why the drive to reduce cs rates in nhs trusts?

[cakebaby]

Hello ladies
Long time shadow dweller, after 12 week scan its definitely a real baby and not just cake, so I've ventured into the light.
l'm 39 & have had to delay pregnancy for a number of reasons, one of them being a total horror of all things birth related. I have no idea where this has come from & cannot rationalise it. I hate hospitals & have to visit them fairly regularly for work. I get light headed, sweaty, spots before eyes, the works. I suspect this is related to my mothers slow death in hospital when I was in my teens.

At my booking in appt the MW briefly mentioned the b word & gave some options like hospital, birthing unit, home birth, completely ignoring elcs. My pack from the MW with hospital leaflet also completely ignores elcs but states they are proud to be reducing the cs rate. She laughed off talk of an elcs as if I was bonkers and gave the old line 'women have been giving birth for millions of years.... body designed for it' blah...
This was not a great start for me, in one sentence she has compounded my suspicion I will not be in control of my body and what happens to me when it comes to birth, that I won't be listened to or have any say in things. This is not just about requesting an elcs, but about being treated with respect & being listened to.

So, why are NHS trusts so keen to reduce the number of cs, to the point of seemingly aggressively campaigning against them or at least cheerfully ignoring the possibility of one?
Sorry for long post, this is causing me increasing anxiety already.

Apart from the cost issue - CSs are expensive - having a CS does put greater strain on the mother. The healing tinge tends to be longer than a Vbirth & complications can arise from CSs. I had an emergency CS & was in a great deal of pain, lots of bruising for approx 6 weeks. Even now, 5 months later, the area is still sore.

That said, NICE guidelines have changed & if you do want a CS, you shouldn't be refused one. I really would do your research though, a CS is major surgery & may not necessarily be the better option to a Vbirth.

It's a tough one, oh for a crystal ball. I know it's major surgery with risks, seemingly predominantly for me. However I have a family member 20 years younger than me who had an horrific birth experience resulting in her baby being born with very severe cerebral palsy last year. It has had a massive impact on everyone's life. My friend also gave birth last summer & still has half her undercarriage hanging out (her words). I have a physical job I would not be able to conduct if I had her injuries.
Besides, it's my thoughts & opinions being blatantly disregarded I struggle with, if this is a sign of things to come. Of course an elcs must surely be cheaper than litigation for birth injury or assault?

But you're assuming things will go wrong and they're very unlikely to. A CS is major surgery. Makes it difficult to do things with your baby after the birth and return to normality. If your DH only gets a couple of weeks paternity leave it makes things difficult when he goes back to work. you will be in pain potentially for weeks.

An elective Csection is fine if you're loaded and have people waiting on you. Otherwise it can make life very hard.

If you really want one can't you pay for it privately?

OP it seems you are focusing on a few VERY rare negative situations regarding childbirth (understandably) and getting worried before there is anything to worry about.

We all hear the negaive awful stories when we are pregnant, I was terrified at first then stopped listening and got all my mum friends to really focus on the best bits to help me stay positive and it helped so much.

I don't know if it's an option to pay for a doula or private midwife? I was lucky enough to have my best friend who is an experienced MW to deliver my first and so I relaxed more and therefore it was straightforward & no complications.

If you had the chance to discuss things with an experienced professional and build up a relationship with them then you might find your views change. Sadly this is no longer an option with NHS midwives as the service is so stretched.

CS is an emergency op and not to be taken lightly as previously said, and is difficult to get over with a new born-not impossible obviously but hard work at a time when you will be wanting to rest and enjoy your DC.

Good luck whatever you decide.

Sadly not, I do not have the luxury of access to such funds. I've tried not to assume things will go wrong, my opinion is based on experience of friends, family & colleagues.
My experience of my local maternity services so far has not given me any confidence in them; no early scan as promised, rushed booking in appt with questions unanswered, 2 hr delay in 1st scan with full to bursting bladder & being told I could have a wee but it could be inconvenient for so they may refuse to keep my appointment,10 min scan with seemingly disinterested operative unable to take any meaningful measurements, refusal of 2nd scan/another try. Maybe I'm being precious, but it's not filling me with confidence so far!

I sympathise, sorry you're feeling so unsettled.

Fact is that CS is marginally more expensive than a VB (see NICE Guidelines which assessed this) but ONLY if you discount ALL additional costs of VB esp. VBs that aren't "textbook". So Pelvic floor physio and surgery, continence advice, repairs and restitches via readmission, all mental health related impacts and litigation costs are in someone else's budget and not worried about.

