the treatment options they would prefer under NHS care in a huge range of areas outside of obstetrics.

Including children like my son who has waiting nearly a whole year for an assessment for autism.

It's very distressing not to get treatment on the NHS you feel you want and need, due to a lack of resources, and it's wrong that people's quality of life in these situations isn't seen as a priority. But it's not an infringement of your human rights.

rainrainandmorerain Thu 20-Dec-12 14:18:32

I think many people feel that leaving a woman in childbirth in extreme and traumatising pain by denying her an epidural is not a humane way to treat people.

You diminish experiences like that by talking about them as 'treatment options" we might 'prefer'.

And if you want to talk about funding outside obstetrics - at my local a&E, over 70 percent of the people treated there, for free, across the weekend, are seen for alcohol related injuries. Over 70 percent - using ambulances, triage staff, surgical staff, nurses, taking up beds.

So I don't buy this argument of 'you can't have better access to epidurals because it costs too much." If the NHS can afford to stitch up a self inflicted wound on an aggressive drunk, it can afford to give labouring women in intense pain pain relief.

The sad thing here is that (perhaps naively, I don't know) I think that women are capable of supporting others' birth choices, and their right to choose, even if it is emphatically not their own choice. I think that way it would be possible to get enough momentum going to change things. Like peonies said upthread.

But people like you, Shagmund, alienate some of the women who might be happy to come on board a campaign on the shared grounds of rights over our own bodies, because actually, at heart - it's not all mothers and babies you care about. It's the mothers who share your particular beliefs. Not the rest of us.

Shagmundfreud Thu 20-Dec-12 14:57:03

I don't think anyone would agree that it is fair or ethical to deny a woman an epidural if the services of an anaesthetist are available.

The question is whether we should be spending more money on employing anaesthetists or more money on employing midwives.

Ideally the money would be there to have both. But things are very far from ideal in relation to maternity funding. At the moment there simply isn't the money for EITHER and if more funding becomes available choices will have to be made as to how it'll be spent.

If you want to widen the debate to include NHS spending on self inflicted conditions (smoking, obesity, drinking) then that is another issue. I can see a lot of people would appreciate the idea of removing free healthcare from these people and diverting it into other aspects of patient care. Not sure the general public would rather see any money thus saved being used for non-essential surgery or higher rates of epidural use, but who knows.

And I do support other women's right to have an epidural. Christ - I've had one myself and very grateful I was too! Just because I'm making a case for any additional funding going to provide safer care for women and babies rather than elective surgery and more access to epidurals it doesn't mean I'm fundamentally anti-choice. Of course I could always just court popularity by writing washy washy posts arguing that we must have epidurals and c/s on demand, plus a first rate home birth service, case loading midwifery care for all women, water birth services for all who want them, etc etc but really, it's all cloud cuckoo land, because at the moment there isn't even the money to provide adequate midwifery cover on many labour wards.

Xenia Thu 20-Dec-12 15:34:57

i have not see the film but I was very comforted when expecting my twins by the fact that under English law I could decide what I liked,. Eg I chose and my private midwives agreed to let them stay in to 40 weeks. NHS doctors like to whip twins out 2 weeks early although the science is not that decided on the topic and I think mine hugely benefited from my not following what many NHS doctors recommend for twins for example. Instead they came when they were ready - that is just one example of mother's choice even if it might hurt the unborn child. We are lucky to have these rights.

There was another case just before the twins were born where the English court held a mother in labour did have enough mental capacity despite contractions to determine what was done to her. Very comforting.

The issue though of whether you can force the state to provide expensive intervention at tax payer expense when not medically necessary is totally different and not one I would equate with "choice" really.

Ushy Thu 20-Dec-12 16:13:46

Xenia You wrote The issue though of whether you can force the state to provide expensive intervention at tax payer expense when not medically necessary is totally different and not one I would equate with "choice" really.

Two things - a caesarean being 'not medically necessary' - is your personal opinion but another woman may fear hypoxia or perineal trauma much more than surgery so it may be medically necessary for her. How we perceive safety and risk is not absolute - it depends on our previous experience, personality and a host of other factors.

Secondly, there is actually hardly any difference between the cost of caesareans and planned natural birth if you take long and short term costs into account. (Only about £84.00 as estimated by NICE).

Planned natural births result in lower short term cost but more need for perineal trauma operations so have higher long term costs. However, the £84.00 extra cost of caesareans excludes the significantly higher litigation costs of natural birth - overall both modes of birth are probably about the same.

Personally, I think we should ALL be arguing for women's choices to be respected whatever they choose.

elizaregina Thu 20-Dec-12 16:35:20

http://www.bbc.co.uk/programmes/b01nbryp

I dont belive there should be a choice one way or another - is that how they decide things on the NHS? Is that how they allocate funds?

Before anyone does allocate funds in that manner they should watch this program.

It encompasses the various ways our government ( S) have let people who do not pay NI abuse our health system and how surprisingly easy it is.

Once someone has been refered by a GP - the hospital has no system in place to actually check if that person is entitled to free care - which can run into the thousands.....its assumed that because the person has come via a doctor that they are bonefide....

It also shows how the most money we loose is by not claiming back from Europeans visiting us - the documentary shows how If brits abroad use another countries healthcare - they vigoursly chase us for the money - but the UK doesnt chase other countries for the money spent on thier nationals.

As well as all the other ways the NHS heomrages money - I personally think before a debate starts on the nitty gritty details of who should have what care - I say - all women should have the right to choose the best care for themselves - and if cost is a problem - address all the other issues first, including drunks in A&E etc etc etc.

All the women on here - should be lobbying for all womens choice - not to bear the brunt of cuts and cut backs - instead of splitting hairs over personal preferences at the detriment of general rights and choices...

elizaregina Thu 20-Dec-12 16:36:33

http://www.bbc.co.uk/programmes/b01nbryp

elizaregina Thu 20-Dec-12 16:37:16

Declan Lawn reports on how 'health tourists' are obtaining free NHS treatment they should be paying for - at a cost of millions to our health service. Panorama goes undercover inside a black market where NHS access is being bought and sold, and finds an NHS practice manager taking money to register health tourists. Declan also discovers how easy it is for foreign nationals to get free treatment - with many hospitals across the country not making the required checks.

rainrainandmorerain Thu 20-Dec-12 16:41:17

Good post, Ushy.

Odd and a bit sad somehow that often, those of us who do support epidurals on demand, and elcs as an informed and valid birth choice can be supportive of those who choose to go down a very different birth choice route.

But they don't support us in return.

Shagmund - you were the one who broadened the debate to funding and provision outside maternity and obstetrics by discussing your son. I simply continued the discussion about resources.

rainrainandmorerain Thu 20-Dec-12 16:45:54

Yes, good posts too eliza.

I think the 'debate' over costs in maternity care is often a smoke screen for ideological hostility, tbh.

Shagmundfreud Thu 20-Dec-12 17:15:26

"Secondly, there is actually hardly any difference between the cost of caesareans and planned natural birth if you take long and short term costs into account. (Only about £84.00 as estimated by NICE)."

But that's because a planned vaginal delivery now has a high chance of ending in a planned c/s or assisted delivery, which is where the costs accrue.

And the reason the emergency c/s rate is so high is because the vast majority of low risk women are giving birth in obstetric units, which have almost double the rate of emergency c/s than midwife led units.

High emergency c/s rates are also linked to staffing issues, namely a lack of one to one care, and a lack of consultant input after a labour starts to become complicated.

So surely it should be a priority for the NHS to spend whatever money they do have on bringing down emergency c/s rates (which would also significantly reduce maternal and neonatal mortality and morbidity) by:

a) increasing midwife numbers
b) improving access to birth centres and out of hospital birth
c) improving consultant cover in obstetric units

The average rate of unplanned c/s nationally is 14%. Some hospitals are as high as 20%, while others are as low as 13%. If rates were reduced (by spending money on doing the things I suggest above) to bring most hospitals in line with the national average, then planned c/s would begin to look like a very expensive option in comparison. In other words, it's only comparable because women planning vaginal births are so often getting suboptimal care which is resulting in high rates of complications. sad

As for lobbying for increases in NHS funding for maternity services - well, yes! But if we are having to make decisions about how CURRENT funds are used, then I still hold that safety has to be prioritised, and that means increasing midwife numbers, even if it's at the cost of reducing access to c/s on maternal request and in the absence of a diagnosis of tokophobia.

Shagmundfreud Thu 20-Dec-12 17:16:06

sorry, that should read: planned vaginal delivery now has a high chance of ending in an unplanned c/s or assisted delivery

PeoniesPlease Thu 20-Dec-12 17:19:44

"No - it's about optimising health outcomes."

But health outcomes are optimised when women's choices are respected and they are able to take an active role in deciding what their birth is going to look like. (Whether that is a homebirth or an ELCS).

"Safety has to come first in any system of health care surely?"

Safety is important, yes. But this is a discussion about human rights violations in birth. I think respecting women's human rights is equally as important. (Even when a labouring woman chooses a path of action which may endanger her baby - I would still support her right to do that.)

Shagmundfreud Thu 20-Dec-12 17:22:29

Oh for goodness sake rain - do you have to engage in character assassination in order to make your point?

I have no 'ideological' objection to epidurals or to planned c/s.

elizaregina Thu 20-Dec-12 17:25:02

Two women are in hospital, the same hospital in different areas a few corridors away from each other.

One is UK national giving birth - she wanted an ELC but was denied one due to lack of funds....she also cant get an epidural due to shortage of staff, and pruning back of services....her other choice - a HB was also ruled out - due to lack of MW's....so she gives birth - traumatised - etc etc...and the NHS people are looking at ways to prune back her care and others like her - even further.

SECOND lady - has brought her way into our system, she has no entiltement at all - to any of our services and yet - she is going to run up a bill in the thousands for treatment to her stomach. The NHS people dont care one jot....and this abuse will happen over and over and over again. There isnt even any one in the hospital to check her credentials - even if someone was suspicous there is no body to check!!!!

THAT is the current allocation of funds - that is what we should all be asking to be addressed!

Shagmundfreud Thu 20-Dec-12 17:26:37

"But health outcomes are optimised when women's choices are respected and they are able to take an active role in deciding what their birth is going to look like. (Whether that is a homebirth or an ELCS)."

Health outcomes are optimised when you have the greatest number of women and babies coming through labour in optimal physical and mental health. If we increase access to c/s on demand and widening access to epidurals instead of increasing midwife numbers (which is what most people involved in delivering maternity care are desperate for) we will continue to see very high rates of birth trauma and emergency c/s rates linked to inadequate care of women planning vaginal births.

At the moment women who have a planned c/s are getting optimal care on the NHS.

Women planning vaginal births are often getting suboptimal care, which is leading to high rates of emergency surgery. This isn't acceptable and any increase in funding needs to be used to address this problem FIRST.

LaVolcan Thu 20-Dec-12 17:27:41

even if it's at the cost of reducing access to c/s on maternal request and in the absence of a diagnosis of tokophobia.

Rather than that shagmund I would like to see a good hard look taken at why the EMCSs are happening, and some serious attempts to reduce this rate. And no, that's not by telling the woman who had an EMCS the first time that she has to try for a VBAC. We could probably start by questioning the rate of inductions, in particular those which happen because of a date on the calendar - I am sick of reading about women who 'had' to have an induction because they were 40 +10/12/14/choose your hospital's date overdue, which then failed and led to an EMCS. Who knows whether they would have had a straightforward delivery if the baby had been allowed to come in its own good time?

Shagmundfreud Thu 20-Dec-12 17:34:50

"SECOND lady - has brought her way into our system, she has no entiltement at all - to any of our services and yet - she is going to run up a bill in the thousands for treatment to her stomach."

Yes - lets just stop treating refugees and illegal immigrants who pitch up at our hospitals. They can die on the streets. sad

Eliza - a mum who has serious mental health issues in relation to labour and birth in our current system should be offered a) counselling and b) a planned c/s if she is unwilling to have a vaginal birth following counselling. If this isn't happening then obviously it needs to be addressed nationally as well as at a local level.

