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.

It might be different if the conversation went:

Woman: "Oh no, I wouldn't fancy that. I don't think I would want to take the risk. If it goes wrong they have got it all there, they will pull out all the stops."

Friend: This is assuming that they let you in. Last year they closed their doors xxx times to new admissions. How happy are you driving up the motorway to the next hospital and hoping they can take you in? How happy would you be sharing one midwife with three other women in strong labour? They say you can have an epidural if you ask, but if the anaesthetist is in theatre with a CS you will probably have to whistle for it? Post-natal care, forget it, it's just about collapsed."

But friend probably won't say that because they don't want to scaremonger. I wish they would because then the country might just wake up to how overstretched the maternity services have become.

There are number of separate issues here however in terms of basic 'choice' - in the UK we have the right to chose whatever birth you want - the only issue is that if the NHS don't offer the service you want you have to pay for it privately e.g. by hiring an independent midwife or going to a private hospital. Affordability is the only limitation on choice. We might disagree with whether that is right, however this is exactly the same as for any other health service in the UK. If I need heart surgery or another type of procedure of treatment but am not happy with the options offered by NHS surgeons then I have no choice but to go with what the NHS is offering or I can pay for what I want privately. This is the reality and you cannot argue that the NHS should support every single choice for birth on the NHS while not also argue that they should do so for every single other aspect of our health. There is nothing magic about the medical support with need during birthing over and above medical support in other situations.

In terms of how NHS allocate their limited funds, which is clearly a separate issue, I think spending should focus on providing care which provides the safest means of birth to the majority of women, which is undeniably to go with how out bodies were designed to deal with this i.e. vaginal birth with the minimal level of intervention possible. There are additional risks in every single intervention added to the birth process, from providing chemical pain relied to the major abdominal surgery that is a cesarean. I simply don't understand why more of us are not clamouring for focus on the safest means for the majority of our babies to be born.

+1 Rainbow

rainbow -

There are risks and benefits to various situations (epidural pain relief, planned cs) - and these are not the same for every woman.

The risk to one woman's mental and emotional health of being left in severe pain for a long time may be considerable. The physical risks to me of major abdominal surgery (planned cs) were pretty much the same as they would be for any fit and healthy woman of my age. But the mental risks to me of a vb - as assessed by a perinatal psychiatrist - were considerable.

In any case, 'risk' is one thing - the values different people attach to the same set of risks vary hugely.

A first time mother planning a homebirth may be aware that the risk of a serious outcome for her baby is greater than that of a hospital birth - but she may have a strong fear of hospitals, and medical intervention etc, and prefer to take the risk (albeit small) of injury to her baby. Another woman with an identical pregnancy may equally strong feelings in another direction.

I think much of this debate is about how holistically we view women and families, tbh. the arguments about rationing resources always boil down to people arguing that money should be directed towards the kind of birth they want - which sometimes, if they are very dogmatic! automatically becomes the kind of birth they think everyone should have - whether or not the poor deluded girlies want it or not.

as for funding arguments.... when the police and local hospital have to set up field 'triage' services to deal with drunks and their injuries 'Black Friday' and the weekend, so they don't overwhelm A&E - asking for extra staff to sign up for overtime to cover the extended service - don't tell me we can't afford anaesthesia for women in severe pain.

"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."

I'm not in a position to make decisions for anyone and never will be.

I'm was just responding to Ushy suggestion that it's psychologically beneficial for women to have a planned c/s if that's what they'd prefer.

"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."

Ok - please can you stop this. What is the difference between the staffing necessary to accomodate a low risk mum in a birth centre, and a low risk mum at home? Both get one to one care. Midwives on average spend less time at homebirths as they tend to arrive later in labour, and women labouring at home tend to have shorter labours on average than women labouring in hospitals and birth centres.

NHS evidence has homebirths as the cheapest of all care options for low risk mums.

And I haven't said 'simply everyone' will want a c/s. Why do you feel the need to distort what I'm saying? Is it because you have no answer to my valid points and therefore need to make up rubbish so you can then refute it? That's called 'creating a straw man argument' and is a well known strategy used by people on mumsnet with poor knowledge of their subject and weak debating skills.