Whilst posters upthread are correct in reassuring you that things are very unlikely to go wrong on the scale of your family member or friend, you will find it quite difficult to find clear statistics on your chances of having an intervention free birth because outcomes for first time and subsequent mothers are almost always aggregated and yet those having subsequent babies will fair much better (lower intervention rates).

Also be wary of warnings about the downsides of ELCS. I'm not saying ignore them and I'm not saying they're not real but they can IME be overplayed to suit an agenda. Get statistics on the likelihood of it going wrong. Also the recovery from a CS is always portrayed as a negative, having done both I don't view it as such. After an ELCS you are under medical advice not to do certain things. This enforces rest and a slow recovery. Rest encourages more bonding and bf time with baby if you choose to do this.

Find the statistics of your chances of having an instrumental delivery and compare that recovery to an ELCS recovery. Bear in mind your age as a first time mother when looking for this information. Also bear in mind you'll get less pain relief and less help post VB. I'm not scaring you intentionally, I'm trying to make sure you're more informed than I was.

A consultant may well also pooh pooh your concerns. Be firm and be well informed. Be prepared to ask for a second opinion and take someone with you (partner, friend) who can advocate on your behalf if you get overcome by stress and emotion. Your feelings are valid, as are your concerns. Don't allow them to be belittled.

Good luck.

I sympathise too and think older mums often have these concerns (I had my DDs at ages 39 and 41 after a traumatic stillbirth due to pre-eclampsia in my first pregnancy in 2009 and several miscarriages -I was very worried about obstetric emergencies with my past experiences). Like you I can't stand the midwives telling me "your body will know what to do" [after all women have been dying during childbirth throughout history in large numbers until obstetric care improved....]

Both my living DDs were born by ELCS (my stillborn DD was a vaginal delivery). My first DD was ELCS due to transverse lie, my second a few months ago by repeat CS (my choice).

My first CS was straightforward but my second had more problems (wound infection and kidney infection) which meant I was readmitted to hospital twice in the first 6 weeks after birth. This was very problematic with a toddler and a baby to look after (and very painful and unpleasant for me) but i don't regret my decision to have a second CS as we are both completely fine now. However, be aware they can lead to complications for Mum in particular.

I think you will probably be offered a CS on the NHS if you stand your ground and insist this is what you want and show that you understand the risks. You will need a consultant appointment though. Many consultants are happy to offer CS to older mums as they are less likely to have a large family (the medical problems with cs tend to manifest in later pregnancies).

Good lucj

I totally sympathise
I am weighing up whether or not to have a CS or VB and am finding it very difficult, I think because I would be going so against the grain opting for a CS when people with much worse symptoms go for VB (have read many threads on this). My first birth was fine and natural - quick, no pain relief, no intervention - but in the months following it I found I was suffering stress incontinence and, after much reading, have come to appreciate much more the cumulative effects of multiple pregnancies and births on women's pelvic floors and the organs they hold in place. So I began to think about CS for this pregnancy. I know people will think I'm mad though. There is such a strong feeling against it in the UK. Maybe it's a bit like breastfeeding - all the literature you read promotes it so everyone ends up buying into and believing it is infinitely better (whereas from what I understand, there are some advantages but not on the scale we are led to believe). Likewise CS? we're surrounded with negative feelings towards it, while at the same time the NHS is keen to minimise costs, though I feel the latter does women a disservice - esp in cases like yours, when you are not being given the choice. At least not yet. Keep fighting for it up the chain and refer to the NICE guidelines. At the same time try maybe try and rationalise VB a bit more (easier said than done perhaps). You tend to hear the horror stories and not the many that go fine, though of course you know people firsthand for whom it has not gone well, which cannot not influence your judgement.
I'm rambling. Good luck and hope you get the birth you want.

