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.

Fed up with reiterating my points numerous times only for them to still be ignored. That's the whole point of this thread! Oh the irony.

My reasons for delaying pregnancy and not financing a private elcs are irrelevant to this thread and I will not discuss them, so please do not ask.

Thank you to those who are answering my queries in my original post and taking time to read the responses so far.

You ask:
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?

If the question has been answered it's only in passing.

I assume that the answer is cost - not long term costs but immediate ones. A CS needs an obstetrician, anaesthetist, theatre nurse - don't know who else, but about 8 people. With a VB they can scimp on staffing and have one midwife between 3-4 women - not an acceptable standard of care in my book, but 'they' appear to think otherwise.

IMO they are aiming for the wrong target - what they should be trying to avoid is EMCSs. Most people agree, (I think, but no doubt someone will challenge me!) that this is one of the least safe forms of birth. I feel this is where the focus should be, and questions like 'why did this happen', and 'how could it have been avoided' should be asked much more often than they seem to be.

LaVolcan "what they should be trying to avoid is EMCSs. Most people agree"

EMCS are certainly dangerous ones but I think we have to take into account the jaw dropping stupidity of the NHS. What they will no doubt do is 'target' EMCS reduction - the easiest route to which is to leave more women struggling in complicated labour for longer and to take more risk.

The end result? More traumatised women, more brain damaged babies, more horror stories about birth.......and more requests for ELCS.

LaVolcan, I think what you say is a subject for another thread, rather than this one though I do think its partly relevant in terms of fear, psychology and trials of labour.

I don't dispute that an EMCS is generally the most risky physically. I'm not aware of much research in the area of whats riskier psychologically though, since its not something that really gets much thought thought and doesn't take into consideration whether a women is ambivalent to her outcome of birth or very pro CS or VB which could potentially distort any findings.

There are women to whom the idea of an EMCS is utterly awful. I also think there are a lot of people who are more afraid of an instrumental delivery than an EMCS. And if they think thats a possibly then want to have a CS sooner.

Which creates a bit of a debate about the point of intervention.

In theory, the principle is, the sooner you intervene and perform a CS the less the risk - hence why trials of labour are allowed to a point in certain circumstances.

So you could argue whether that CS is a 'low risk EMCS' or a 'higher risk ELCS' in that situation. I know the definition is strictly whether they are labouring or not, but its open to a certain about of debate.

It could make for an interesting discussion but something I doubt you really couldn't do much research on which would be very meaningful and comparable.

One for another thread I feel.

Agreed Ushy - I think someone said this upthread a couple of days ago, that the targetting needs to go alongside more support for women, which isn't happening.

Hang on a minute there....I think the issue of privately funding an informed decision when it is likely that the current system will pooh-hoo you out of the office door IS relevant to this discussion. While my initial reasoning was based on an erroneous belief that ELCS is more expensive than most VBs, it is not an invalid point to make, and don't think I don't speak from experience: I KNEW I was going to be bullied into going into hospital for my first birth - by the Drs and the medical insurance companies who play a game of cat and mouse with their clients so I made sure I had the money to pay for a private midwife and homebirth - the only reason I ended up in hospital that time was because my lovely ExDH went out and spent that money because he didn't want me to get my way and I was left with no choice. I do know what it is like to have your choices taken away from you as a pregnant woman and to be left powerless - more women voting with their feet and playing Drs at their own game by taking the power back could have an impact on the possibility of more listening ears in the future. While standing your ground and keeping on going until you get what you want is one way to get it, I personally would not want to put myself through all that stress while pregnant. I felt that you knew based on who you are what you wanted ahead of time and could have possibly planned for the eventuality of having to go private. It was a valid question.

The trouble with people going private is this:

1. It doesn't change the NHS because unless there is demand there is no funding allocated
2. Not everyone can afford to go private (and frankly, nor should anyone have to go private to get necessary medical care)

I've had two home births on NHS including for my first baby, so while I didn't get a caseloading midwife aka continuity of care from a single HCP, neither did I have to pay to go private. Yes I came up against some bull shit from time to time but equally most people were just casually dismissive because they didn't have to do anything for a home birth until the actual labour. I can well see how people requesting an ELCS which needs people to be much more active in actually arranging it and has much more bureaucracy and hierarchies to negotiate would be much, much harder than getting my home birth.

Katie - I should have added that my 1st child was born in the US - different ball game - but same outcome, I was bullied and my choices taken away.