But that's not really what we're discussing here is it? There are already systems in place to accommodate women with tokophobia (which are working imperfectly at the moment - this needs addressing). The issue is whether ANY and ALL women should be able to request elective surgery on the NHS.

PeoniesPlease Thu 20-Dec-12 17:38:07

Firstly, I don't know what evidence you have to suggest that women who have an ELCS get optimal care. Secondly, there are frequently women on these boards in a terrible state because they have requested ELCS and been refused. That is hardly optimal is it?

This comes back to the same point though. ALL women should be respected before, during, and after birth, whatever that birth looks like. We shouldn't be playing different groups off against each other when actually, what we all want (and need) are improved maternity services.

Shagmundfreud Thu 20-Dec-12 17:38:13

Yes - look at the ridiculous disparity in induction rates between hospitals.

But also I think it's a national scandal that healthy women giving birth in obstetric led units are having DOUBLE the rates of unplanned surgery when compared to women in midwife led units. I mean - HELLO! - this is completely insane!

LaVolcan Thu 20-Dec-12 17:44:11

I doubt whether health tourists are really the cause of the problem. There are loads of parts of the country where this just doesn't apply and yet still services are poor.

Those parts of the country where it does apply (near Heathrow?) probably should provide some clerical staff to bill the defaulters. It is not the job of the health care staff to question her credentials. Their job is to offer appropriate care.

Shagmundfreud Thu 20-Dec-12 17:45:16

Oh for goodness sake Peonie - nobody is 'playing' one group of women off against another. How you give birth to your baby doesn't put you in one group or another!

We are talking about how resources are allocated within maternity services AT THE MOMENT, and without further massive increases in funding.

There are many people on this thread who appear to be calling for a large increase in elective surgery and epidural birth - knowing that we have a massive current crisis in relation to midwife numbers which is impacting on women's safety in birth.

And women who have an ELCS will at the very least have the attention of an obstetrician, an anaesthetist, a midwife, a scrub nurse and a paediatrician during surgery, unlike many labouring women who don't even have one bloody midwife to themselves.

LaVolcan Thu 20-Dec-12 17:46:21

But also I think it's a national scandal that healthy women giving birth in obstetric led units are having DOUBLE the rates of unplanned surgery when compared to women in midwife led units. I mean - HELLO! - this is completely insane!

Absolutely agree here, and it's not as though it can be justified by better outcomes for the baby.

PeoniesPlease Thu 20-Dec-12 17:46:25

I think it is a national scandal that women's choices in such an important area are disregarded and minimised, even by other women. Instead of pointing to potential barriers, why don't we all work to support each others choices, even when they are completely different from what we would choose for ourselves?

PeoniesPlease Thu 20-Dec-12 17:53:33

"We are talking about how resources are allocated within maternity services AT THE MOMENT, and without further massive increases in funding."

Actually, I am talking about the rights issues in intervening without consent/refusing treatment arbitrarily. This thread was started as a discussion about the ruling in the ECHR. If women start having to enforce their rights in court, then perhaps the NHS bods will have to stump up more cash to ensure that women are respected in their birth choices. This should not be a zero sum game and I'm not going to agree that women who choose a vaginal delivery should have more access to resources than women who choose a surgical one. No one has any less right to appropriate and respectful treatment here.

LaVolcan Thu 20-Dec-12 17:54:14

unlike many labouring women who don't even have one bloody midwife to themselves.
...or worse, can't even get across the threshold of the maternity unit because it's heaving and has had to close its doors. Who then have to go driving up the motorway to find another unit, who eventually get the support they need after being in labour for 50 hours. This is only one example I know of; perhaps it's an exception but sadly I think, not so much of an exception as it should be.

Ushy Thu 20-Dec-12 18:04:07

Shag "obstetric units are having DOUBLE the rates of unplanned surgery when compared to women in midwife led units. I mean - HELLO! - this is completely insane!"

But there is a trade off between interventions and safety and it should be the parent's choice.

Induction is a case in point. 'Doing nothing' at 40+14 days might result in more normal births but it would also result in a huge rise in total baby deaths which rises eightfold from 37 weeks to 43 weeks. Shouldn't it be the parents who decide whether they want intervention or not?

Excellent post Peoniesplease It's a bit of a battle, though, to get that simple, reasoned, ethical, argument across sad

Ushy Thu 20-Dec-12 18:05:33

Ugh! I used that horrible term 'normal' birth by mistake. Wash my mouth out. It's a vaginal birth.

Shagmundfreud Thu 20-Dec-12 18:16:11

Peonie - the NHS has a responsibility to provide the safest possible care and the most clinically beneficial care for the largest number of mothers. That is its remit. It is a health sevice after all. If 'respecting women's choices' to have elective surgery means diverting funds currently used to pay for midwifery and consultant cover on labour wards into increasing access to surgical birth when there is no evidence of clinical benefit, then you are basically prioritising maternal choice over safety and efficacy - and there is no other area of the NHS where this would be encouraged or even tolerated.

You have to be realistic - the biggest barrier to a healthy and happy birth in the NHS at present is the lack of midwives and lack of consultant cover on labour wards. This needs fixing FIRST. And if we have to choose how limited resources are spent - and we do - then we can't justify widening access to surgical birth while basic safety on the wards is being neglected due to poor staffing.

And yes - in a fantasy world it would be wonderful if we could all have everything we want from the NHS, including free dentistry and as many rounds of IVF as it takes to get pregnant. But this is the real world and it's not going to happen any time soon. Or ever.

Shagmundfreud Thu 20-Dec-12 18:19:15

Do you not use the term 'normal conception' or 'natural conception' either Ushy? What about normal breathing? Normal eating? Would you prefer the term 'physiological birth'.?

Shagmundfreud Thu 20-Dec-12 18:22:22

There is no trade off between intervention rates and good outcomes when you are comparing births to healthy women which take place in different settings Ushy.

Healthy w omen who give birth in obstetric units have massively higher levels of medical input and yet are no more likely to take home a well baby than a mother giving birth in a birth centre.

elizaregina Thu 20-Dec-12 18:22:56

Yes - lets just stop treating refugees and illegal immigrants who pitch up at our hospitals. They can die on the streets. sad

No Shag, if you saw the documentary these are health tourists - they are NOT POOR REGUGEES OR IMMIGRANTS they are people who would have to pay thousands for the same care in thier own country - therefore they come here - pay back handers to people who get them onto a Gps books. The cost of the flights - the back hander is STILL cheaper than paying for thier own medial bills back home.

Also as said - other Euorpean countries are robust at chasing us for hospital bills our nationals have run up. We however for some reason are not so robust at chasing up thier nationals.

Your issues are cost related - you are saying the NHS should prune and chose X Y and Z on womens care because they are very poor at the moment.

I say we should ALL be campaigning for the NHS to stop needlessly hemoragging money as per - PANORAMA documentary ......

As well as looking at ways to stop the mindless drunkness that our emergency services are having to deal with on weekends and all the problems/costs incurred by that.

BEFORE we start looking to prune back already crap maternity services.

I can only agree with a previous poster - that cost is infact a smoke screen - its nothing to do with cost for some people just blind ideolagy....and an inability to look at the bigger picture.

elizaregina Thu 20-Dec-12 18:26:51

Lavolcan, where we are hospitals regulary close doors as they cant cope sadly.

LaVolcan Thu 20-Dec-12 18:29:18

Who talked about 'doing nothing' Ushy? What about monitoring? It's the policy of using protocol to drive a woman's care which I find wrong.

Yes there is a trade off between interventions and safety and it should be the parent's choice. One thing last year's Place of Birth study showed was that more intervention didn't equate with more safety for the baby but did show a substantial increase in EMCS/perineal trauma etc. Would women necessarily choose intervention if they knew this? How many are given a real choice? I don't call being told 'We will book you in for induction...' a choice if you don't know that you can say no.

elizaregina Thu 20-Dec-12 18:29:20

Declan Lawn reports on how 'health tourists' are obtaining free NHS treatment they should be paying for - at a cost of millions to our health service. Panorama goes undercover inside a black market where NHS access is being bought and sold, and finds an NHS practice manager taking money to register health tourists. Declan also discovers how easy it is for foreign nationals to get free treatment - with many hospitals across the country not making the required checks.


" And if we have to choose how limited resources are spent - and we do - then we can't justify widening access to surgical birth while basic safety on the wards is being neglected due to poor staffing.

And yes - in a fantasy world it would be wonderful if we could all have everything we want from the NHS, including free dentistry and as many rounds of IVF as it takes to get pregnant. But this is the real world and it's not going to happen any time soon. Or ever. "

Shagmundfreud Thu 20-Dec-12 18:46:04

There is no trade off between intervention rates and good outcomes when you are comparing births to healthy women which take place in different settings Ushy.

Healthy w omen who give birth in obstetric units have massively higher levels of medical input and yet are no more likely to take home a well baby than a mother giving birth in a birth centre.

Shagmundfreud Thu 20-Dec-12 18:54:52

Eliza - nobody is suggesting pruning outlay on maternity services. I'm suggesting the absolute opposite in fact. More money. More midwives. More doctors. More birth centres. And if funds allow and basic safety is being attended to, more access to elective surgery and epidurals. But only once all women have access to one to one care in labour.

As for ideologically driven views of birth - google an article on birth called 'fish can't see the water'.

rainrainandmorerain Thu 20-Dec-12 19:07:49

Very good posts Peony.

Out of interest - how many rounds of ivf in the nhs do you think a woman should get right now, Shagmund?

Btw, I barely saw my mw when I had my elcs. She sad hello before the op - weighed the baby - left. I shouldn't think she was there for ten minutes (to no ill effect, I should say - I and ds were absolutely fine). It's actually quite nice to think she was freed up to go and attend to a mother who needed her care more.

LaVolcan Thu 20-Dec-12 19:13:14

How many people were in the room when you had your ELCS?

Xenia Thu 20-Dec-12 19:16:29

If it costs no more for an intervention than not then I'm not against a woman's choice for an intervention even if she doesn't need it as long as medically it is not damaging to her. We cannot have doctors do things that are medically wrong because someone patient is forcing them to do so.

If there is extra cost and the thing you want costs more then you can pay for it but I don't want to fund it. I am already in the 1% of tax payers who pay 30% of all tax and one feels little thanks for that.

I am pretty happy with my right to kill my child in utero by refusing all intervention. I think that's the right line for the law to draw. Once the child is born then the rights position changes. That is perfectly correct.

As for health tourism there needs to be a better curb on that as we seem to do nothing about recovering the money after. Could we not not let them leave until they have paid for example or seek when possible to have them put up a bond before we do very expensive treatment (those who are not entitled)? Or put it in the hands of people paid on commission. If someone said to me I could have 10% of recoveries from Russians or Nigerians who had gone back abroad (or student loan defaulters) I would be more than happy to start a business with contacts in those countries to recover the money and that would only cost the state my commission.

PeoniesPlease Thu 20-Dec-12 19:18:08

"the NHS has a responsibility to provide the safest possible care and the most clinically beneficial care for the largest number of mothers."

Yes, and as a public service it also has a positive obligation to uphold human rights. The ECHR ruling has gone some way to clarifying the law in this regard, although there is still room for further progress as RedToothbrush outlined way upthread.

Ushy Thu 20-Dec-12 19:31:18

Shag Healthy women who give birth in obstetric units have massively higher levels of medical input and yet are no more likely to take home a well baby than a mother giving birth in a birth centre.

I know the study you are talking about and medical interventions are higher in obstetric units but one of the 'medical interventions' was epidural - yes, of course, this intervention is lower - most birth centres don't offer them.

Secondly, that study did not match women for risk and the 'low risk' women who went to the obstetric unit had lots more risks than women who went to birth centres.

As for 'fish can't see the water' I did google it and some of it is so one sided!

Look at this extract below - complete and utter bunkum:

"How effective is epidural block in relieving pain? In around 10% of epidural blocks it doesn't work and there is no pain relief. Even when it works, around a third of women given an epidural will trade a few hours of pain-free labour for days or weeks of pain after the birth. Thirty to forty percent of women receiving an epidural during labour will have severe backs pain after the birth and 20% will still have back pain a year later."

