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.

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.

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.

"
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?

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.

"
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.

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.

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.

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.

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.

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.

"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.

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.

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.

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.

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.

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?

"
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%

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?

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?

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.

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?

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.

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

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.

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.