Hello :) Like yourself for emotional/psychological reasons that I wont go into found the idea of childbirth absolutely horrific. Not the pain or the process just the idea of being out of control of the situation. I approached this issue with my midwife who like yours laughed it off and ignored every thing I said. So I went to see my GP who LISTENED to my concerns and after much discussion referred me to a consultant who agreed to give me a c-s as he believed (after listening) that it was the only way forward for me. My point is, if you tell someone enough (preferably your GP first) you WILL eventually be heard. Good luck. Oh and furthermore I have heard some wonderful stories about c-s from friends, family and strangers. It can still be an emotionally charged experience just like v-birth so don't let anyone's negativity sway you :)

So touched by your responses ladies, thank you. This morning I received a bland letter informing me of an additional appt at 22 weeks, which I rang to query. Turns out I have a consultant appt due to my 'advanced' age (!) So maybe I can discuss this then. I admit I am a complete control freak, very self reliant & work in a male dominated environment, which seems to have made me fearful of being out of control and dare I say it, quite mistrusting of others. I can see myself completely losing the plot with panic and fear during birth. I am also looking into hypno birthing etc to see if that could be something that works for me.

Being fobbed off by the mw, like a six year old asking for a pony, did nothing for my confidence in the system. I didn't expect it from a professional and will be more prepared for it next time!

Thank you for all the advice about research, something I'm well versed in - it took me 2 years to buy a dining table....

One of the reasons - because one of the factors that hospitals are rated on are their CS rates.

Despite there being no 'optimum' level. Despite the fact that the Department of Health and Who do not advocate targets.

Why? Because of ignorance and a belief that those women who ask for a CS are somehow weak and because CSs are SUPPOSED to be more expensive. So the response of hospitals is hugely political. And actually very few people are really challenging this. The cynic in me doesn't fail to notice that the natural birth movement is big business.

They don't want to look at the reasons why women are asking for a CS. They don't want to look at what types of women are asking for a CS. No of course not, because then they would be forced to actually do something about those issues and provide more support.

It is far, far easier to bully, brainwash and blindly TELL women what they should do and what they should be thinking. To the point that this is still something of a taboo subject.

There is also a massive tendency to lump EMCS with ELCS for everything, which drives me nuts and is completely distorting all the information out there. Not to mention, how many times when you ask about an ELCS on here do you get someone saying "well I had an EMCS and..." when the two are carried in for very different reasons and this has a massive physical and mental difference.

The NICE guidelines are a step forward, but they don't tell the whole story; and in fairness they do miss a couple of very important points. They only looked at first time mothers and the risks involved and this is a pretty relevant thing. The risks of an ELCS go up for second and subsequent births whilst those for VBs go down.

But in the case of older first time mums, who are much higher risk than the population as a whole, and perhaps are only planning on having one child for various reasons, then there really is a case to be made for an ELCS being the best option and indeed potentially the cheapest option for the NHS. Somewhat ironically.

FWIW, I do think midwives who trot out the line, 'women have been giving birth for millions of years.... body designed for it' should be retrained in cases where a woman is asking for an elective. They are SUPPOSED to a) listen to patients b) understand signs that perhaps you need extra reassurance and support c) keep their beliefs to themselves d) be educated on just how many women have died or suffered serious injury in childbirth (and perhaps say this is something that modern medicine can help with if there is a problem and help people get reassurance that way) rather than just giving a rosy lie.

Basically, we need more research, more education and staff need to be better trained.

Goodluck with whatever you decide to do btw. I hope you get what is right for you.

OP, I know where you're coming from. We mentioned ELCS to our GP and asked his view on the risks, and he laughed annoyingly and just said 'it's major abdominal surgery so I wouldn't recommend it. People ask about them, because they see all these celebrities having them, but... Etc etc'. I was so fricking cross. I understood his first point, but in my view it was then completely undermined by his next reference to celebrities. I want to make an educated personal decision about my own body and I like to think I'm intelligent enough not to be influenced in that decision by e.g. Posh Spice. Patronising sod. Eugggghh.

Anyway, if you want to do further reading, I found this very helpful: www.amazon.co.uk/Choosing-Cesarean-Natural-Birth-ebook/dp/B00867U590/ref=tmm_kin_title_0
It's completely and utterly biased towards c-sections, but I found it to be a useful counter-balance to the flood of anti-ELCS info that comes our way.

cakebaby

The biggest problem at your stage - early, is simply getting an " honest" un biased conversation with anyone about your birth choices.

This is a huge problem, you may be lucky and your consultant may not be cost driven, but it should not be this way.

You should be able to have an honest conversation without having to second guess any underlying agendas.

Anyway, good luck, you cannot wave a wand either way, the best thing is to really think how you cope under extreme pressue. And weighing up the risks of both, which set of risks you would rather be saddled with and you as a person could cope with.

If you were labouring OK, and then panic set in the babys heart rate fell, how do you think you would feel. Similary if you were in surgery and they hit a blood vessel, again how would you feel. Neither would likely happen but if they did in which situation do you think you would most likely be able to cope with.