What I actually said was that it wasn't unreasonable to assume that our c/s rates could end up being similar to other countries in the high 30's or low 40's.

With no increase in numbers of midwives on postnatal wards and without an increase in consultant hours, anaesthetist cover, postnatal beds and community midwives this would be disaster for the mothers and babies who are experiencing complicated pregnancies. Ushy is implying by saying: " It's called configuring services to meet client need" that the government would be expected to cough up more money for maternity services to fund this increase in medically unnecessary surgery. 'Instead of' or 'as well as' the funding increases needed to provide appropriate staffing to plug the current gap in the service she doesn't say.

And rain - your 'charge drunks for A&E care' is not a 'get out of jail free' card in this argument. I don't really care where additional funding for maternity services comes from - that's not something I'm particularly interested in and it's a separate argument. I'm interested in how maternity services are organised with the money they've got NOW, or the money the government intends to allocate to them in the next few years.

As for women being traumatised by pain - well yes, but if the government is planning on what services to provide for women over the next few years and looks at the evidence, what they tend to find is that women are more likely to feel positive about their births and their care when they give birth in settings where epidurals aren't immediately available - ie, in birth centres and at home.

That's not to say we shouldn't have the options of epidurals and I'm glad that most women in the UK who opt for an epidural get one and don't have to wait too long for it. If the government spent more money on birth pools, homebirth services, midwives and birth centres the evidence suggests that the rate of epidural request and emergency c/s would go down signficantly, and this would free up anaesthetists to care for mums who need an epidural.

Every one a winner no?

Should add that 'severe pain' in labour is not always or even usually traumatising. It's common and most women sustain no permanent emotional or psychological damage from experiencing it.

but shagmund.... You said over and over again on this thread that women are not, now, currently, in nhs maternity care, actually getting one to one care. Because there are not enough mws.

It was one of the things (and I agree with you) you think women should have that they are not currently getting.

So it is just plain common sense to say that if you get a rise in a mode of birth where you DO get one to one care.... then there are fewer mws to go round the other women.

It is you who keeps talking about the situation now, with no changes to funding or staffing etc, when you are arguing against having the things you don't want. If you can magic up more mws overnight, then I can magic up more anasthetists overnight. Problems solved.

And my point about you knowing women who were terrified of vb but couldn't get a cs going on to have 'fantastic' births after being forced to vb against their will - well, you tell me what the point you are making is. Do, please. It seemed to be offered up in contradiction to Ushy's point that women who want an elcs would benefit psychologically from knowing they can have one.

Let me reframe the issue for you. A mum to be desperately wants a homebirth. Their mw/local hospital thinks that actually, they will be quite well served by a hospital birth, even though the mum is very unhappy about the idea. She is forced to have a hospital birth in a medical environment against her wishes.

Which is very much where this thread began. I would support the mother who very much wanted a homebirth - as I would support the mother who really wanted access to spinal anaesthesia and planned cs.

Their mw/local hospital thinks that actually, they will be quite well served by a hospital birth, even though the mum is very unhappy about the idea. She is forced to have a hospital birth in a medical environment against her wishes.

I think it's the PCT at the moment which decides what Maternity Service it will provide - God knows what it will be in future.

That aside, I think this is one of the problems - if the Maternity Service to be provided could be defined as a standard of care that each woman is entitled to, rather than just a requirement of the PCT to provide a maternity service, maybe things would begin to improve. Something like, 'each woman is entitled to the appropriate care as to ensure the physical and mental wellbeing of herself and optimum care for her baby.' OK, you have a problem deciding what is appropriate, but it the approach at the moment seems to be Provide a few hospitals - job done. IMO it's just as bad for the woman who is high risk to be fobbed off with say, a newly qualified midwife, when they need the services of the top consultant, as it is for a low risk woman to get fobbed of with someone popping in and out occasionally.

I the very short term I imagine this would cost money, but I would suspect that it would begin to pay dividends fairly quickly.

[Ah well, I can dream]

I see what you mean LaVolcan.

