AIBU about "Birth after Caesarean" clinic.

[Caff2]

I had an elective section for my second child after previous traumatic birth. At booking in appointment for current pregnancy, I asked the community midwife about elective section this time, and she said she would refer me to consultant again, and did, to same consultant I had last time, and I got an appointment letter through to see said consultant in September.

Today, I had a letter from the "Birth after Caesarean" team giving me an appointment in August to "discuss options for women considering vaginal births aftersection or planned sections". I was confused as to what this clinic was, as I already have an appointment to see the consultant to discuss this. So I rang up to enquire. The hospital midwife I spoke to was quite cagey about what the appointment was for and said it was to "discuss it". So I said "Well, I already have an appointment to discuss the elective section I want with Mrs X (consultant) in September - won't she go through it all with me again?". At which the midwife said "Well, I'll cancel this appointment then, as it's clear to me that we won't be able to change your mind, so there's no point"!!

AIBU to be a bit upset about this and think that they should be more honest about what this clinic is for, as it is plainly to try and talk people out of having planned sections, and not to discuss "Options for women considering vaginal birth after section OR PLANNED SECTIONS"?

Head my recent experience of the VBAC clinic was that they wanted to discuss VBAC'S not surgery options even though I decided before getting pregnant I wanted am ELCS this time. Wouldn't discuss the section. Said that was for a consultant appointment she'd then book for me if I was sure. OP just cut out the pointless middle man VBAC clinic bit.

It is a vbac clinic not a clinic to discuss options, I phoned to double check today. I will mention the misleading letter when I see my community midwife next week.

Australia has a very high caesarean rate, and in New South Wales they tried to bring it down by encouraging VBAC. The results have not been great:

www.smh.com.au/national/health/after-five-years-of-towards-normal-birth-in-nsw-are-mothers-better-off-20150725-gijhxu.html

I had a traumatic and complicated VB, so much so that I'd end up in tears if I had to explain/discuss it afterwards. I went on to have a private ELCS, though I could have got one on the NHS. One of my reasons for going private was that I didn't want to have to explain my reasons for having an ELCS more than once and my experience on the NHS was that there was little continuity of care and you had to explain things from the beginning for each new member of staff. Going to that kind of clinic would be exactly the kind of unnecessary upset that I wanted to avoid.

The Australian article is excellent and really interesting reading, hackmum. Thanks for posting. It adds a new angle on the cost issue.

Some midwives have a real bee in their bonnet that CS are evil - to the point of being dangerous at times

Spot on there, spot on.

I really dont see why we need to bring c section rates down.

If anything they should be going up as more women choose to have one.

And who will pay for all these ELCS Rambling?

I know in countries like the US and South Africa, CSs are high as they have private health insurance, but I can't see how the NHS can fund them all here.

Mine was called a birth options clinic. The irony was that the only date they had available was about 4 months down the line when I would have been 37 + weeks. The clinic clerk didn't think this was too late!!

I declined the appointment as there was no way that I was having a VBAC.

A friend did go and found it really helpful.

Fugget - the NHS will either be paying for the C Sections or the major pelvic floor surgery required by many women later. I suspect that the cost of a CS is lower as it is a pretty quick op compared to a rather fiddly pelvic floor fix.

That Australian article is great - it does address the elephant in the room of pelvic floor trauma from VB.

I'd be interested in what the log term costs of pelvic floor repair is. I suspect it's not cheap, to put it mildly.

Which they certainly are bumbley, but I think it's really important we're all clear that these section reducing efforts are not being implemented on the advice of the World Health Organisation.

Fugghet this idea that ELCSs are definitely so much more expensive doesn't really hold water. For one, they tend to get cheaper the more people have them (NICE say they'd be the cheapest option if we all had them!). As a population, UK pregnant women are getting older, fatter, sicker and more primagravida heavy, and these factors all make the sort of straightforward VB that's definitely cheaper than ELCS harder to come by. These trends aren't likely to reverse any time soon. We don't really have a great idea how much the after effects of the various different types of birth cost the NHS either, and clearly this is something that would need to be factored in too. The picture is rather more complex.

In the UK, Caesarean sections have been found to cost an average of £1,701 while a vaginal delivery costs an average £749. The Audit Commission has estimated that a 1% rise in Caesarean section rates costs the NHS £5m per year (Parliamentary Office of Science and Technology ; 2002).
Women with spontaneous vaginal deliveries spend on average 1 day in hospital after delivery, women with instrumental deliveries 1 or 2 days and CS deliveries is 3 or 4 days (Hospital Episodes Statistics; 2004)

www.institute.nhs.uk/building_capability/general/promoting_normal_birth.html

Yes I don't think anyone disputing that the NHS claim ELCS cost more fugghetaboutit. (although I'd like to see the link you quote specify whether they're talking about all sections or just ELCS). Some of us just take issue with how they arrive at the figures. There's also a discussion needed about how current trends in maternal health and demographics are going to impact costs for the future, which the 'Promoting Normal Birth' link you provide singularly fails to consider.