Women need accurate information and be left to make their choice - home birth, caesarean, epidural ...I do't mind.. I do care that their choice is respected whatever it is. Can we agree on that?

elizaregina Thu 20-Dec-12 19:38:30

My Father has just been abroad and need farily urgent medical assistance becasue he injured himself and couldnt stop bleeding.

He was so soaked in blood they had to cut his clothes off him when he finally got to hospital - THEY WOULDN'T TOUCH HIM BEFORE SEEING HIS INSURANCE DETAILS.

Did he blame them - say they were wrong? no!!!!

Simples.

As a start Xenia they could try actually being bothered to get a grip on the health tourism and claming money back from other EU states!!! Why are other EU countries zelously claiming back money and we are slack on it?

Its the lack of care - filmed on Panorma - by bodies involved that deeply upsets me - especially when the health minister has no idea how much money is being wasted in this manner! Most hospitals dont even have one person checking to see if the person is entitled to the care.

How can other countries manage to make sure WE have to produce x, y and z- and yet WE simply ignore it - whislt at the same time - talk about choosing how to manage a womans care due to cost.

The way alot of people acted on the panorma documentary you wouldnt think there was any cost problems....if the powers that be think that - why are we arguing about this service to women being denied because that one is more worthy...

Then people come on here and talk about denying women ELC or epidurals - to " cut costs"!!!!

Yes Shag - you want more money but your saying " right now" there is none so we have to choose.

I am saying - look at the broader picture - campaign for NHS to tighten up costs across the board BEFORE punishing women.

However if you think that someone who has deliberlty come here to fraudulently abuse our NHS for treatment to save themselves money is more worthy of that money than a woman wanting an ELC or epidural.....who is entitled to it from the UK....

Xenia Thu 20-Dec-12 20:01:44
LaVolcan Thu 20-Dec-12 20:33:53

Given that the Place of Birth study refers to one of its strengths being .... the ability to compare groups that were similar in terms of identified clinical risk (according to current clinical guidelines) and to further increase the comparability of the groups by conducting an additional analysis restricted to women with no complicating conditions identified at the start of care in labour, and the ability to control for several important potential confounders. i.e. as far as able to compare like with like how do you work out that:

Secondly, that study did not match women for risk and the 'low risk' women who went to the obstetric unit had lots more risks than women who went to birth centres.

Their language seems pretty plain to me.

This is one of the things which annoys me about the current system. The vast majority of women are booked into CLUs either by choice or by lack of realistic alternatives. As long as units continue to hide behind the stock answer that their rates of intervention as as a result of the risk factors of the women presenting there will be little incentive for them to attempt to reduce them. Other things being equal I would imagine that most women would prefer to avoid an EMCS, forceps, severe tear etc..

rainrainandmorerain Thu 20-Dec-12 20:44:24

la Volcan, how many people were in the room when I had my cs? It felt like a lot! I will try and remember.... anaesthetist, a theatre nurse, mw (briefly), surgeon, someone who seemed to be assisting the surgeon....

I think that was it. It is a fair few medical staff - although worth remembering that the op took less than 45 minutes.

my point about mws, because this is the group that shagmund keeps talking about, is that I used a FRACTION of that mw's time. Compared to someone having a homebirth, say. Women wanting to ensure one to one care are often advised on these boards to have a homebirth - sometimes, a bit controversially, told that if they just wait until they are in labour then a hospital HAS to send a mw out to them, regardless (no idea if that is true, btw - just something i have seen here).

I am not at all anti-homebirth, btw, for those women that want them. I'm just not sure why elcs mothers are criticised for getting 'one to one' care at the expense of other labouring women when the time a mw spends with them is so minimal.

Yes, I did see them after the op while i was i hospital - for the briefest of checks, and to hand me painkillers. That was all the care i needed, so I am not complaining - but including the op AND postnatal care over 2 days, I don't think I had a mw with me for more than an hour, total. (and they spent a lot of that time writing!)

rainrainandmorerain Thu 20-Dec-12 20:48:36

An aside - but didn't the place of Birth study show that for severe tearing (3rd and 4th degree) then actually the rate was pretty consistent across all the various birth places?

Other differences were notable - but severe tearing seemed to be a similar percentage wherever the mothers were.

I'm happy to be corrected if I have misremembered.

LaVolcan Thu 20-Dec-12 21:22:06

I will try and remember.... anaesthetist, a theatre nurse, mw (briefly), surgeon, someone who seemed to be assisting the surgeon....

So quite a lot of people then. I ask because I feel that by skimping on one-to-one care if you then need an EMCS/forceps/ventouse, which perhaps might have been avoided, you are going to need a lot more input from Health Professionals, and so it's a false economy.

I don't have problems with a woman needing an ELCS getting the care she needs, and if that's the top consultant, anaesthetist, theatre nurse then that's fine. I do have problems with a woman without risk factors having to put up with one midwife running between two or three other women, or not getting any care at all until the last minute because the hospital has had to close.

I also have problems with the woman who needs obstetric care not getting it because it's the weekend and the consultants are not on duty, and no-one realised that problems were developing because they were too short-staffed.

Ushy Thu 20-Dec-12 21:38:14

La Volcan I don't think anyone is arguing with you. Of course women should get one to one care. They should also get caesareans and epidurals when they request them.

LaVolcan Thu 20-Dec-12 21:52:21

Forgive me Ushy - I thought you were. You were saying that a study (Place of Birth) didn't match the risk factors of CLUs v MLUs. I said that as far as I could see they did, and that some CLUs are hiding unecessary interventions behind a stock answer that their cases are all high risk, when they are not.

Of course, women should get one to one care, but they are most certainly not doing so. Various reports/government committees have been banging on about this for how long, ( 20 odd years, Changing Childbirth?) and what's happened? Nothing, and now the birth rate has risen, cuts are being made left right and centre and a significant number of women are not even getting a basic standard of care.

rainrainandmorerain Thu 20-Dec-12 22:25:42

Yes LaVolcan - I do see there's very likely a false economy in a lack of supervision and support for women in labour creating emergency situations (which then require a spend which might have been avoidable) - also agree with your points about hospitals closing to new admissions, and understaffing.

(For me personally, I was always heading for an elcs, so I wasn't a case of someone whose care 'mushroomed' from one to one to a room full of people etc. And yes, i pointed out twice in my post that it felt like a lot of people in theatre! but as i say - the mw was the most fleeting of presences during a short op' and that was what I was drawing attention to).

I think your recent posts have been helpful in that you focus on the bigger picture of care and cost for women giving birth. It's a false debate to try and set those wanting epidurals and planned cs's up as the 'big bad', stealing maternity care away from other mums, when there are systemic problems that have nothing to do with that.

CailinDana Thu 20-Dec-12 22:36:38

Isn't there always going to be the issue though that maternity services are trying to balance the wishes of the mother to have a certain birth with budgets, yes, but also with the needs of the baby? And that those wishes and needs will sometimes (if not often) be in conflict? Medicine is a naturally risk-averse discipline, for good reason, and so midwives and doctors will usually err on the side of caution, even if that means the woman doesn't always get what she wants. The issue is where to draw the line. If a woman is clearly making a very foolish decision, one that could affect the life of her child, what should happen? Should staff override her decision, or take the view that she is responsible for whether her baby lives or dies and the staff must go along with her regardless? Either way there is a price to pay. On the one hand you might have staff overriding a woman's wishes even if they're not life threatening simply because the staff have another agenda, which they can dress up as protecting the baby. But if the mother is totally responsible for the child's welfare, doesn't that place too much pressure on a non-medically trained person to make decisions in a very fraught situation where they probably don't have enough clarity of mind or information for that decision to be a sensible one?

I am thinking of my labour with DS. I wanted to go the MLU but when I got there my bp was slightly raised so they sent me to the CLU. That wasn't my choice, but it was made on medical grounds, on the basis that things could have gone downhill and I would have needed intervention. I was ok with it, but right away my choice to give birth in an MLU was taken away on the basis of a relatively small risk.
Once I got to the CLU I carried on just as I'd wished - by moving about the room, only using gas and air. But when there was meconium in my waters once again my wish to stay active and avoid interference came into conflict with the need to monitor the baby, just in case. As it stood the g and a made me very very bolshy and I refused point blank to go on a bed as I felt I just wouldn't cope with the pain. That resulted in them having to bring in one and at some points two extra midwives (so at times there were 3 midwives in the room) to hold a monitor to my belly and to keep an eye on things. They wanted to put a clip on DS's head, which would have solved the whole monitoring problem but the machine was broken, again another unforeseen factor that meant my wish to stay active was difficult to accommodate. So a combination of concern based on two relatively minor risk factors (slightly raised bp and meconium) combined with equipment failure meant that on the day things didn't go exactly as I wanted.

Of course from there the cascade was ready to go - ventouse was mentioned, they were all set to do an episiotomy, and again it was my bolshiness that stopped these interventions, which turned out to be unnecessary in the end. Of course they could have been totally essential - how was I to know? How were the midwives to know? Was my desire to avoid pain and to stay active a legitimate reason to take risks with my son's life? Who gets to decide?

In the end I was finally coerced onto a bed (something that still annoys me to this day) but DS was fine and born without any intervention. I only had a couple of stitches, rather than the episiotomy they wanted to give me.

I do feel I shouldn't have had to fight so hard for what I wanted, but at the same time I understand that to the midwives, it is a job, where the main goal is, as shagmund said, safety. And to them the signs I was showing indicated DS was not safe and that he needed help, help that as a birthing woman I did not want. A midwife has huge responsibility on her shoulders and if at any point it is seen that she did not do what was needed to protect a baby she could have a death on her conscience and possibly a law suit.

So do we get mothers to sign a form going into the labour ward to say they can make all the final decisions but that if the baby dies it's on their shoulders?

Shagmundfreud Fri 21-Dec-12 08:01:14

"I know the study you are talking about and medical interventions are higher in obstetric units but one of the 'medical interventions' was epidural - yes, of course, this intervention is lower - most birth centres don't offer them."

No - the study includes women who transfer from a birth centre to an obstetric unit for an epidural in the 'birth centre' arm of the trial.

Secondly, that study did not match women for risk and the 'low risk' women who went to the obstetric unit had lots more risks than women who went to birth centres.

No - the study matched women for risks at the start of labour. It's considered good enough quality data to be included among those studies currently being used as part of NHS evidence on place of birth.

RAIN - I'm seriously disturbed by your comments about 'punishing women' by withholding epidurals or planned c/s. Also your comment "I'm just not sure why elcs mothers are criticised for getting 'one to one' care at the expense of other labouring women" - I want to point out that NOBODY IS CRITICISING INDIVIDUAL MOTHERS FOR THE CHOICES THEY ARE MAKING OR MAKING DECISIONS ABOUT MATERNITY CARE.

Ok? Sorry to shout.

This debate here is about SYSTEMS of maternity care and how they they are managed and funded. You seem to think that people trying to influence maternity services policy are sadists who hate women. In my experience (thinking of the midwives and obstetricians I know who are involved in this area), this is not true.

"Of course women should get one to one care. They should also get caesareans and epidurals when they request them."

They mostly DO get epidurals when they request them. And women with tokophobia should be catered for in the current system. If they are not - as I said above - this needs addressing.

But you are calling for more staffing resources to go towards increasing access to surgical birth and epidural provision. Out of a budget which is currently failing to fund even basic, safe care for many women attempting vaginal births.

I'm completely with you if you are calling for a MASSIVE increase in funding that will fix the current problems with maternity care which are resulting in such high levels of emergency surgery in labour - namely the shortage of midwives. And then if funds allow, to extend access to surgical birth for mothers who want it.

On the other hand, if you are talking about simply diverting money from current funds to open up access to surgical birth/more epidurals then no - nothing you've said on this thread has made me think that this is fair or safe on the basis of our current situation.