I can totally sympathise with how you are feeling.

I have never had a cs but this is not for the want of asking. I have given birth 'naturally' twice. The first involved an instrument delivery which has resulted in a few problems. The second involved only gas and air after being refused an epidural which I had been asking for for over 4 hours. Surprise surprise by the time it became available it was conveniently too late. Without being too graphic, I wouldn't allow an animal to suffer and be denied pain relief as I was.

My understanding of current guidelines having researched this myself, is that you are entitled to an elcs but given my experience, you have to be very persistent.

Good luck.

Just to add to carpetbagger's suggestion, if you are comparing what could go wrong in VB and ELCS don't forget to think about the relative chances of it going wrong, ie: surgeon hits blood vessel causing haemorrage in 1 in x number of ELCS, baby in distress and EMCS needed in 1 in y births or instrumental delivery for emergency needed in 1 in z births.

I'd panic more when both my life and that of my baby were at risk but I may still choose the procedure if I knew that those emergency scenarios were (for example) hundreds of times less likely to happen.

Part of the reason has to be that 'targets' are set by those who have no clinical knowledge. The power in the NHS is not with clinicians but with those who think they can make 'economies' at the expense of women's health and the health of babies.

Anyone who KNOWS about the true risks and long term costs, would love a request for a 39 year old to have a c/s; much less likelihood of a legal action or costly and traumatic vaginal birth that gets complicated and ends up with an emergency cs. It actually only costs £84.00 extra to do a caesarean if you take into account the higher cost of the repair of birth injuries arising from vaginal birth - this is based on NICE's own statistics.

Complications in older mums are not rare - they are common in older first time mums. I don't quite think it is fair to say otherwise because it is blatantly not true. Moreover, humans have one of the most ill designed bodies for giving birth as a result of walking upright, having a small pelvis and giving birth to offspring with large round heads. Yes, we have been giving birth for millions of years and dying in droves doing so.

Scotland surveyed its delivery related deaths in 2009. About 1 in 200 planned vaginal births ended in a baby dying from oxygen starvation. There were 48000 planned caesareans and NOT ONE baby died from oxygen starvation.

What I find so infuriating is that there are doctors working in the NHS who are telling NHS patients one thing but their private patients something else (hence the high rates of planned c/s at the Portland).

Good luck with the battle but hope you keep it up

Because they carry higher risk to both mother and baby, longer recovery time and can result in subsequent repeat sections for further births. It's major surgery (my dr likened the scar size to a heart surgery scar yet woman are back in their feet trying to do too much within days).

How about undertaking a hypnobirthing course and see if you work through your fears? Hiring a doula may help too. X

If only there was counselling or CBT therapy offered on the NHS for those scared like yourself, such a shame. Xx

First of all, congratulations on your pregnancy!

"This is not just about requesting an elcs, but about being treated with respect & being listened to."

Exactly. Regardless of her own views, the midwife should be taking your fears seriously, not making flippant remarks. I particularly hate comments about how we are "designed" to do something-or-other. Erm, no, sorry, we're not "designed" to do anything, actually. That's not how evolution works.

I think you should consider some sort of counselling/therapy regardless of how you eventually give birth. If you have deep-rooted phobias to do with birth, hospitals etc. then the mere process of being pregnant (especially as you start to show) and having examinations and other procedures could be traumatic or disturbing to you.

Planned cesarean certainly can be a good way to give birth, and I would maintain that if you are sure of your dates and committed to having a small family, it is a very valid way to give birth too. If you have tokophobia you may have success in getting one if that's what you decide to go for. However, planned cesarean is certainly not right for every woman.

I'd just like to second the recommendation of the "Choosing Cesarean" book. I've no doubt you'll have plenty of people coming along to tell you why you shouldn't do a cesarean and should have a natural birth instead; this book will give you the other side of the story so you can come to your own opinions.

Most important thing is, do not let anyone (including me, LOL) tell you how to give birth. You are the best judge of this.

"Because they carry higher risk to both mother and baby" Tranquilitybaby is INCORRECT in this assertion. CS is the safest form of delivery for baby (see Ushy's fact-based evidence). It does carry a higher risk of initial breathing difficulties but the risk of permanent damage to baby is higher with VB.

