New guidance to reduce epidurals and a target rate of 20% for C-Sections

This is the Doula UK response to the new guidance

Doulas are not there to 'push their agenda' nor are they (or should they be) natural birth zealots. Our role is to support the choices of our clients. We tend to be great believers in informed choice and informed consent, which doesn't always happen. We signpost research based evidence when asked, but again, as I said, our role is one of support whether our clients wants a homebirth or a hospital birth, epidurals or not.

With regards to feminism (and I've really only skimmed through this), surely we are all, or ought to all be, feminists. I don't think of it (personally) as an insult. I think of it as people loving women and that feminism brings us choice.

Patron

My last post was not directed at you but to Lackingnamechange who followed my comments with a question as to whether I was going to give detached houses to all women who wanted home births. I don't think there is anything wrong with being middle class, that is my point. To dismiss those who want a natural birth as middle class seems to be implying that it is either a) a rather silly, frivolous obsession for women with large houses or b) something which only more privileged women have access to. I just wanted to make the point that both of those views are flawed.

Not the same midwife for whole of labour - mine was 2 days! - but having one midwife per labouring woman, not needing to wait when pressing call bell - midwife on mine popped in ever hour until it went wrong, but had 2 other women labouring at same time so when I was vomitting, panicking and having a hypo, I had a maternity support worker who, while lovely, couldn't do anything bar comfort which didn't help me at all.

I don't know anyone who has had a successful home birth but the ones I've seen on tv the midwife is often at the kitchen table having a brew or writing up note. They only really step in to examine or near delivery which is the same as at hospital.

As a PO mentionedI think it would be great if they invested in alternatives such as more in depth parentcraft, more pools (there's one in our local hospital), tens machines to loan out for use in early labour, mobile epidurals. I'm sure there's much more but I've had two hour sleep. Without all this how can they lower the epidural rate.

Kellykettle "Reduce the epidural rate by giving women alternatives and reducing the number of epidurals requested not the number of epidurals allowed. "

This

I agree 100%. Then the onus is on the midwives to work with the mother to help her manage her pain relief. Hard to police. A MW under pressure might "pretend she didn't hear" a request, but still it shifts the responsibility to the MWs rather than making the mother have to put up with it because it doesn't suit someone else.

FrillyMilly, the latest episode of "The Midwives" mentioned that 40% of first-time mothers who have or rather attempt a home birth end up being transferred to a hospital. It's rather high. But I am sure it's much lower for subsequent births as they tend to be easier and perhaps more predictable.

Could I ask what is meant here by 1-1 midwife care? Does it mean always having at least one midwife with you during the whole of the labour/birth process or having one and the same midwife curate the whole process? If it's the latter, then it is not really available in home births either or at least not always. My impression is that home-birth midwives also work on a shift basis.

P.S. There is nothing wrong with being middle-class. I am middle-class and feel rather happy and fortunate about it.

rosabud, you are really blowing things out of proportion a bit. Nobody here "dismissed" home-birthers as middle-class. I was just trying to point out that the mantra that a woman would always be more comfortable giving labouring and giving birth at home than the hospital is not always true. And yes, home births happen in all sorts of homes. But my I have a rather strong hunch that they happen more in bigger houses or simply better built houses/flats with thicker walls because many women like to have some privacy in labour.

I described my own experience of why I felt more comfortable in the hospital rather than in my own house. I have also seen similar experiences described here on other threads. Now that I have a house that affords me more privacy, I would like to try for a home-birth or at least longer home-labour for my next child.

Women who prefer hospitals are not always unenlightened. They may have very good reasons for their preferences. Take, for instance, the woman with four children who featured in one of the BBC "The Midwives" episodes. She very expressly wanted to be in the hospital rather that at home so she could be guaranteed some privacy and rest from the rest of her large family/other children and have time one-on-one with her newborn.

Apologies for typos and spelling mistakes

I'm coming to the thread quite late but have found it really interesting. I think birth is absolutely a feminist issue but not just around pain relief but the bullying of pregnant women and women in labour.

There are several groups working towards supporting women in getting the birth they want (I think one might be called The Birth I want) but they all have slightly different agendas and are small and not joined up.