Cailin - my view on interventions in birth isn't necessarily that they are being used in a cavalier way. The two main reasons for emergency c/s are fetal distress and failure to progress. Often these two things go hand in hand. I personally believe that many aspects of the way women are cared for in labour obstructs the normal physiology of birth and therefore makes problems more likely. Staffing issues are massively important. If you look at the NICE guidelines on c/s they make a number of recommendations as to how to reduce the likelihood of an emergency c/s. One is that a mother should have one to one care from another woman, and another one is that she should have a consultant involved in the decision to go to c/s. Also that she should be offered fetal blood sampling if time allows, as this is often better than CTG at identifying if babies are really struggling in labour. However, at the moment many women are not getting one to one care in labour because there aren't enough midwives to go around. They're also not having enough consultant input - because there aren't enough consultants to go around. Also some units are not offering FBS round the clock for funding reasons. It's not good enough - these are basic things that the system isn't providing.

rainrainandmorerain Fri 21-Dec-12 08:25:39

I don't think I said 'punishing' did I?

And yes, no need to shout. No need to apologise - just don't do it in the first place, eh.

My point was that I had very little time with a mw during or after my planned cs. As I've said - for me, fine - I didn't need any more involvement as my birth was easy and quick and my baby was healthy.

whereas someone having a homebirth gets a mw sent out to their home, don't they? As I said - women on this board are often advised to have a homebirth to guarantee one to one care, which they will not get in hospital. A few times, they are advised that if they run into resistance booking it, they should just go ahead anyway, as they have a legal right and if they just ring the hospital who then have to send a mw out.

[worth pointing out too that spontaneous birth is unpredictable, timewise - what does a maternity ward do when it is flat out at the weekend, at a busy time of year, and a call comes in about a homebirth?)

Now, I am very pro homebirth for those women that want it. I totally support their right to choose one.

But you insist on talking about NOW, the situation now with no extra funding etc etc. I am happy to be corrected if I am wrong - but wouldn't an increase in women asking for homebirth NOW, with no change in maternity provision or funding, mean fewer mws available in hospital or MLUs? Because homebirthers are getting one to one care?

That was my point. You are focusing (unlike others, it has to be said) very much on epidurals on demand and requested cs's specifically because you say that RIGHT NOW they would deny other women one to one care during labour. i suppose someone like me would take the wider view that successful homebirths are very cheap, and so would save the nhs money, and that could be spent on more mws.

But you are resisting the scenario where more money is available, and thus more mws can be trained and employed. You keep talking about right now. So.... right now, if there aren't enough mws, and women are not automatically gettting one to one care in labour.... then someone insisting that they get one to one care through home birth is making that problem worse for other women, aren't they?

(again - I am not bashing homebirth, I am supportive of it. I am just pointing out that if you really want to go down a particular route re: funding, as Shagmund is, then there are consequences that are not just to do with epidurals and caesarians)

rainrainandmorerain Fri 21-Dec-12 08:44:32

To update - this from homebirth.org -

"Women planning a homebirth are sometimes told that the local health authority may not be able to provide a midwife on the day, because of staffing problems. If you hold out for a homebirth in these circumstances, you may feel guilty that you may be taking other midwives away from other women who need them on the labour ward. This is an understandable concern, but going along with it is unlikely to help other women in your area in the future, as there will be little incentive for the healthcare providers to improve their service. It is important to remember that staffing levels are the health authority's responsibility, not yours."

i have to say, as someone who had a very anxious time arranging her elective cs, I have HUGE sympathy for women planning a homebirth who run into resistance. And I pretty much agree with the above. (and it seems to be a terrible shame that women cannot support each others' birth choices in campaigning for bettter maternity care).

Shagmundfreud Fri 21-Dec-12 08:58:32

"My point was that I had very little time with a mw during or after my planned cs. As I've said - for me, fine - I didn't need any more involvement as my birth was easy and quick and my baby was healthy"

Yes but rain, you will will now need consultant care for all future pregnancies, and if you opt for a VBAC with another baby, you will need a lot of monitoring and midwife time. You really need to look at the impact on budgets across the whole of a mother's reproductive experience. A first c/s is a very safe operation with very good outcomes, but thereafter it becomes more complicated and more dangerous. A spontaneous v/b with a first baby usually leads on to uncomplicated births with future babies. In any case, this is about funding. Planned ELCS only looks comparable with planned v/b because so many planned v/b's are ending in emergency c/s. And also only looks comparable when you don't factor in the cost of dealing with problems in future pregnancies and births following a c/s. Our first priority for spending should be getting the emergency c/s rate down. And in order to do this we need more midwives. That's where the money should be spent.

"whereas someone having a homebirth gets a mw sent out to their home, don't they? As I said - women on this board are often advised to have a homebirth to guarantee one to one care, which they will not get in hospital."

Planned homebirths are cheaper than planned hospital births. Mainly because women who plan a homebirth have less than half the likelihood of ending up needing loads of obstetric input into their labours. For second time mums it results in absolutely optimal outcomes: high rates of breastfeeding, low rates of infection and surgery. here

According to NICE a planned c/s costs £2365. This is higher than the figures given for 2009 as it factors in future costs. The comparable figure for a homebirth is £1,066

"The news is based on a large study that examined the costs and safety of births in various planned settings, including at home and in hospital. It used data on almost 65,000 women with pregnancies considered to be at low risk of complications, and compared planned births at home, in stand-alone midwife-led units, in midwife-led units located alongside hospital facilities and in hospital. Researchers found that the average cost for a home birth was lowest, at £1,066. The most expensive were hospital births, at £1,631 on average, while midwife-led births came in at around £1,450.
Importantly, though, the research did not simply rank birth options on cost. It also looked at how safe each setting was. It found that the four settings had comparable risks of adverse birth outcomes, although first-time births at home were more likely to have them."

This is an interesting discussion of the issue: here

rainrainandmorerain Fri 21-Dec-12 09:06:18

Shagmund, you are not answering the point I made.

Yes to increased funding and more mws and one to one care for all mothers. Absolutely. I made the point about the relative low cost of homebirths myself.

But you have argued repeatedly on this thread that you will not support an increase in provision of epidurals and planned cs NOW because there will be no additional resources NOW.

By the same token, an increase in women demanding homebirths and thus getting one to one care from mws in a limited pool RIGHT NOW would result in fewer mws available to care for women in labour elsewhere.

You can't have it both ways.

Personally, as I've said, I support a woman's choice of hb, even if it does compromise existing staff levels, for the same reasons mentioned on the hb website. But then I also support a woman's right to make an informed choice about other births.

Shagmundfreud Fri 21-Dec-12 09:39:46

"By the same token, an increase in women demanding homebirths and thus getting one to one care from mws in a limited pool RIGHT NOW would result in fewer mws available to care for women in labour elsewhere."

My understanding is that women having their babies at home spend no more time with a midwife over all than a mum labouring in hospital who is having one to one care.

Usually because their labours are considerably shorter.

In any case, homebirth teams work in a completely different way to hospital midwives. They are not usually drawn from some general pool of staff who are also available to cover on labour ward and in birth centres. If they're not caring for a labouring mother at home they are running clinics in the community and doing postnatal and antenatal clinics.

Would like to raise the issue of postnatal care actually in relation to this issue. At the moment postnatal care is often described as the 'cinderella service' , and is heavily criticised by women as being inadequate in many hospitals. Even a 10% increase in the numbers of planned c/s would put a huge additional strain on postnatal midwifery services, which are barely coping as it is. It would be completely unsafe to extend the offer of surgical birth to many more mothers without having many more beds and midwives on postnatal wards and working in community.

There's also a question in my mind about to what extent operating theatres and staff are working to capacity at the moment, and how it would work if there was a large increase in demand for theatre space. My understanding is that the NHS is very 'efficient' in the sense that there is often very little slack in the system. If this is the case, how would the NHS magic up the very large increase needed in anaesthetist hours? Theatre space? Consultant cover? And how would this work in a system where nationally 14% of women are having emergency surgery in labour (0ver 20% in some hospitals).

Just a thought!

Shagmundfreud Fri 21-Dec-12 09:50:48

rain - if I was advising a friend going to give birth on the labour ward in a big hospital known to have issues over midwife numbers, one of the things I would say to her is 'remember that having an epidural guarantees you one to one care in labour'.

For an individual mother making the decision as to how to get the best and safest care in labour, this is something worth thinking about, if they know they're going into an environment where they may otherwise not get one to one care.

However, if I was sitting on a panel of doctors and midwives at the same hospital talking about how funds were going to be allocated, and the issue of increasing the number of anaesthetist hours on the unit came up, so as to make epidurals more available, I'd be asking the question - is it sensible or right to increase the availability of a treatment which necessitates that more women have one to one care and medical input (because women are about 40% more likely to need medical help to get their baby born following an epidural) in a service which may already be stretched to the limit?

And where would the money come from to have even one extra anaesthetist on duty day and night, unless the overall budget was increased to accommodate this change? And if the budget were increased, would it not be a better use of the funds to employ more midwives, as this may well reduce the emergency c/s rate, and therefore free up the anaesthetists already in situ to do more epidurals!

rainrainandmorerain Fri 21-Dec-12 09:52:00

You're dodging the question badly, Shagmund.

It may well be the case that a woman at home gets the same amount of time with a mw as a woman labouring in hospital with one to one care.

But you have said, repeatedly, that women are not getting one to one care at the moment. Far from it.

And that is one reason why women are told to go for hb as a way of getting the one to one care they don't get in hospital.

And these mws come from somewhere, don't they? Even if it is 'just' postnatal care, which you identify as being threatened by an increase in planned cs's. So if there is a finite pool of mws.... then someone getting one to one care, especially at short notice, means that other women must be getting a decrease in time with a mw.

LaVolcan Fri 21-Dec-12 09:57:26

Increasing homebirth provision wouldn't necessarily detract from hospital staffing. It depends on how the PCT organises its services.

Homebirths don't usually take midwives away from the CLU; they are usually done by community midwives, and yes, more homebirths would increase the burden on them. If there was a serious attempt to increase home births this is a problem which would need to be addressed.

For every woman who insists on staying at home and having a midwife sent, there are much more likely to be women booked for a homebirth who are told they have got to hospital because there is no-one to send out.

As far as planned CSs go, personally I have every sympathy with a woman who had a bad delivery the first time ending in an EMCS thinking that they will go for a ELCS next time and avoid the trauma. I do think (as I have said before so sorry for repeating myself) that there should be serious attempts to look at why the EMCSs are happening and find ways to reduce them. Except that part of the solution has been known for 20 years or more: that one to one attention by a known attendant improves outcomes and nothing happens. [Bangs head in despair emoticon].

LaVolcan Fri 21-Dec-12 10:09:25

Bit of a cross post there with shagmund.

About the women told to go for a homebirth to guarantee one to one care - I am not sure that many book home births on this basis - that would be a gamble.

What is increasingly seen is women being advised to get a doula to give them the support they need. Doulas were unheard of 30 or even 15 years ago. It's as though, having seen midwifery cut to the bone, women are finding ways to reinvent it.

rainrainandmorerain Fri 21-Dec-12 10:21:44

LaVolcan, that does mostly answer my point (about whether, without increasing current funding/staffing levels, an increase in hbs would place an even greater strain on the numbers of mws available to other women). It is kind of obvious! but a point worth making.

Yes, absolutely, I agree that looking at how to reduce emergency interventions is very important, and it is mad that given one to one care reduces the level of emergency care, that it isn't provided. I think it was you who said 'false economy' - I agree.

I wish people could focus more on that. The proportion of cs's that are planned and for maternal request is TINY. The majority of cs's are emcs's. No one goes into labour hoping for one of those.

Shagmundfreud Fri 21-Dec-12 12:02:31

Rain - it is tiny NOW because low risk UK mums are led to believe (whatever the NICE guidelines are saying) that it's probably not a realistic choice they can make.

However - if it was an issue of planned c/s on demand with no restrictions at all (as is being suggested by many on this thread) then the planned c/s rate could go up MASSIVELY, to match the rates in many other developed countries. In Italy in some regions it's currently 44%, in parts of Brazil it's over 80%, in China nearly half of all babies are born by planned c/s. why would that not happen here, particularly if women are not having to contribute to the cost and within the context of a system where women planning vaginal births are so often having poor care and ending up with unplanned c/s.