Actually I wonder if that link predates the WHO dropping the recommended section rate. That happened in about 2009 or 2010 iirc, and the site mentions figures from 2008-9. Can't seem to see the date anywhere.

Very interesting link Hackmum thanks for posting.

Fugg - if you divide the obsetric litigation costs that average £400m pa by the 76% non-Caesarian rate you get that a 1% increase in Caesarian rates would save £5.26m in expected legal costs.

So if you ignore the costs of pelvic floor reconstruction surgery, costs are about the same.

Women should have a free choice without any bias in the information they get. I find it hard to work out why anyone would not want that to be the case.

Fugg- that doesn't cover lifetime cost, just the one off cost. Muff has explained much better than I can. Also what about the individual costs - 30 years of Tena Lady or 6 weeks off work and never lifting much again after pelvic floor surgery? I'm not looking forward to this, but I know it's what I'll be getting. If I had known that it was about saving the NHS £1000 I would have gladly paid. If I could have just been properly informed of the risks, I could have made a truly informed decision.

I've also seen a lot of people out after 1 night following a CS, so I think it may be out of date.

Women with spontaneous vaginal deliveries spend on average 1 day in hospital after delivery, women with instrumental deliveries 1 or 2 days and CS deliveries is 3 or 4 days (Hospital Episodes Statistics; 2004)

That's very outdated now - I mean it's eleven years ago for a start, but also the trend in recents years is to discharge women ASAP after uncomplicated elective Caesareans. I was out of hospital within 24 hours.

That link is quite old, yes. 2004 statistics aren't particularly helpful here, I think average length of stay after every type of birth has reduced since then. And certainly a figure for all CS is meaningless when assessing cost of ELCS (except insofaras allowing maternal request ELCS would presumably reduce the EMCS rate, as some of the women choosing ELCS would presumably have gone on to have an EMCS anyway. But that's not really my point). The 3-4 day stat does no unpicking at all of that.

I was just addressing that sections are of course much more costly to NHS immediately than vaginal births are and that's why they're always pushing for vbacs.
What's all the pelvic surgeries for? I've had a vaginal birth and will again soon hopefully, how common are these surgeries?

Also, most women ive known to have Emcs desperately wanted vbacs and had to really push for them. I think it's good they're helping build confidence in women to have a VBAC and believe they can

Sure fugget I don't think anyone's disputing that the immediate costs to the NHS for an ELCS are higher on average. Although as I said before, the pregnant population is becoming older, fatter, iller and more primagravida-heavy, all of which make a straightforward VB less likely, so it's possible this won't always be the case. It's just that there are also costs flowing from both VB and CS. Pelvic injuries, birth trauma to mother, birth injuries to baby, wound infection etc. Those obviously need considering too.

Re most women you know who had EMCS wanting VBAC, your experiences are unrepresentative then. The majority of women having an EMCS haven't had a previous CS and so obviously wouldn't be VBAC candidates.

Oh actually you mean the women want VBAC after their EMCS maybe? I thought you were responding to what I said about maternal request ELCS reducing the rate of EMCS.

Planned sections should be discouraged. It's extra strain on the nhs to perform an operation and a vaginal birth is better for the baby.

Firstly get your facts right. The research suggests, in this country, an elcs is slightly safer for the baby than vaginal or emcs but slightly less safe for women - although it is disputed that if all bias in risk factors was reduced (I.e. vaginal birth women tend to be much lower risk in the first place than elcs or emcs women are) that there is no difference.

Fugg your facts are a little off and rather narrow minded, even if we discount the people who would be harmed by the "its cheapest so we should do it that way regardless" attitude. To start with even taking the narrow minded view of only looking at immediate/short term costs it goes, vaginal birth without complication, elcs, vaginal birth with complications, emcs.

If you look at the bigger picture and take into account long term implications (PTSD, vaginal reconstruction, continence problems, etc) , many argue (including NICE) that vaginal birth costs more than elcs, but with emcs costing the most.

Then you could argue the cost of emcs should also be included in the cost of vaginal birth, as the vast majority of emcs are down to problems with vaginal birth. That would make elcs by far the cheapest and statistally safest.