It reminds me too that one of my big frustrations with maternity services in general is that they vary so much from place to place (like much of the nhs) - I know from talking to friends that actually, describing a typical ante-natal 'care path' and birth is problematic because the level of provision varies so much.

Where I live, there has been a lot of anger about all kinds of services, including maternity, being located in a few large hospitals now, rather than in smaller more 'regional' hospitals.

Which means of course that a lot of women now have a much longer journey to get to hospital based maternity care, ante-natal and birth - and it must influence some decisions about homebirth, because there's a big difference between a blue light journey of under half an hour versus one that's over an hour. 2 years ago, a very popular stand alone MLU here was closed (would not have been my choice of birthplace, I think we've established! but was very well thought of by others - no wards, just big individual suites, several birthing pools etc etc) - and the service 'rolled up' into maternity services at a very big hospital. Ironically, it was a stand alone unit that was only about 15 mins max away from the same hospital - so you had all the benefits of a stand alone unit plus the safety of a quick transfer if needed. Of course the argument was that it was cheaper.... but obviously it meant less choice, and statistically the women choosing to give birth were less likely to have the kinds of intervention they didn't want.

But to go back to your point! yes, the PCT was still providing a 'maternity service' albeit by denying some women what they wanted and moving everything to a big hospital.

Oh well, if it's everyone getting what they want then I would have wanted my high risk birth at home with the head of midwifery in attendance and an ambulance and an obstetric flying squad on standby. Not so ridiculous - in the 1950's they had doctors on standby to go put to homebirths which had become complicated.

Now, where's my magic wand?

Ah but that was different you see Shagmund - in the late forties and early fifties the country was bankrupt and the birth rate had risen; it was considered selfish for a healthy woman to want a hospital bed....

Unlike now, when the country is bankrupt and the birthrate has risen, but it's now "selfish" to want a home birth.....

I just can't get my head around how wanting a homebirth - the cheapest possible care option for a healthy mother - is seen by rain as putting similar strain on the NHS as having a planned c/s.

Shagmund. I will put it as simply as I can.

I support a woman's right to choose homebirth. Let's put that up front.

You have consistently argued that any discussions about what should be available on the nhs in terms of birth choices have to take place in the context of 'now'. No change to funding or staffing - literally, where we are right now. You keep painting fictional apocalyptic scenarios where, overnight, the rate of planned caesarians rockets to overwhelm hospitals and maternity services, such that we would see an increase in women dying. Your words.

This is your choice. This is how you want to argue things.

Earlier in the thread, you were repeatedly arguing that there were not enough mws in the nhs. That women were not getting one to one care in labour.

I agree.

As I have pointed out. women on these boards are often advised to consider homebirth as a way of getting one to one care from a mw. In practice, a lot of women asking for homebirth seem to be discouraged from having one, or even refused - because there are not enough mws.

There are not enough mws. I'll repeat that.

If you are are in a situation where you are getting one to one care over some hours - you are getting a premium service to the detriment of other users of that service. You have flipped on this thread from saying 'there aren't enough mws - women are not getting one to one care? to saying 'well, the one to one care you get with a hb is the same as the one to one care you get in a mlu.'

But women are not currently getting one to one care as standard.

The principle for hb is the same for women wanting other forms of non standard care (I use 'standard' here to mean hospital setting, aiming for vb). I don't btw, think that is a reason for not demanding a hb. Far from it.

I think the homebirth.org site sums it up better than I do. Again, this -

"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 would be taking 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 their will be little incentive for healthcare providers to improve their service. It is important to remember that staffing levels are the health authority's responsibility, not yours. You may sympathise with their problems, but remember that "where there's a will there's a way."

Asking for any form of non standard maternity care puts a strain on the nhs as it currently stands. I don't think that is a reason not to ask.

Women in consultant led units - including high risk mothers - are often not getting one to one care.

Women in birth centres are.

Those women who might choose a home birth should it be 'sold' to them more proactively then it is at present would generally otherwise be in birth centres. Getting one to one care.

I have not made any mention of how fast rates of planned c/s might go up. Only that they might go up to bring us in line with other countries. Overnight massive increase in planned c/s rates is yet another one of your inventions.