Again, thank you all for your contributions. It is an emotive issue and divides opinion. Not that I have experienced it yet, but I anticipate birth will be one of the most emotionally charged experiences of my life. I imagine I will be totally reliant on the experience and care of the midwives and I need to have confidence in them. Too many of my friends, in their opinion have been harshly treated, in short told to stop whining and get on with it. I do not expect to be spoken to like that by anyone, at any time, let alone in labour!
By no means have I made any decisions yet, but am continuing my research and have discounted nothing. However, I do not want a vb with instruments which have not been used in other 'developed' countries for a decade. I don't want to end up in crisis, exhausted with a distressed baby at risk of life changing injury. Yes, I know no one would want these things but as carpet points out, getting a straight answer is difficult and figures can be used to support any point of view.

Tranquility What kind of doctor bases advice on recovery periods on the size of the scar? Think about it. Do you really think heart surgery would normally have the same recovery period as an ELCS in a healthy patient? Your doctor is not the brightest.

Cake I had a CS as baby was breech in the end but had one agreed beforehand on request anyway. One of the reasons was that I didn't want to be at the mercy of midwives because I fundamentally disagree with the philosophy of birth that most/many of them share. I didn't want to be dealing with that kind of basic difference in values and understanding with the people caring for me at such an important time and while in a vulnerable position. I also often find medical professionals in general patronising. With a CS they could get on with what they're good at and leave me in peace! If I'd gone for VB and been refused an epidural or something on one of the usual spurious pretexts I'd have had serious rage issues for a long time afterwards and that's not healthy... My CS was great, recovery was fine, really calm and peaceful way to give birth.

This is an interesting thread. I think I see two issues being discussed: the relative merits of CS vs VB and OP's personal fears. On the relative merits, I was discussing this recently with a friend. We realised that all of our medical/doctor friends have opted for CS which I think says a lot about the safety of ELCS. The main reasons cited were mother wellbeing - no undercarriage trauma and later incontinence issues.

fearful of being out of control and dare I say it, quite mistrusting of others. I can see myself completely losing the plot with panic and fear during birth.

Reading this OP, I see that the fear about VB is actually only part of a greater fear of losing control. If I were you, I would be thinking several things: trying to resolve the root of these fears, possibly looking towards a VB as a way of confronting these fears head on. I have another friend who has pretty extreme control issues - she followed the same logic as you but ended up choosing a HB because she decided any medical interference would lead to things going outside of her control. As others have said, a CS is still trusting other people to do their job.

I think one of the most empowering thing about childbirth and having children is you have to hand over control - you can't control everything. I'll give you an example: my DS was born at 33 weeks - I couldn't stop him coming early, I couldn't help him when he got jaundice, I couldn't hold his mouth open and help him bf at 36 weeks. Later on when he got a fever, I did what I could but it was always his body and his fight to fight. I had (and still have) little control over these things. It's quite humbling acutally.

To let go control you have to have trust in place. I think once you find a consultant/GP/doula whatever you trust maybe you'll start to feel differently about your birth.

Wise posts from Sioda, Herethere and cakebaby.

If I were to give birth on the NHS today, I would opt for an elcs simply because midwide-led maternity services on the NHS are understaffed and can be substandard. The hospital I gave birth to ds at was in the news today for having turned away a labouring mother. That same scenario was played out when I was there 6 years ago. However, because I opted for an elcs, the hospital had to give me a fully staffed theatre to perform my elcs. My elcs birth was absolutely uneventful whilst unbeknownst around me, women were being turned away from the hospital and those that were there were giving birth (not just labouring) 4 in one screened off room.

Until the NHS properly supports women who go in for a natural birth, I would be absolutely selfish and put my safety and the baby?s foremost. I got the option of an elcs because my first was an emcs. Generally speaking, an elcs is the safest for baby but more risky for the mother. I see it as taking the risk onto myself, and paying a small premium as insurance for a more certain result. Natural birth can work wonderfully for mother and baby but when it goes wrong, can be highly unpredictable and escalate quickly with grave consequences. In terms of the hierarchy of risk, emcs is the most risky. So rather than take the risk of a natural birth going wrong and ending up as an emcs, an elcs is a more predictable outcome.

If you are not planning a big family, elcs is a choice worth considering.

I don?t understand the need to address any fears of natural childbirth. Men don?t have to. I don?t see why it is inevitable I have to push a baby out of my vagina just because women since time immemorial have been doing so (and many dying or permanently injured the process). If you can have an elcs and you have made an informed decision about the risks, it is a nice place to be.