In my group of friends in the last 12 months I have heard stories of a woman in pain requesting to move in labour being told she couldn't move off their back because "they were doing so well they didn't need to". Refusals of pain relief (again because you're doing well - surely the woman in labour should be the judge of that), women told they must have CS due to previous tear - even though a repeat tear was a less frightening prospect than CS. Bullying in labour, lack of support postnatally and with breastfeeding (a mum told she should bf because her preemie would have respiratory issues and then not supported to bf and encouraged by MW to bottle feed). Another friend told that she needed to have an epidural because she wasn't coping. She said she felt that she was but in the end she had it to shut them up.

Women carry all the guilt, regret and trauma for things they had no chance in achieving in the first place. It makes me very angry.

NHS antenatal classes are crap. I'm not a fan of NCT either but their are antenatal classes out there which equip women with coping techniques for labour but they cost money so aren't an option for all women. If the NHS wanted to reduce its csection rate or drug bill they could reach these techniques in Parentcraft.

Reduce the epidural rate by giving women alternatives and reducing the number of epidurals requested not the number of epidurals allowed.

And trust women to know what they want. I have been pregnant 3 times and have been patronised and spoken to like an idiot all 3 times.

Tell women the facts and all of their options & let them make the decision.

The Daily Mail comments about "I had a natural birth and it was easy but my friends ha epidurals and all tore" are, firstly, too anecdotal to mean anything but also overlook the fact that a woman may choose and epidural knowing it increases her risk of tearing and choose it anyway. That's informed choice. She may also rather manage the pain or discomfort of a tear than endure pain in labour. Surely we should trust a woman to know what is acceptable for her body and emotional wellbeing?

It frustrated me I guess that if I'd been able to opt for a HB, I'd have had 1-1 midwifery care. But it was not safe for mr or my baby. So I had to have CLU, where I had many midwives pop in but certainly not 1-1 care. Struck me as little unfair.

I have found this thread interesting and informative and have tried to engage wiht it in a thoughtful way which I hope adds something to it. But, no, I do not intend to give every woman who would like to have a homebirth a detached house, particualrly as I'm sure many have experience of less medicalised births in homes of all shapes and sizes as well as in various types of hospital, clinic etc. My point was that, dismissing women who would like a more natural birth as middle class does imply that it is a choice not available for all. The reasons why others may not have that choice, or may not feel it is an avenue open to them, are probably varied but it is an important point to make if we are talking about all women being able to make whatever choice they want. In fact, if you are going to argue that natural birth is only open to those with large detached houses then surely it reinforces the point (that some have made on here) that choosing less medicalised intervention whilst still giving birth in a medical environment is a valid thing to aim for.

How many are classed as low risk during pregnancy but would have needed to transfer to a CLU if they had been at home/MLU? It's ok to say 95% are low risk but not every labour can happen at home. I was always low risk in pregnancy but first labour required syntocin and second was induced. I think those figures would be important to make a decision about where to have a baby. I would be terrified of being transferred during a late stage of labour by ambulance.

I'm not sure whether 1:1 midwifery care actually is feasible in a system of finite resources - which other services would you want to cap in order to finance the amount of midwives needed to make 1:1 care achievable, whilst still having the CLUs in the background to take over swiftly if something goes wrong?

Maybe we need to be concentrating on the x% who opt for CLU having a better, pleasant and natural environment, and more midwives in situ for 1-1 care.

As one of the 5% who medically needed to give birth in a CLU I tend to find we're a bit forgotten in these debates - we don't have the choice, we do have substantial risks - but that doesn't mean we can't be supported toward a more 'natural' birth in a better environment!

putting a cap on CSs isn't gonna make me more keen to have a home birth, tripleing the size of my flat and sound proofing it might! whatcha gonna do give everyone nice big detatched houses to give birth in?

I do aplogise, I did not mean to imply a c section is pain free at all (though I can see that my sentence does imply this), I was simply acknowledging that choosing to be pain free (ie pain relief - although even that isn't totally pain free) or choosing a c section on demand are, of course, all valid choices. I know that a c section is a major operation with a relatively long recovery period.

These posts have made me think and I do accept that it is a good thing that advances in healthcare, medical treatment and technology have made childbirth much much safer which is a very good thing. If you argue that homebirths are a middle class thing (which I'm not convinced) then doesn't that suggest that it is something more available to those who have more access to information and who may have more confidence to choose that alternative. This suggests that homebirths or natural births or resisting medical intervention is not really a choice for all women at the moment?

the increased availability of CSs IS the gentler option compaired to how it was in the past!