In any case - you are completely ignoring the points I have made about all the other spending a large increase in planned c/s would necessitate - in postnatal beds, obstetric input, and anaesthetist input.

So while you are right that a mother requesting a home birth is requesting one to one care, this is not 'extra' - this is the basic standard of care considered appropriate in hospital or out, no matter what the model.

Should add that 'severe pain' in labour is not always or even usually traumatising. It's common and most women sustain no permanent emotional or psychological damage from experiencing it

Really?

Now that the culture is changing ever so slightly inspite of some peoples attitides and its becoming " OK" for women to admit they had a horrific time and are still scarred more and more women are admitting they found it traumatic and its been reported - labour can leave you in the same mentally traumatised state as if you were in a war zone.

I know you are fond of your stats and using them to back you up, so I think on this occasion you should withdraw that statement as there will be no stats to back you up...and until the culture and attitudes to CB are opened way up - and its ok for women to say - what they want about it- without being ridiucled and be littled and made to feel unworthy, you wont get honest responses from women able to speak freely.

For the record I was totally damaged by the pain I experienced in labour and I had one on one MW care - I had aromoatherapy - bouncing balls - etc etc etc...my Dh was amazing and didnt stop masaging me from start to finish my MW were amazing and I had a 6 hours labour with 23 mins pushing.

I couldnt have done it better at home the whole experince was fine - i moved arond and did everything i was told for a first birth my experience was amazing in terms of time - no stiches and NO INTERVENTIONS/

it was horrific, the pain was horrific and the next time I had a blissful section...not worry free - not pain free - but much much much much better....

Just in case it hasn't sunk in - one to one care isn't 'premium'. It's what every woman in labour should be getting. Mothers having home births do not have any more midwife input than a mother in a birth centre getting one to one care. Which is why hoe births work out as the cheapest care option for healthy women.

Eliza - the proportion of women saying they were satisfied with their births is highest in low tech birth settings where epidurals are not immediately available. I can give you a reference for this if you like.

And in case you didn't notice - I didn't say that women never find severe pain in childbirth traumatic.

You might not get all that much MW input in a homebirth anyway. I worked out that when I had my son mine was with me for about two and a half hours in total. 15 minutes in the morning and then she went off to do her clinics with a promise to come back at teatime. My son had other ideas and I had to get hold of her quickly - she got there with about 5 minutes to spare and my son was born at 2.55pm. By 5pm she had done all that was necessary and was gone. No chance to call a second MW or the student who hoped to see a home birth.

What of course she couldn't do, was be asked to nip out to attend a woman in the next room, in that two hours. That's probably why the bean counters don't like home birth because it's 'not efficient' but I say that such 'efficiency' isn't an acceptable standard of care.

Eliza: it sounds as though you would have benefited from an epidural. Were you offered one, and would you have taken it?

Shagmund.

Women in labour in mlu's do not all get one to one care. This is the real world we are living in. Oh yes - they SHOULD do. Sure. Totally.

But they don't.

In that sense, one to one care IS a premium service. Oh, it shouldn't be. Sure. But it is.

Have a look at this link. Mlu's and community birthing units (i.e. NOT clu) a little way away from me. Chosen at random.
www.sath.nhs.uk/services/maternity/default.aspx

This is NHS official Info, remember - not a 'behind the scenes' reality. Even so - we have in the first Midwife Led Unit - no promise of one to one care. Instead, 'care is provided by 2 midwives per shift.' So let's hope there's only two labouring mums in there, eh?

On to the Mws at the Community Hospital. 'One to one care is often available.' Hmm. Okay. Let's hope it's not busy, then. Better at Oswestry Maternity unit where one to one care if 'usually' available. Better than 'often', I guess.

And this is the official info. I wonder what the reality is.

Because the real world is where we have to live - and here, women in mlu's are not guarantedd one to one care any more than women wanting homebirths are guaranteed a mw.

You may not like it - I don't - but that is reality.

LaVolcan - not much mw care there, for sure - I reckon had less than half that with the mw who attended my planned cs!