The voices calling for an immediate change to provide c/s on deman within our current system are not thinking about the wider implications for maternity services of a sudden and possibly large increase in surgery rates.

EdgarAllanPond Fri 21-Dec-12 12:36:19

this argument is quite bizarre.

there are pro- ELCS pressure groups - i don't expect them to lobby for homebirth, IMs, minimal interventionism...it just isn't in their remit.

so why the flying fuck should minimal interventionists have to add ELCS on to their list of stuff to campaign for?

it isn't in their remit.

it saddens me that every time people try to campaign for better maternity care, naysayers make out they are trying to make women feel 'guilty; (when they aren't, but are trying to stop so much unnecessary intervention happen)

it saddens me that some need to fudge the issue by going 'should'nt they be campaigning for this other stuff too' rather than supporting their efforts as motivated by the aim of getting women better maternity care.

it is annoying that people repeatedly claim on thread after thread after thread that all intervention is due to the UK population characteristics when the evidence is very strongly against that, evidence that is quoted on thread after thread after thread.

PeoniesPlease Fri 21-Dec-12 12:39:49

Why does it matter to you so much what other women do with their bodies? So what if 80% of women would choose an ELCS? No one kind of birth choice is any more valid than any other. What that says to me is that probably there are a significant number of women in this country who would rather have an ELCS and have not been able to have one. That is a scandal.

As I have said before, ALL women should be able to choose what sort of birth they have, and they should be supported in that. However, your last post reveals that actually, for some bizarre reason, you are terrified that allowing women the dignity to make choices about what happens to their own bodies will result in large number of them making a choice you would not make.

No one here is saying that all women should have to have surgical births if they don't want to. You are setting up a false dichotomy between funding for surgical births and funding for vaginal births. In fact, as has been exhaustively discussed, there is no difference in cost between the two types of birth. What we should all be campaigning for is increased funding for maternity services so that women have a genuine choice about what sort of birth they have, not fretting about what other women would do if they had a free choice. Happily, the only person who I have the ability or desire to make a choice about how to give birth, is me.

This is about allowing women dignity and human rights. We should all be aiming for that, not thinking up barriers to prevent it from happening, or fretting that other people won't make the same choices as us.

PeoniesPlease Fri 21-Dec-12 13:09:30

But, EdgarAllanPond I am not in a pro ELCS pressure group. I don't think things will improve for anyone until maternity services recognise the rights of women to choose their own births. That is why I want increased funding for all aspects of maternity care.

I am supportive of minimal intervention for women who want it but not at the expense of those who would like a surgical birth.

Otherwise, what minimal interventionists are saying is that because they want minimal intervention, that is what all women should be forced to have.

My only interest here is that women should be able to exercise autonomy over their own bodies, and I find it sad and shocking that so many women appear to have such a different view on this.

EdgarAllanPond Fri 21-Dec-12 13:13:14

peonies i didn't say you were confused

but the first point raised on the thread was 'why aren't they after ECS on request too'?

stupid question.

EdgarAllanPond Fri 21-Dec-12 13:14:23

"that is what all women should be forced to have."

who said that? when? where?

Shagmundfreud Fri 21-Dec-12 13:40:57

Women ARE 'allowed' to have. planned C'S in the UK just as they are in any other country. But like in most other countries, in the UK they may end up having to pay for it themselves.

I have no problem with women having planned c/s - their bodies, their choice. What I do have a problem with is this option being offered free to everyone by a cash strapped service which is currently unable to provide safe care for many women because of a lack of consultant cover, one to one care from midwives and adequate postnatal care.

Shagmundfreud Fri 21-Dec-12 14:08:23

"My only interest here is that women should be able to exercise autonomy over their own bodies, and I find it sad and shocking that so many women appear to have such a different view on this."

But that's because you are living in cloud cuckoo land - you are in complete denial about the reality of NHS provision now and in the future.

LaVolcan Fri 21-Dec-12 14:21:59

I wonder if we watched a different film? It was about women having autonomy over their own bodies. The two US labour and delivery nurses said that it was a question of when intervention occurred not if. Where was the autonomy in that?

rainrainandmorerain Fri 21-Dec-12 14:47:52

Still not responded to my point about hb, Shagmund. Just upped your vehemence about elcs. As usual.

As ever, with debates about cost of birth - we don't know what a birth costs. Because we only ever see 'on the day' costs. We never see the cost of physiotherapy, reconstructive surgery, counselling, aftercare for women and babies of any kind once they leave hospital. It is an utterly reductive and shortsighted way of accounting for birth. The cost of a birth where a baby is healthy versus one that has cerebral palsy will show up as the same - despite the lifelong care and medical help the latter might need.

And Edgar - it is so sad that you think that women can only campaign for one kind of birth, and shouldn't give a shit about what anyone else wants, birthwise. For your information - yes, I support the right of women to make an informed choice about planned cs. I also support the right of women to choose a homebirth, to use a birthing pool, to choose whatever birth they want in an informed manner. Because I think I can understand how desperately important it is to them, their beliefs, their values, and their emotional and mental health.

In fact, many of the same issues are shared by women who choose hb and planned cs (control after a traumatic birth, for example). We are not as far apart as those seeking to drive a bloody wedge between us would like to think.

It is about maternal empowerment and basic human respect. The idea that we should only pursue the birth WE personally want and screw the rest of you is just sickening. Any humane and rational conversation about 'birth rights' cannot take place by promoting the interests of one group over another.

LaVolcan Fri 21-Dec-12 15:11:43

I think we've got two issues going on here.

One is about maternal empowerment and basic human respect, which is something I think we are all in agreement with. The film happened to focus on a homebirth midwife who had been imprisoned, but a film could equally be made about the lack of autonomy felt by women being shunted through hospital systems.

The other issue is how we ration scarce NHS resources, which is a thorny problem that isn't going to go away.

EdgarAllanPond Fri 21-Dec-12 16:06:51

"
And Edgar - it is so sad that you think that women can only campaign for one kind of birth,"

What the Jeffing Jeff?
i didn't say that.

can we not debate without you making stuff up?

Shagmundfreud Fri 21-Dec-12 16:10:14

The thing is Rain that we do have some idea what it costs to provide certain types of care on the NHS, even though it involves sophisticated and somewhat speculative calculations about future costs to the NHS for things like urinary incontinence.

In any case, the reality is at the moment that postnatal wards are usually FULL of women and there is no spare capacity at all in many hospitals. And operating theatres are often working at full capacity on many NHS maternity units, with staff having to juggle space for elective c/s with high risk women needing emergency surgery.

Under current conditions a large increase in elective surgery for low risk mothers with no increase in funding would be a complete organisational disaster in relation to theatre space and theatre staff and in relation to postnatal care.

But hey ho - never mind reality. Because the government is going to allocate wads of extra cash to maternity services simply so they can do more unnecessary surgery. Not.

EdgarAllanPond Fri 21-Dec-12 16:15:22

"
I am supportive of minimal intervention for women who want it but not at the expense of those who would like a surgical birth."

except, as the best indication is that minimal intervention approaches are cheaper, it is at no ones expense so your point is specious.

a 2.3% forceps rate (compared with 8% in a clu) could save a lot of women from reconstructive surgery and the associated costs.

Shagmundfreud Fri 21-Dec-12 16:18:40

Oh and Rain - this has got NOWT to do with my births. I'm past all that now. But actually we should all individually pursue the birth we want for ourselves. That's FINE.

But when it comes to a discussion of how limited public funds can be used to best effect in maternity services, then the mantra has got to be 'it's not all about me'. In other words we've got to think about getting the best health outcomes for as many women as possible (it is a health service after all) for the money we've got to spend.

rainrainandmorerain Fri 21-Dec-12 16:39:57

Edgar - my comment (saying it was very sad that you thought women could only campaign for one kind of birth) was based on your comment: "why the flying fuck should minimal interventionists have to add ELCS on to their list of stuff to campaign for?"

I apologise if I misread your comment. It seemed pretty clear to me.

Shagmund - you keep dealing with a fictional apocalyptic future where large numbers of women suddenly demand ELCS's, and hospitals are swamped overnight. Now, one could equally argue that a sudden sharp increase in the the number of women demanding homebirths will derail existing maternity care with catastrophic consequences.

But is's just foolish scaremongering. Neither scenario will happen. And after all, most women would prefer a vaginal birth, wouldn't they?

I would also be careful about your use of the word 'unnecessary'. Many people consider hb 'unnecessary' - but for the women who want it, it is hugely important to them. The same is true with elcs. Much of the debate about cost (and we don't know the true cost of any birth) will depend on how much you value women's emotional and mental health.

EdgarAllanPond Fri 21-Dec-12 16:52:10

ECS pressure groups campaign for ECS
minimal interventionists campaign for minimal intervention

they don't have to do each others campaigning for them

not in their remit

quite an easy point to understand, i would have thought

and does not mean i only think one kind of campaign is valid.

there you are just making stuff up.

EdgarAllanPond Fri 21-Dec-12 17:04:57

you know what shag?

this will come up in a few weeks time, in another thread

people (probably the same people) will post things that are untrue again.
you, an others will post the evidence that disproves them

again

they will make out that you and others hold opinions you don't actually hold and have not expressed.
you will try to reply calmly.

it goes on and on, what is the point in this debate ? gets no one anywhere.

and all the while the Status Quo is that more women than ever have intervention during their birth which they would prefer to avoid if possible. not a triumph for choice at all. and yet people seem to think that status quo is terribly threatened by pro-womens rights campaigners.

if only it was.

LaVolcan Fri 21-Dec-12 17:13:11

Either scenario of vastly increased homebirth or vastly increased ELCSs would derail the current system.

As far as I can tell all the best efforts to quantify the cost have shown homebirths/MLUs to be cheaper, so maybe increased homebirths would derail the system less. There would be a saving on the 'housekeeping costs' of food and cleaning, for a starter. Home/MLU births have lesser rates of EMCS/ forceps so you would reduce some obstetric/anaesthetist costs.

Closing a stand-alone maternity unit often offers what looks like a quick financial gain on paper. Some years ago I was involved in the campaign to save the local one, which got closed on 'cost - saving' grounds. When they did the sums a year or so later they found that they hadn't actually saved a penny.

I can't see any improvements happening though. I really do feel despondent at times and fear for the services that my daughter and daughter in law will be offered in future.

Shagmundfreud Fri 21-Dec-12 17:46:58

"Shagmund - you keep dealing with a fictional apocalyptic future where large numbers of women suddenly demand ELCS's"

If rates of planned c/s are MASSIVELY higher in many other developed countries than they are in the UK (they are, and that's in systems where women are usually expected to make a financial contribution to their care costs) then why is it outrageous to assume that the planned c/s rate would go up significantly in the UK, if it was made clear to women that they could have one on request?

"Now, one could equally argue that a sudden sharp increase in the the number of women demanding homebirths will derail existing maternity care with catastrophic consequences."

The government has pledged to try to provide one to one care for all mothers in labour. This is the gold standard of care, and it's not unreasonable of women to expect this whether they are giving birth in hospital or in the community.

But yes - you are right. If the homebirth went up from the current 2% rate to the 10% that is seen is areas with pro-active homebirth services, then they would have to start employing more midwives, because one to one care is clearly not being delivered to all women in a hospital setting.

In financial terms however this may well end up being cost neutral because a large increase in the homebirth rate would, going on current evidence, result in a proportionate decrease in the emergency c/s rate and in rates of other interventions requiring medical input. This would take pressure off hospitals and free up theatre space and doctor time for high risk women who need specialist input.

On the other hand a sharp overnight increase in the number of women having planned c/s would result in ongoing funding issues in maternity care.

Increasing the number of beds on postnatal wards, midwives on postnatal wards, obstetricians, paediatricians, anaesthetists, theatre staff, and theatre time necessary to safely deliver a maternity service which encompassed c/s on demand would be only the immediate challenge.

Then there would be the increase in the number of doctors needed to deliver antenatal care, as all these women would need doctor led care in their next pregnancies and births, and ongoing snowballing costs as these women move on through life, with each subsequent pregnancy and birth becoming more and more risky.

"I would also be careful about your use of the word 'unnecessary'. Many people consider hb 'unnecessary' - but for the women who want it, it is hugely important to them."