"Lacking, I did sort of feel that some on here were arguing for being hooked up straight away, that it is a choice to say no pain at all, c section on demand or whatever. And, of course, that is a valid choice"

an on demand C section is not pain free, not afterwards, not always during! I think most women who choose CSs do know this! You have made a decision about people's motivations and I think its quite innacurate. I don't know anyone who chose elective surgery to "have no pain". There are all kinds of motivations, there may be a percentage for whom it is about pain, but there are many many others

those who have rosey images of childbirth pre access to CSs, go look up some of the alternatives that were commonly practiced when CSs were not, like "sympysiotomy", and may I also remind you about Kielland?s forceps! I'm sick of this camp thinking the alternative to CS would be a peaceful natural birth with live and undamaged mothers and babies!

'This is the main feminist aspect i find in maternity care. there are others - such as the poor value attached to midwifery as opposed to obstetrics (even on this thread - this guidance came from RCOGs also and yet people are sounding off against MWS not Obs !)'

I attach a lower value to midwifery than obstetrics because I don't value or want midwifery led care for myself. It has nothing to do with the gender balance of either profession and nothing to do with feminism. I fully support access to midwifery for women who do value it. There is nothing inherently either feminist or patriarchal about either midwifery or obstetrics.

The reason people are sounding off more against MWs is because the record of the RCM on birth choices is appalling. This is the organisation which proposed to charge women for epidurals a few years ago. The RCOG's record is simply not as bad. There are also plenty of individual OB's who genuinely and publicly support birth choices - including maternal request caesareans and access to epidurals. I've never heard a midwife do so in public. For what it's worth though I complained equally vehemently to both organisations because in respect of this particular guidance they are both equally guilty AFAIC.

Edgar, because other outcomes matter too. Because people place different values on different risks. Because the Birthplace study is flawed. Because risks have to be weighed against benefits. Because the Birthplace study doesn't include planned caesareans in low risk women. Because where differences in some risks and benefits are insignificant enough, it's not appropriate to advise one course of action over another.

As for why women choose hospital births- can you link to that analysis in the Birthplace study? The fact that many women may not be aware that HBs or MLUs are an option and that they treat hospitals as a default does not prove that they would choose HB or MLU if they were informed about them and given the choice.

Just because women state that they don't plan to get an epidural before they go into labour doesn't mean that they don't want the facility to be (at least theoretically...) available on site. Most women are sensible enough to realise that they are not going to know in advance just what pain relief they will want. Most are also sensible enough to realise that just being low risk to begin with is no guarantee that everthing will go smoothly, and they would prefer to be in a place with all the facilities possible available to them on site should things go wrong. That reasoning is exactly what women respond with when someone, in say the Childbirth forum here, suggests that they consider HB or MLU. It's easy to frame a question about birthplace choice in such a way that you get the answer - 'because doesn't everyone just go to hospital?' - but it would be misleading.

EdgarAllanPond sums up this matter perfectly in her last paragraph:
"maternal satisfaction is seen as irrelevant by policy makers - that is also a feminist issue."

in terms of this being a feminist issue:

i think there are huge issues relating to choice, information, and how women are treated in labour.

women are often told 'you will be have a VE/ sweep/ be induced/' without being treated like rational human beings with the power to decide for themselves. The words 'allow' and 'let' are used eg. 'we will allow you a birth pool' 'we will let you have an ELCS' - rather than 'we advise'

This is the main feminist aspect i find in maternity care. there are others - such as the poor value attached to midwifery as opposed to obstetrics (even on this thread - this guidance came from RCOGs also and yet people are sounding off against MWS not Obs !)

bear in mind a 'natural' delivery is something you are more likely to get with a skilled midwife present as opposed to a 'maternity attendant'. i always put 'natural' in brackets, as skilled midwives don't just pop out of the undergrowth - they need training and a situation that nurtures professional development.

'natural' isn't a supported choice when MWs become deskilled.

the way 'maternal satisfaction; is seen as irrelevant by policy makers - that is also a feminist issue. MLUs get high rates of maternal satisfaction. So do HBs. So do CLUs with higher MW:attendee ratios. 1:1 midwife care is a feminist issue.

but even in the area they surveyed where one was available, (case study) they found women put hospital as choice of birthplace sometimes without being aware of alternatives.