And I agree, no one should have to go private for necessary medical care - but necessary is to some extent a subjective position. My son has buck teeth - it affects him, he hates his smile, people make fun of him, it's a disfigurement in his eyes, and in mine...but in the eyes of the NHS, and others, having braces for him is not medically necessary...but a cleft lip would be seen to...

People choosing to go private for an ELCS may not change funding to the NHS but for those that could plan ahead and do it could help to change the tide. It's not for everyone, and I applaud the women who have the strength to go through the disrespect they recieve while they are pregnant and the stress it causes, but I just personally would have made sure I was going to get what I wanted - nature allowing of course too.

With regards to necessary I refer to NICE on this one. RedToothBrush has posted the exact wording above.

Other things that are not considered necessary are a different ball game and irrelevant to this debate. The current postcode lottery and drug funding is not acceptable but until such time as one can change the system one needs to play the system.

In the OP's case she has a right to ELCS as established by NICE.

I have posted up thread about the bullying of choices and taking away of rights for any woman who wishes to deviate from the general protocol and made some comparison with ELCS and home birth because there is often much in common with the thought process and rationale applied by women to those choices and how both groups experience the same patronising attitudes about how and why they come to those decisions.

I've seen your post upthread about this Katie...but I don't understand why you are pointing that out to me...do you think I'm of some sort of 'it's-okay- for-homebirthers-to-fight-for-choice-but-no- ELCSers to do so' bent? That would be rather hypocritical of me. Since you've already described me as rude and condescending I assume you think the worst of me.

You missed 3 there Katie

3. There is pretty much no option outside London for women in the UK to have a private CS even if they CAN afford it.

eh? I said earlier that your posts were rude and condescending and that you should read the thread. This was because in context they were quite rude and condescending (IMO) for the reasons i alluded to and other posters including the op expressly stated. I didn't say you or all your subsequent posts were. I try to take an attack the post not the poster attitude.

I was concurring with you on the point about choice, hence the reference to my earlier thread. Common practice when debating.

If I think anything of you I will say it if it is relevant. At the moment I am thinking, based solely on what you have posted, that you may be a little over sensitive because you make inferences from my posts that I have not implied and take offence at my use of some common Internet acronyms. I also think you are probably not unreasonable in your actual opinions about the subject but I'm finding it hard to pick out the salient points in between the other stuff.

But mainly I'm just thinking "eh?"

Earlier post up thread.

Yy RTB. You're quite right. Very few options and also I would not want to buy a CS in a hospital with no provision for emergencies. Currently only NHS hospitals have the staff and facilities to manage an accute emergency.

..."but until such time as one can change the system, one needs to play the system."....Katie, you say that the NHS deciding unfairly what is medically necessary (which would include often ignoring NICE guidelines, which I gather is a common occurrence) is unacceptable...I would think that would be for all relevant needs wouldn't it, not just ELCS and since it is the NHS we are dealing with here and not a different medical branch it's all the same thing. My point original point was that the OP was already in the zone of knowing oneself and knowing one will almost certainly not want to have a birth that the NHS deems acceptable and had known for some time, was about possibly having to play the system...which would, validly, include planning ahead if circumstances allowed and paying for it instead of relying on a body that seems to be proving itself to be more and more unreliable.

And Red, no option outside London stinks and is unacceptable...but if demand doesn't increase by people voting with their feet while the NHS drags it's heels...how are there ever going to be hospitals outside of London that do this?

There's more than one way to skin a cat..that was certainly the approach I took when I found myself at the opposite end of the spectrum - fighting for a homebirth in a country that relies on compliance and patient co-operation to fund it's extremely lucrative medical industry and I planned ahead.

Katie, I don't think saying for fucks sake and read the fucking thread to someone you don't even know is inoffensive, it is highly offensive and I would never dream of talking to someone like that unless they had overtly been rude to me - and I wasn't overtly rude...misinformed maybe regarding the cost of ELCS, but I was not rude...now if I had called the OP various names for her choices and pooh-hooed her and ridiculed her I think you would have been quite justified in swearing at me...but for making a mistake on old information I had had been daft enough not to check up on first? That's offensive, so yes, you've offended me and yes, I'm not particularly expecting you th be pleasant toward me or not condescending towards me. But thems the breaks...it is mumsent afterall. Lets leav it at that before I say something offensive.

If you knew anything about NHS funding you would know that people going privately reduces NHS funding and provision. It doesn't make politicians who hold the purse strings more likely to give money. It makes them more likely to say there's no demand. They look at waiting lists and who is shouting loudest.