Actually a homebirth is unnecessary. A hospital birth can also said to be 'unnecessary' if the mother is low risk. Luckily for women wanting home births there is no unearthly reason for the NHS not to provide one, as they are cheaper than hospital births, and tend to have better clinical outcomes.

rainrainandmorerain Fri 21-Dec-12 18:52:19

Edgar - you are just being irrational and abusive now. No point/need to engage with that.

LaVolcan, thank you for a sensible and measured response.

Shagmund - is your argument now thus - in countries where women pay for healthcare, they have more choice over how they give birth, and therefore a lot of women choose elcs? Why on earth aren't they choosing homebirth, or vb in a non hospital setting?

I think there is something odd and a bit sinister in the assumption that if elcs's were available on demand, we'd simply ALL be having them... and we must be stopped by a penny pinching and paternalistic state.

Re: hb - you keep talking about increased demand leading to more mws etc. Well, maybe, that would be nice. But upthread you were consistently refusing to entertain the idea of more funding and insisted on talking about all birth choices being accommodated NOW.

In which case - we don't have enough mws for more homebirths. We haven't got enough now, for goodness sake! Hence the number of women discouraged from or refused a homebirth. You argue one set of circumstances for one kind of birth and then move the goalposts when discussing another.

Another alternate reality - women campaign for better access
to epidurals, more anaesthetists are found and paid for, and the savings to the nhs in terms of counselling, mental health care and litigation pay for the extra anaesthetists.

Except no one will care because they don't show up on the 'birth balance sheet'. Where costs begin when you go into labour and end when you are discharged. Regardless of what happens durinng your birth and what kind of care you need afterwards.

Ushy Fri 21-Dec-12 18:57:04

Shag "Luckily for women wanting home births there is no unearthly reason for the NHS not to provide one, as they are cheaper than hospital births, and tend to have better clinical outcomes."

Not exactly - for first time mums the outcomes for home birth are three times worse BUT the risk is still low so a reasonable choice - just as elective caesarean is a reasonable choice. Yes, the risks do increase if you have multiple caesareans but, just like home birth, no choice is totally risk free.

Plus - and sorry to repeat this - once you factor in litigation it is highly unlikely there are any cost differences between caesarean and vaginal birth.

The thing that matters most is that women are treated with dignity and have their choices respected.

Where I do agree is this statement you made 'Many people consider homebirth unnecessary - but for the women who want it, it is hugely important'

EXACTLY!! Now replace home birth for the words 'elective caesarean'- can you not understand? Mode of birth is very important to women so please respect everyone's choice.

Xenia Fri 21-Dec-12 19:10:13

Home birth does not have to cost anything . You have a right to give birth alone in the UK if you want to. The state has to take decisions about what it will fund and what it will not but luckily we still regard women's bodies as their own so if they want to hire their own private midwife or use a friend or give birth entirely alone their choice, their risk.

LaVolcan Fri 21-Dec-12 19:34:42

It's more nuanced than that Ushy as I am sure you are well aware:
The Place of Birth study says:
For nulliparous women, there is some evidence that planning birth at home is associated with a higher risk of an adverse perinatal outcome.
which is not the same as your
for first time mums the outcomes for home birth are three times worse

once you factor in litigation it is highly unlikely there are any cost differences between caesarean and vaginal birth.

'highly unlikely' isn't necessarily fact. It also appears to makes the assumption that caesarean births are always successful and that it's only vaginal births which go wrong. Another problem with our maternity services is that obstetricians are overstretched too, and some women are not getting a CS when they need one, or having one performed by inexperienced staff, both with adverse consequences.

Some obstetricians would welcome low risk women giving birth outside CLUs so that they could concentrate their efforts on the women who need them.

Shagmundfreud Fri 21-Dec-12 20:24:10

So Ushy, are you saying that we could simply tell all women now that they can have an elective and not need any increases in maternity care funding? No new beds on postnatal wards? No more doctors or theatre space? No more midwives on postnatal wards?

EdgarAllanPond Sat 22-Dec-12 12:23:19

"
Not exactly - for first time mums the outcomes for home birth are three times worse BUT the risk is still low so a reasonable choice "

the actual stat for comparison is +0.4%

Ushy Sat 22-Dec-12 17:34:35

Shag You said; So Ushy, are you saying that we could simply tell all women now that they can have an elective and not need any increases in maternity care funding? No new beds on postnatal wards? No more doctors or theatre space? No more midwives on postnatal wards?

Relatively few women want an elective caesarean AND relatively few want home birth but given the psychological benefits for these small groups of women, their wishes should be respected.

It is far better to spend money on good care then on treatment for Post Natal Depression and PTSD.

But yes, there should be more one to one care- no argument about that. Why, though, don't you argue for improvements for ALL women not just those who support your particular views?

Shagmundfreud Sat 22-Dec-12 20:32:28

Ushy - where do your confident assertions about numbers come from? you are just plucking things from the top of your head as actually you have no idea.

At least I'm basing my speculation about numbers on something - namely elective rates in other developed countries and on home birth rates in areas of the UK which have a home birth friendly maternity service.

We have no idea how many women would want a home birth if a good, experienced home birth team was available in all areas and if women were properly informed at the start of their pregnancies about the clinical benefits of opting for an out of hospital birth. It might be as high as 10% (as in Brighton) or maybe even higher.

We also don't know how many women would want a planned c/s. Why do you think it would be massively fewer than women in other developed countries like Italy and the USA, especially if it's free?

Shagmundfreud Sat 22-Dec-12 20:37:34

Should add - I believe that ELCS may have some psychological benefits for some women who have tokophobia. However I'm also aware of women who were utterly terrified of childbirth who were unable to arrange a c/s - went on to have fantastic births which left them feeling stronger and happier.

On the whole you find women are pretty loyal to their birth choices, whatever they are - if they have good care and a good outcome.

Ushy Sat 22-Dec-12 21:03:50

Shag you said Ushy - where do your confident assertions about numbers come from? you are just plucking things from the top of your head as actually you have no idea.

I am at a loss as to why you are so hostile.

There are innumerable studies on this:

Behind the myth--few women prefer caesarean section in the absence of medical or obstetrical factors.
Karlström A, Nystedt A, Johansson M, Hildingsson I.

For home birth - look at the last Care Quality Commission study - most women were offered a choice but relatively few took it up. 74% were offered homebirth (probably close to 100% of low risk women) but overall only a small percentage choose it.

You may indeed be aware of women who were terrified of childbirth and were forced to go through vaginal birth against their will. That's great then is it? Nine months of terrror just to prove you were right all along?

No doubt there are some stuffy old school obstetricians who will rant on and on about how they declined home birth for some woman who was only too glad she had been forced into hospital because she ended up with an EMCS
Can't you see it is exactly the same thing?

Can you not just stand back and acccept that we should ALL be supporting everyone's choice not just trying to impose our own?

Shagmundfreud Sat 22-Dec-12 21:26:55

Ushy - I'm not being hostile!

There are NOT 'innumerable' studies on how many women would opt for a planned c/s if it were freely offered at their booking visit at the start of their pregnancy because this situation has never arisen in the UK.

And even the study you quote (which is from Sweden) quotes a figure of 10% of women wanting a planned c/s!

I repeat, if the rate of planned c/s is other countries is massively higher than the UK why on earth should ours not rise if women were offered it on the NHS?

Even in the UK, when women can afford to pay for their care they are MASSIVELY more likely to opt for a planned c/s, which is why the Portland hospital in London has a c/s rate of 47%.

"For home birth - look at the last Care Quality Commission study - most women were offered a choice but relatively few took it up. 74% were offered homebirth (probably close to 100% of low risk women) but overall only a small percentage choose it."

I have observed many booking visits and this is how the option of homebirth is generally approached:

Midwife: [gets leaflet out] "Have you considered a homebirth?"
Woman: "Oh no, I wouldn't fancy that. I don't think I would want to take the risk".
Midwife: "Ok" [puts leaflet away]

Most women turn down the option of a homebirth because they wrongly think it's dangerous. They usually know almost nothing about it. However, there have been some teams of midwives like the Albany and the Briarly who have had incredibly high homebirth rates (43% at one point for the Albany team) among very untypical client groups (namely very young mothers and mothers from diverse ethnic background) who have raised the home birth rate through offering caseloading care, which enables them to increase women's confidence about the safety and viability of home birth over a period of time.

"You may indeed be aware of women who were terrified of childbirth and were forced to go through vaginal birth against their will. That's great then is it? Nine months of terrror just to prove you were right all along?"

Hostile? Moi?

Of course it's not a good thing for a woman to go through her pregnancy in a state of fear.

"No doubt there are some stuffy old school obstetricians who will rant on and on about how they declined home birth for some woman who was only too glad she had been forced into hospital because she ended up with an EMCS
Can't you see it is exactly the same thing?"

If she went into hospital, experienced a severe shoulder dystocia and had her baby saved by paediatricians no doubt she'd be delighted about having had a hospital birth. No doubt a woman who had wanted a elcs but ended up with a traumatic vaginal birth would also be unhappy. But as I said - it tends to come down to the having brilliant care and a good outcome. If this is achieved then most women are fairly happy with their births.

"Can you not just stand back and acccept that we should ALL be supporting everyone's choice not just trying to impose our own?"

If we had a planned c/s rate of 10% among low risk mothers, our over all c/s rate would be nearly 40%. Well over this in some hospitals.

A c/s rate of 40% with no increase in midwife numbers, postnatal beds, theatre space, obstetricians and community midwives, would put maternity services under such extreme pressure I think we'd start to see an increase in deaths among high risk women in hospital and in the community.

So no - I can't support every one's choice is that choice ends up resulting in a situation where the safety of other mothers and babies is compromised.

Ushy Sat 22-Dec-12 21:36:12

It called configuring services to meet client need, Shag but
it's Saturday night...I'm going out...I give up!!!!

LaVolcan Sat 22-Dec-12 21:40:39

I do wonder how the choice of home birth is offered. If it's 'you could have a home birth, but....' then it won't be surprising if the 'offer' isn't taken up.

One of the GPs surgery in town until very recently used to say on its website that they didn't support home confinements. They were known for throwing you off their list if you asked. So fat chance there of 100% or even 70% of low risk women being offered a home confinement, (or MLU for that matter, but there is no MLU in the town). Unless of course, the question never arose because all their maternity patients were high risk, but that isn't likely either. I have just checked now and this statement has gone and been replaced by a link to the NHS choices website which does tell you the full range of options. However, I can't really see women at that surgery feeling that a home birth is a realistic choice knowing what the Practice's attitude was.

rainrainandmorerain Sat 22-Dec-12 21:53:03

And as I keep saying...

A sharp increase in HOMEBIRTHS with no increase at all in staffing or funding (i.e the exact same circumstances you envisage, Shagmund, for your fictional apocalyptic future where simply everyone will be clamouring for a planned cs) would also have an appalling effect on other women's care. And yet you would support this - but not elcs. I do stop short of shroudwaving as you do - but I think the consequences of a serious and damaging lack of provision is clear.

You cannot wave a magic wand and make more mws appear overnight. Argue a chance in culture and future funding.... fine. I accept that argument, and would make the same for more anaesthetists/consultants, with the savings being found in post natal mental healthcare.

I admit, what I am baffled by is this. You say that when given genuine choice - as in, you pay for it, you get what you want - in terms of birth choice - you think that A LOT of women choose elcs.

(why they are not choosing planned vb, I do not know - I was under the impression that that was what most women wanted)

And the main reason why women on the nhs should not be given the birth choice they want, if they want elcs, or painkilling epidurals, is because it costs too much, in your view. One rule for the rich, and another for the poor, eh.

There is something very revealing about your statement that you know women who were 'utterly terrified' of childbirth but who were unable to get a cs who had 'fantastic' births etc. So you want to make paternalistic and controlling decisions on their behalf, do you? Deny them a cs because you think they'll actually have a jolly good time of it. Ignore their feelings and wishes because (heart of the matter) - YOU think YOU know what is best for them. Regardless of what they want.

That is no different from railroading a woman into a hospital birth she does not want on the grounds that you 'know best.'

