Trying to stick to the original questions in MNHQ's post, but a lot of the points actually overlap quite a bit so this is the best way in which I can express this:
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There is nothing in the framework about for women who have a severe anxiety about childbirth and want an ELCS before they become pregnant for the first time or after a previous birth.
If the aim is to try and help women overcome anxieties, then only taking action once a woman has become pregnant adds to the stress of the experience. Baring in mind that one of the reasons that NICE changed the CS guidelines was to recognise the fact that small scale studies had shown that women with tokophobia had, in extreme cases, terminated their pregnancy.
The emphasis is solely on women once they are pregnant, which perhaps means the success rate of any counselling is likely to be much lower and ineffective as it is a race against the clock.
It also leaves a number of women in a state where they are putting off pregnancy and anxious about the process before it even starts, as they are not formally recognised in any guidance. It is wrong that women have to make such an enormous leap of faith before they are considered important enough to be considered.
The only thing in the guidance that comes close to this, is where women Draft Quality Statement 8: Debriefing where women who have had a CS are offered a discussion with a health professional about her CS and birth options for future pregnancies.
There is nothing for women who have had a difficult or traumatic VB delivery, and may want similar help and advice.
- Encourage of much clearer separation of Planned CS from EMCS in all planning and commissioning of services.
The two are still being widely lumped together as they are the same procedure, however, the risks and psychological impact on woman are hugely difference.
This is particularly true in the way that risks are being presented to women in a biased way.
When rates of CS are talked about, the number is almost always presented in a single figure - as was the case in the intro that Mumsnet posted to this very NICE consultation. Its very unhelpful as the issues surrounding both can be quite different. It is distorting things in a way that is quite alarming. EMCS are made to look safer and ELCS are made to look more dangerous. This is not helpful in the decision making process.
In using a single figure it is affecting planning, particularly in a climate which is hostile to 'expensive CS' as there are political moves to try and reduce this single figure, rather than to look the two as similar but different issues and on medical grounds alone.
- Encouraging all HCP to make publicly available clear procedures and policies about what happens if you want/request a CS or a VBAC before you see a midwife or consultant.
There is no way of finding out the procedure for going about getting a VBAC or ELCS until you are in the system and this means you are very dependant on the individual HCPs you encounter. This means from the word go, women are going into things relatively blind. Making the system transparent and encouraging the promotion of services in some way so that women do not feel that they will have to 'go into battle' in order to be listened to. Many women seem to feel that the decision is immediately out of their hands.
By making policies more open before women even see a consultant or midwife, empowers women to be more able to go and find out information before a meeting and be able to ask the right questions.
Obviously each woman is on a case by case basis, but certainly there must be generalised things that could be put forward so the majority of women have a better idea about whether they are a good candidate for a VBAC or an ELCS.
For example better use of the hospital websites could make a huge difference to this and could be relatively inexpensive.
- Better publishing of data would be hugely helpful.
Presently you can chose hospitals on the basis of what facilities they have, but data on method of birth is still quite primitive. Again this is hindering care, with many people, including HCPs having inaccurate perceptions of birth.
Data to show VBAC success rates would be hugely helpful - however, this also needs to be countered with a measure of patient satisfaction with involvement in the decision making process, in the same way that is suggested for maternal request in the Draft Quality statement 1. Rates alone are not reflective of success and should not be treated so.
Also there is nothing to breakdown rates for why ELCS are being done. This should be encouraged, particularly making clear distinctions about ELCS on the basis of mental health reasons, rather than 'maternal request' would be a massive step forward.
The term "Rates of planned CS in women in women where there were no indications for a CS" is somewhat misleading, misunderstood and frustrating in this regard. Its a fuzzy term that makes it an easy target for cuts.
More detailed rates about VBACs and ELCS are important to women to understand that both are available for their individual circumstances.
This is also hugely important to gain greater understanding of why ELCS rates in particular still seem to be increasing (I believe EMCS rates are more stable) in order to tackle issues, rather than be bogged down in politics that are being dominated by the tabloid press and to the detriment of women.
This is also true of EMCS but perhaps to a lesser extent. Women need to feel confident that hospitals are not practising in an overly defensive or being overly adverse to performing CS in certain areas.
How women are being judged when it comes to method of birth is an important aspect that is being woefully neglected. This hopefully would help to address some of those issues.