We already see cases where people cannot access Speech and Language Therapy for their children or proper postnatal and breastfeeding support due to NHS cutbacks. Where i live our community mw teams are being cut back alomg with the service they provide. I have sat in NHS consultations where the debate has not been about clinical need (there is unanimous agreement and plenty of evidence to back up there being a clinical need) nor had it been about longer term cost implications of avoiding early intervention (again complete agreement) but the debate is about can we get funding? We can funding for the following postcodes because they are "deprived". We cannot get funding for these postcodes despite there being clear evidence of greater clinical need.

Going private will not improve NHS provision. It will just make it worse.

You can't have a CS at a regular private hospital. Simply not an option. Its a myth that people think that they can and they can have a CS such hospitals - precisely for the reason you mention - they don't have the facilities to deal with it. So when people say 'go private then' they really have very little understanding what they are saying.

Private insurers generally refer women one of the private London wards which are in NHS hospitals or the Portland (or the few birthing centres out there) or you go through NHS facilities for giving birth.

If you have private insurance, it doesn't necessarily cover you for a maternal request either. Most policies don't cover it. I am aware of a case where women who have needed a CS have found herself in a mess, where the insurance company refused to pay for it, as they have argued over the 'validity' of this CS. The decision was very controversial and the insurers were condemned for it.

So if the insurers refuse to recognise your request for an ELCS, that means you have to go through the system independently without their back up and have to pay the full whack. And there isn't information on how to do this, and few NHS workers would know where to point you to get this, even though it would be done on their premises and with their staff in many cases.

I'm sure if you asked the NHS midwives on here, they wouldn't have a clue how it worked or who you would need to talk to, to arrange it yourself.

All of which is pretty much why I've ruled it out as a option. It'd be another battle of a different kind against the same system, which is what I'm looking to avoid in the first place!

Daft isn't it. You effectively have no choice, whether you can pay for it or not due to the facilities, the system and who controls them.

If you find FFS and RTFT offensive then maybe Internet forums are not for you trustissues.

And Red, no option outside London stinks and is unacceptable...but if demand doesn't increase by people voting with their feet while the NHS drags it's heels...how are there ever going to be hospitals outside of London that do this?

There are women who travel hundreds of miles to give birth in London. The Portland has been criticised for having such a high CS rate, and yet no one looks at where these women have come from - its a situation similar to the Edgeware Birth Centre statistics earlier on this thread.

Women HAVE been voting with their feet; but some are still more able than others to do this. The logistics of having to be in London when I have no family there, make it impossible for me to do, even if I did have the funds to pay for it.

And people really aren't paying much attention to this voting with their feet either.

In terms of building facilities outside London, you also forget the British opposition and suspicion of private health facilities and worship of the NHS. You forget the additional bureaucracy and politics of setting them up in that climate. Politically building a private maternity hospital in the NW which is Labour's heartland, would create a storm. It would be seen as a threat to NHS services. Which would make it unlikely to ever actually be built; it'd never get past planning.

If you book in at The Portland a CS is about £12k I think (haven't looked for a while). If you needed accute emergency expertise and facilities they would transfer to St Mary's (I think - memory not terribly reliable for names at the mo!). There was a news report a few years ago where a woman died because it was alleged The Portland didn't transfer her quick enough. I'll see if I can find it.

I know the story you mean and I believe they have changed their procedure as a result; if its the one I'm thinking about they made a lot of fuss about what they have changed as a result. Feasibly, how is this really any different to a woman giving birth at home or in a stand alone MLU tbh though?

There was even case a year or two back of someone travelling 300 miles or more to go to a birth centre in Scotland. When she went into labour they jumped in the car and drove like crazy up north. I think the person had had her first there which is why she wanted to go back.

I think the difference is known risk. Mainly from anaesthetics and the actual surgery. That's not an issue in MLU or hb.

I could only find DM links which are not exactly impartial or balanced.

They don't even do forceps or ventouse at MLU because it need an obsetrician to do it.

Fwiw I think The Portland is probably no more or less safe than an NHS hospital.

Redtooth - I wasn't implying that going private meant through going through a private health insurance company...I trust them even less than the NHS maternity services having had 6 years experience states side of dealing with health insurance snakes.

You make some very valid points about what would basically be closing ranks on women by opposing alternatives for them...but what is to be done? How does one take their power away? Mine was only one suggestion based on personal experience and I realise that I was working in a reverse system...