Ideological blindness, Shagmund. This is your problem.

LaVolcan Sat 22-Dec-12 21:55:54

It might be different if the conversation went:

Woman: "Oh no, I wouldn't fancy that. I don't think I would want to take the risk. If it goes wrong they have got it all there, they will pull out all the stops."

Friend: This is assuming that they let you in. Last year they closed their doors xxx times to new admissions. How happy are you driving up the motorway to the next hospital and hoping they can take you in? How happy would you be sharing one midwife with three other women in strong labour? They say you can have an epidural if you ask, but if the anaesthetist is in theatre with a CS you will probably have to whistle for it? Post-natal care, forget it, it's just about collapsed."

But friend probably won't say that because they don't want to scaremonger. I wish they would because then the country might just wake up to how overstretched the maternity services have become.

Rainbowbabyhope Sat 22-Dec-12 22:21:28

There are number of separate issues here however in terms of basic 'choice' - in the UK we have the right to chose whatever birth you want - the only issue is that if the NHS don't offer the service you want you have to pay for it privately e.g. by hiring an independent midwife or going to a private hospital. Affordability is the only limitation on choice. We might disagree with whether that is right, however this is exactly the same as for any other health service in the UK. If I need heart surgery or another type of procedure of treatment but am not happy with the options offered by NHS surgeons then I have no choice but to go with what the NHS is offering or I can pay for what I want privately. This is the reality and you cannot argue that the NHS should support every single choice for birth on the NHS while not also argue that they should do so for every single other aspect of our health. There is nothing magic about the medical support with need during birthing over and above medical support in other situations.

In terms of how NHS allocate their limited funds, which is clearly a separate issue, I think spending should focus on providing care which provides the safest means of birth to the majority of women, which is undeniably to go with how out bodies were designed to deal with this i.e. vaginal birth with the minimal level of intervention possible. There are additional risks in every single intervention added to the birth process, from providing chemical pain relied to the major abdominal surgery that is a cesarean. I simply don't understand why more of us are not clamouring for focus on the safest means for the majority of our babies to be born.

Rhianna1980 Sat 22-Dec-12 22:32:40

+1 Rainbow

rainrainandmorerain Sat 22-Dec-12 22:39:40

rainbow -

There are risks and benefits to various situations (epidural pain relief, planned cs) - and these are not the same for every woman.

The risk to one woman's mental and emotional health of being left in severe pain for a long time may be considerable. The physical risks to me of major abdominal surgery (planned cs) were pretty much the same as they would be for any fit and healthy woman of my age. But the mental risks to me of a vb - as assessed by a perinatal psychiatrist - were considerable.

In any case, 'risk' is one thing - the values different people attach to the same set of risks vary hugely.

A first time mother planning a homebirth may be aware that the risk of a serious outcome for her baby is greater than that of a hospital birth - but she may have a strong fear of hospitals, and medical intervention etc, and prefer to take the risk (albeit small) of injury to her baby. Another woman with an identical pregnancy may equally strong feelings in another direction.

I think much of this debate is about how holistically we view women and families, tbh. the arguments about rationing resources always boil down to people arguing that money should be directed towards the kind of birth they want - which sometimes, if they are very dogmatic! automatically becomes the kind of birth they think everyone should have - whether or not the poor deluded girlies want it or not.

as for funding arguments.... when the police and local hospital have to set up field 'triage' services to deal with drunks and their injuries 'Black Friday' and the weekend, so they don't overwhelm A&E - asking for extra staff to sign up for overtime to cover the extended service - don't tell me we can't afford anaesthesia for women in severe pain.

Shagmundfreud Sat 22-Dec-12 23:15:50

"There is something very revealing about your statement that you know women who were 'utterly terrified' of childbirth but who were unable to get a cs who had 'fantastic' births etc. So you want to make paternalistic and controlling decisions on their behalf, do you? Deny them a cs because you think they'll actually have a jolly good time of it."

I'm not in a position to make decisions for anyone and never will be.

I'm was just responding to Ushy suggestion that it's psychologically beneficial for women to have a planned c/s if that's what they'd prefer.

"A sharp increase in HOMEBIRTHS with no increase at all in staffing or funding (i.e the exact same circumstances you envisage, Shagmund, for your fictional apocalyptic future where simply everyone will be clamouring for a planned cs) would also have an appalling effect on other women's care."

Ok - please can you stop this. What is the difference between the staffing necessary to accomodate a low risk mum in a birth centre, and a low risk mum at home? Both get one to one care. Midwives on average spend less time at homebirths as they tend to arrive later in labour, and women labouring at home tend to have shorter labours on average than women labouring in hospitals and birth centres.

NHS evidence has homebirths as the cheapest of all care options for low risk mums.

And I haven't said 'simply everyone' will want a c/s. Why do you feel the need to distort what I'm saying? Is it because you have no answer to my valid points and therefore need to make up rubbish so you can then refute it? That's called 'creating a straw man argument' and is a well known strategy used by people on mumsnet with poor knowledge of their subject and weak debating skills.

What I actually said was that it wasn't unreasonable to assume that our c/s rates could end up being similar to other countries in the high 30's or low 40's.

With no increase in numbers of midwives on postnatal wards and without an increase in consultant hours, anaesthetist cover, postnatal beds and community midwives this would be disaster for the mothers and babies who are experiencing complicated pregnancies. Ushy is implying by saying: " It's called configuring services to meet client need" that the government would be expected to cough up more money for maternity services to fund this increase in medically unnecessary surgery. 'Instead of' or 'as well as' the funding increases needed to provide appropriate staffing to plug the current gap in the service she doesn't say.

And rain - your 'charge drunks for A&E care' is not a 'get out of jail free' card in this argument. I don't really care where additional funding for maternity services comes from - that's not something I'm particularly interested in and it's a separate argument. I'm interested in how maternity services are organised with the money they've got NOW, or the money the government intends to allocate to them in the next few years.

As for women being traumatised by pain - well yes, but if the government is planning on what services to provide for women over the next few years and looks at the evidence, what they tend to find is that women are more likely to feel positive about their births and their care when they give birth in settings where epidurals aren't immediately available - ie, in birth centres and at home.

That's not to say we shouldn't have the options of epidurals and I'm glad that most women in the UK who opt for an epidural get one and don't have to wait too long for it. If the government spent more money on birth pools, homebirth services, midwives and birth centres the evidence suggests that the rate of epidural request and emergency c/s would go down signficantly, and this would free up anaesthetists to care for mums who need an epidural.

Every one a winner no?

Shagmundfreud Sat 22-Dec-12 23:19:02

Should add that 'severe pain' in labour is not always or even usually traumatising. It's common and most women sustain no permanent emotional or psychological damage from experiencing it.

rainrainandmorerain Sat 22-Dec-12 23:43:53

but shagmund.... You said over and over again on this thread that women are not, now, currently, in nhs maternity care, actually getting one to one care. Because there are not enough mws.

It was one of the things (and I agree with you) you think women should have that they are not currently getting.

So it is just plain common sense to say that if you get a rise in a mode of birth where you DO get one to one care.... then there are fewer mws to go round the other women.

It is you who keeps talking about the situation now, with no changes to funding or staffing etc, when you are arguing against having the things you don't want. If you can magic up more mws overnight, then I can magic up more anasthetists overnight. Problems solved.

And my point about you knowing women who were terrified of vb but couldn't get a cs going on to have 'fantastic' births after being forced to vb against their will - well, you tell me what the point you are making is. Do, please. It seemed to be offered up in contradiction to Ushy's point that women who want an elcs would benefit psychologically from knowing they can have one.

Let me reframe the issue for you. A mum to be desperately wants a homebirth. Their mw/local hospital thinks that actually, they will be quite well served by a hospital birth, even though the mum is very unhappy about the idea. She is forced to have a hospital birth in a medical environment against her wishes.

Which is very much where this thread began. I would support the mother who very much wanted a homebirth - as I would support the mother who really wanted access to spinal anaesthesia and planned cs.

LaVolcan Sun 23-Dec-12 00:37:12

Their mw/local hospital thinks that actually, they will be quite well served by a hospital birth, even though the mum is very unhappy about the idea. She is forced to have a hospital birth in a medical environment against her wishes.

I think it's the PCT at the moment which decides what Maternity Service it will provide - God knows what it will be in future.

That aside, I think this is one of the problems - if the Maternity Service to be provided could be defined as a standard of care that each woman is entitled to, rather than just a requirement of the PCT to provide a maternity service, maybe things would begin to improve. Something like, 'each woman is entitled to the appropriate care as to ensure the physical and mental wellbeing of herself and optimum care for her baby.' OK, you have a problem deciding what is appropriate, but it the approach at the moment seems to be Provide a few hospitals - job done. IMO it's just as bad for the woman who is high risk to be fobbed off with say, a newly qualified midwife, when they need the services of the top consultant, as it is for a low risk woman to get fobbed of with someone popping in and out occasionally.

I the very short term I imagine this would cost money, but I would suspect that it would begin to pay dividends fairly quickly.

[Ah well, I can dream]

rainrainandmorerain Sun 23-Dec-12 02:35:38

I see what you mean LaVolcan.

It reminds me too that one of my big frustrations with maternity services in general is that they vary so much from place to place (like much of the nhs) - I know from talking to friends that actually, describing a typical ante-natal 'care path' and birth is problematic because the level of provision varies so much.

Where I live, there has been a lot of anger about all kinds of services, including maternity, being located in a few large hospitals now, rather than in smaller more 'regional' hospitals.

Which means of course that a lot of women now have a much longer journey to get to hospital based maternity care, ante-natal and birth - and it must influence some decisions about homebirth, because there's a big difference between a blue light journey of under half an hour versus one that's over an hour. 2 years ago, a very popular stand alone MLU here was closed (would not have been my choice of birthplace, I think we've established! but was very well thought of by others - no wards, just big individual suites, several birthing pools etc etc) - and the service 'rolled up' into maternity services at a very big hospital. Ironically, it was a stand alone unit that was only about 15 mins max away from the same hospital - so you had all the benefits of a stand alone unit plus the safety of a quick transfer if needed. Of course the argument was that it was cheaper.... but obviously it meant less choice, and statistically the women choosing to give birth were less likely to have the kinds of intervention they didn't want.

But to go back to your point! yes, the PCT was still providing a 'maternity service' albeit by denying some women what they wanted and moving everything to a big hospital.

Shagmundfreud Sun 23-Dec-12 07:38:34

Oh well, if it's everyone getting what they want then I would have wanted my high risk birth at home with the head of midwifery in attendance and an ambulance and an obstetric flying squad on standby. Not so ridiculous - in the 1950's they had doctors on standby to go put to homebirths which had become complicated.

Now, where's my magic wand?

LaVolcan Sun 23-Dec-12 09:08:05

Ah but that was different you see Shagmund - in the late forties and early fifties the country was bankrupt and the birth rate had risen; it was considered selfish for a healthy woman to want a hospital bed....

Unlike now, when the country is bankrupt and the birthrate has risen, but it's now "selfish" to want a home birth.....

Shagmundfreud Sun 23-Dec-12 10:37:13

I just can't get my head around how wanting a homebirth - the cheapest possible care option for a healthy mother - is seen by rain as putting similar strain on the NHS as having a planned c/s.

rainrainandmorerain Sun 23-Dec-12 11:26:52

Shagmund. I will put it as simply as I can.

I support a woman's right to choose homebirth. Let's put that up front.

You have consistently argued that any discussions about what should be available on the nhs in terms of birth choices have to take place in the context of 'now'. No change to funding or staffing - literally, where we are right now. You keep painting fictional apocalyptic scenarios where, overnight, the rate of planned caesarians rockets to overwhelm hospitals and maternity services, such that we would see an increase in women dying. Your words.

This is your choice. This is how you want to argue things.

Earlier in the thread, you were repeatedly arguing that there were not enough mws in the nhs. That women were not getting one to one care in labour.

I agree.

As I have pointed out. women on these boards are often advised to consider homebirth as a way of getting one to one care from a mw. In practice, a lot of women asking for homebirth seem to be discouraged from having one, or even refused - because there are not enough mws.

