EU law on woman's rights during birth

[cantreachmytoes]

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.

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.

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.

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.

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.

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?

"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.

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)

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).

"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

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.

"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!

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!

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.

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].

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.

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.

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.

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.

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.

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.

peonies i didn't say you were

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

stupid question.

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

who said that? when? where?

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.

"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.

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?