Although that was in a hospital - I have no complaints, as I've said, because I didn't actually need any more care than I got - and I imagine as she was in a hospital setting she was looking after several other women as well, and they can't all have been as low needs as I was.

rainrainandmorerain - but perhaps when you are having an ELCS the amount of time the midwife spends with you isn't the key measure of an acceptable standard of care? Maybe instead it would be better measured by whether you got your CS at the right time or whether you are continually being bumped as EMCSs come in, or whether the Consultant ought to do it, but he's not in til next Tuesday, (or whenever) so you either wait or get someone less qualified to do it?

Shag, you said; the proportion of women saying they were satisfied with their births is highest in low tech birth settings where epidurals are not immediately available. I can give you a reference for this if you like.

Women are most satisfied when they are listened to and their choices respected.

Women who go to low tech settings and have an uncomplicated birth without the interventions they wanted to avoid understandably have high satisfaction rates. Ditto, women who want caesareans and get them: high satisfaction.

The smaller percentage of women who choose low tech birth but end up with complications and blue lighting to hospital +EMCS or forceps - they have the highest dissatisfaction rate of all. Likewise, women forced to go through vaginal birth against their will - much higher levels of dissatisfaction AND postnatal depression.

I can give references too but won't bother unless you want them because it is common sense.

Sensible post, Ushy.

LaVolcan, yes, I agree - the whole idea of one to one care from a mw for. woman having an elcs is a different kettle of fish - she is not the sole carer for the mother and has such a different role anyway.

It is worth mentioning that a long way upthread, women having planned cs's were described as having a team of staff to support them - including mws - while other women were left to labour unattended. Which was partly why I posted to point out the speed of my elcs and the very small amount of time (roughly) that I had with a mw during the op and postnatally. If other women were wondering where their mws were, they sure as heck weren't with me!

Actually, on further reflection - i did have a community mw come out to me for flying visits every day for 5 days after I left hospital, to administer an anticoagulant jab. That would be an increase in care levels, for the community mw team (who in my area have nothing to do with actual birth, just pre and post natal care). On the other hand.... having had such a positive birth experience, and having enjoyed it more than I thought possible, the nhs was spared the cost of any mental health issues (I was considered high risk for pnd and dissociative disorders given my history). Which ties in with what Ushy was saying. Not that the costs of any pnd or postnatal mental health care would have shown up on any maternity balance sheet of course.

Shag "we don't know what percentage of women don't get epidurals following a request for one, or who experience a significant delay in getting one."

True because it is hardly the sort of thing anyone would be willing to commission any research in. However, when someone posted the thread 'Tricked out of epidural' so many mners posted that not only did the thread have to be closed when it reached a 1000 but it got in the Sunday Times!

www.mumsnet.com/Talk/childbirth/1147361-Anyone-else-tricked-out-of-epidural/AllOnOnePage

Here it is;
www.thesundaytimes.co.uk/sto/news/uk_news/Health/article555691.ece

So yes, there is a problem with one to one care, there is also a problem with epidural and caesarean acces so we should be asking for all choices.

le volcan"Ah but that was different you see Shagmund - in the late forties and early fifties the country was bankrupt and the birth rate had risen; it was considered selfish for a healthy woman to want a hospital bed....

Unlike now, when the country is bankrupt and the birthrate has risen, but it's now "selfish" to want a home birth....."

VERY VERY weak argument.

1.You are choosing to ignore the resources: percentage of beds in hospitals to patients needing attention and also available midwives, and how it compares between the 40s and now.

1. you are ignoring the fact that after the war there were and will be lots of war patients who needed the beds more than pregnant women do so amputees will have higher priority over child birth, so therefore using up beds will be seen selfish.

3.you are ignoring the fact that in the old times midwifery training was different than now. My nana's sister was a practicing midwife who never had the official training/degree that midwives TODAY have at university. They used to be experienced ladies/older family members etc who help deliver babies. It was easier to be a midwife than now.

1. you are ignoring the fact that the population is bigger by over 13 million ppl compared to the 40s so therefore there are much more resources needed now.

The fact that you went back 70 years to the 1940s to validate your argument is itself weakening it. The country was on its knees after the war. Anyone using hospitals for minor issues was seen as selfish at those times.