There are not enough mws. I'll repeat that.

If you are are in a situation where you are getting one to one care over some hours - you are getting a premium service to the detriment of other users of that service. You have flipped on this thread from saying 'there aren't enough mws - women are not getting one to one care’ to saying 'well, the one to one care you get with a hb is the same as the one to one care you get in a mlu.'

But women are not currently getting one to one care as standard.

The principle for hb is the same for women wanting other forms of non standard care (I use 'standard' here to mean hospital setting, aiming for vb). I don't btw, think that is a reason for not demanding a hb. Far from it.

I think the homebirth.org site sums it up better than I do. Again, this -

"Women planning a homebirth are sometimes told that the local health authority may not be able to provide a midwife on the day, because of staffing problems. If you hold out for a homebirth in these circumstances, you may feel guilty that you would be taking midwives away from other women who need them on the labour ward. This is an understandable concern, but going along with it is unlikely to help other women in your area in the future, as their will be little incentive for healthcare providers to improve their service. It is important to remember that staffing levels are the health authority's responsibility, not yours. You may sympathise with their problems, but remember that "where there's a will there's a way."

Asking for any form of non standard maternity care puts a strain on the nhs as it currently stands. I don't think that is a reason not to ask.

Shagmundfreud Sun 23-Dec-12 12:15:25

Women in consultant led units - including high risk mothers - are often not getting one to one care.

Women in birth centres are.

Those women who might choose a home birth should it be 'sold' to them more proactively then it is at present would generally otherwise be in birth centres. Getting one to one care.

I have not made any mention of how fast rates of planned c/s might go up. Only that they might go up to bring us in line with other countries. Overnight massive increase in planned c/s rates is yet another one of your inventions.

In any case - you are completely ignoring the points I have made about all the other spending a large increase in planned c/s would necessitate - in postnatal beds, obstetric input, and anaesthetist input.

So while you are right that a mother requesting a home birth is requesting one to one care, this is not 'extra' - this is the basic standard of care considered appropriate in hospital or out, no matter what the model.

elizaregina Sun 23-Dec-12 12:18:11

Should add that 'severe pain' in labour is not always or even usually traumatising. It's common and most women sustain no permanent emotional or psychological damage from experiencing it

Really?

Now that the culture is changing ever so slightly inspite of some peoples attitides and its becoming " OK" for women to admit they had a horrific time and are still scarred more and more women are admitting they found it traumatic and its been reported - labour can leave you in the same mentally traumatised state as if you were in a war zone.

I know you are fond of your stats and using them to back you up, so I think on this occasion you should withdraw that statement as there will be no stats to back you up...and until the culture and attitudes to CB are opened way up - and its ok for women to say - what they want about it- without being ridiucled and be littled and made to feel unworthy, you wont get honest responses from women able to speak freely.

For the record I was totally damaged by the pain I experienced in labour and I had one on one MW care - I had aromoatherapy - bouncing balls - etc etc etc...my Dh was amazing and didnt stop masaging me from start to finish my MW were amazing and I had a 6 hours labour with 23 mins pushing.

I couldnt have done it better at home the whole experince was fine - i moved arond and did everything i was told for a first birth my experience was amazing in terms of time - no stiches and NO INTERVENTIONS/

it was horrific, the pain was horrific and the next time I had a blissful section...not worry free - not pain free - but much much much much better....

Shagmundfreud Sun 23-Dec-12 12:18:27

Just in case it hasn't sunk in - one to one care isn't 'premium'. It's what every woman in labour should be getting. Mothers having home births do not have any more midwife input than a mother in a birth centre getting one to one care. Which is why hoe births work out as the cheapest care option for healthy women.

Shagmundfreud Sun 23-Dec-12 12:21:23

Eliza - the proportion of women saying they were satisfied with their births is highest in low tech birth settings where epidurals are not immediately available. I can give you a reference for this if you like.

And in case you didn't notice - I didn't say that women never find severe pain in childbirth traumatic.

LaVolcan Sun 23-Dec-12 13:23:45

You might not get all that much MW input in a homebirth anyway. I worked out that when I had my son mine was with me for about two and a half hours in total. 15 minutes in the morning and then she went off to do her clinics with a promise to come back at teatime. My son had other ideas and I had to get hold of her quickly - she got there with about 5 minutes to spare and my son was born at 2.55pm. By 5pm she had done all that was necessary and was gone. No chance to call a second MW or the student who hoped to see a home birth.

What of course she couldn't do, was be asked to nip out to attend a woman in the next room, in that two hours. That's probably why the bean counters don't like home birth because it's 'not efficient' but I say that such 'efficiency' isn't an acceptable standard of care.

Eliza: it sounds as though you would have benefited from an epidural. Were you offered one, and would you have taken it?

rainrainandmorerain Sun 23-Dec-12 13:32:06

Shagmund.

Women in labour in mlu's do not all get one to one care. This is the real world we are living in. Oh yes - they SHOULD do. Sure. Totally.

But they don't.

In that sense, one to one care IS a premium service. Oh, it shouldn't be. Sure. But it is.

Have a look at this link. Mlu's and community birthing units (i.e. NOT clu) a little way away from me. Chosen at random.
www.sath.nhs.uk/services/maternity/default.aspx

This is NHS official Info, remember - not a 'behind the scenes' reality. Even so - we have in the first Midwife Led Unit - no promise of one to one care. Instead, 'care is provided by 2 midwives per shift.' So let's hope there's only two labouring mums in there, eh?

On to the Mws at the Community Hospital. 'One to one care is often available.' Hmm. Okay. Let's hope it's not busy, then. Better at Oswestry Maternity unit where one to one care if 'usually' available. Better than 'often', I guess.

And this is the official info. I wonder what the reality is.

Because the real world is where we have to live - and here, women in mlu's are not guarantedd one to one care any more than women wanting homebirths are guaranteed a mw.

You may not like it - I don't - but that is reality.

rainrainandmorerain Sun 23-Dec-12 13:35:29

LaVolcan - not much mw care there, for sure - I reckon had less than half that with the mw who attended my planned cs!

Although that was in a hospital - I have no complaints, as I've said, because I didn't actually need any more care than I got - and I imagine as she was in a hospital setting she was looking after several other women as well, and they can't all have been as low needs as I was.

LaVolcan Sun 23-Dec-12 14:21:21

rainrainandmorerain - but perhaps when you are having an ELCS the amount of time the midwife spends with you isn't the key measure of an acceptable standard of care? Maybe instead it would be better measured by whether you got your CS at the right time or whether you are continually being bumped as EMCSs come in, or whether the Consultant ought to do it, but he's not in til next Tuesday, (or whenever) so you either wait or get someone less qualified to do it?

Ushy Sun 23-Dec-12 17:01:08

Shag, you said; the proportion of women saying they were satisfied with their births is highest in low tech birth settings where epidurals are not immediately available. I can give you a reference for this if you like.

Women are most satisfied when they are listened to and their choices respected.

Women who go to low tech settings and have an uncomplicated birth without the interventions they wanted to avoid understandably have high satisfaction rates. Ditto, women who want caesareans and get them: high satisfaction.

The smaller percentage of women who choose low tech birth but end up with complications and blue lighting to hospital +EMCS or forceps - they have the highest dissatisfaction rate of all. Likewise, women forced to go through vaginal birth against their will - much higher levels of dissatisfaction AND postnatal depression.

I can give references too but won't bother unless you want them because it is common sense.

rainrainandmorerain Sun 23-Dec-12 21:35:15

Sensible post, Ushy.

LaVolcan, yes, I agree - the whole idea of one to one care from a mw for. woman having an elcs is a different kettle of fish - she is not the sole carer for the mother and has such a different role anyway.

It is worth mentioning that a long way upthread, women having planned cs's were described as having a team of staff to support them - including mws - while other women were left to labour unattended. Which was partly why I posted to point out the speed of my elcs and the very small amount of time (roughly) that I had with a mw during the op and postnatally. If other women were wondering where their mws were, they sure as heck weren't with me!

Actually, on further reflection - i did have a community mw come out to me for flying visits every day for 5 days after I left hospital, to administer an anticoagulant jab. That would be an increase in care levels, for the community mw team (who in my area have nothing to do with actual birth, just pre and post natal care). On the other hand.... having had such a positive birth experience, and having enjoyed it more than I thought possible, the nhs was spared the cost of any mental health issues (I was considered high risk for pnd and dissociative disorders given my history). Which ties in with what Ushy was saying. Not that the costs of any pnd or postnatal mental health care would have shown up on any maternity balance sheet of course.

Ushy Sun 23-Dec-12 22:04:52

Shag "we don't know what percentage of women don't get epidurals following a request for one, or who experience a significant delay in getting one."

True because it is hardly the sort of thing anyone would be willing to commission any research in. However, when someone posted the thread 'Tricked out of epidural' so many mners posted that not only did the thread have to be closed when it reached a 1000 but it got in the Sunday Times!

www.mumsnet.com/Talk/childbirth/1147361-Anyone-else-tricked-out-of-epidural/AllOnOnePage

Here it is;
www.thesundaytimes.co.uk/sto/news/uk_news/Health/article555691.ece

So yes, there is a problem with one to one care, there is also a problem with epidural and caesarean acces so we should be asking for all choices.

Rhianna1980 Sun 23-Dec-12 23:03:32

le volcan"Ah but that was different you see Shagmund - in the late forties and early fifties the country was bankrupt and the birth rate had risen; it was considered selfish for a healthy woman to want a hospital bed....

Unlike now, when the country is bankrupt and the birthrate has risen, but it's now "selfish" to want a home birth....."

VERY VERY weak argument.

1.You are choosing to ignore the resources: percentage of beds in hospitals to patients needing attention and also available midwives, and how it compares between the 40s and now.

2. you are ignoring the fact that after the war there were and will be lots of war patients who needed the beds more than pregnant women do so amputees will have higher priority over child birth, so therefore using up beds will be seen selfish.

3.you are ignoring the fact that in the old times midwifery training was different than now. My nana's sister was a practicing midwife who never had the official training/degree that midwives TODAY have at university. They used to be experienced ladies/older family members etc who help deliver babies. It was easier to be a midwife than now.

4. you are ignoring the fact that the population is bigger by over 13 million ppl compared to the 40s so therefore there are much more resources needed now.

The fact that you went back 70 years to the 1940s to validate your argument is itself weakening it. The country was on its knees after the war. Anyone using hospitals for minor issues was seen as selfish at those times.

LaVolcan Mon 24-Dec-12 01:06:36

Rhianna1980 - that was meant to be tongue in cheek although there is certainly some truth in it.

There certainly weren't the hospitals available then because the country was shattered by years of war plus the depression prior to that. Whether the hospitals were filled up with amputees I wouldn't know. It's worth pointing out that today other parts of the health service are extremely stretched and being cut to the bone, as probably anyone who has helped to nurse elderly relatives will be aware, so there is still some truth in my statement.

Midwifery has been regulated since 1902 with the aim of securing better education of midwives and regulating their practice, but until sufficient training schools were set up, the Central Midwives Board had to admit so called 'bona fide' midwives who were women of good character who had practiced for at least a year. By 1933 only 3% of women admitted to the roll were untrained, with the last one in this category finally being admitted in 1947. (Majorie Tew: Safer Childbirth?) By the time I am talking about, there must only have been a handful of such women left, so the vast majority of women would have been attended by a qualified midwife. E.g. my husband's grandmother paid 15/- for a qualified midwife to attend her in 1940. The Domiciliary Service was run by the Local Authority. This has all got absorbed into the NHS now, and I doubt whether it could ever come back, even if Local Authorities had the will to do so.

Then, as now, there is still nothing to say that you have to have a qualified midwife/doctor to attend you. As Xenia points out up thread you could still get your friends in to help. What they are not allowed to do is pass themselves off as qualified midwives.

Yes, the training was shorter - 1 year for qualified nurses or two years for non nurses, although at the same time, for example, a teaching certificate only took two years.

Anyone using hospitals for minor issues was seen as selfish at those times.
Maybe that's part of the problem now - the health authorities see women's health care as minor?

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