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.

[ByTheWay1]

Oh thank you- ignorant and irresponsible... mmmmmm.....

Our local midwife led unit has closed now.... I'm glad I had my kids when it was a 22 min drive away - not the 1hr 10min people have had to do since last year....

[Shagmundfreud]

"Sharing anecdotes as a way of illustrating the risk of surgery is really unethical"

But not sharing it in relation to vb? If people stopped doing that here half the traffic on this board would dry up overnight.



"For what percentage of women is it not a 'normal' process though? Its not a small percentage"

Depends where you give birth doesn't it?

Healthy first time mums giving birth at home or in a free standing birth centre have a normal birth rate of around 70% and an emergency c/s rate of 7%.

In the same settings healthy mums having their second babies have a normal birth rate of over 90%, emergency c/s rate of about 2%, so if you can get through your first delivery without a c/s and still be categorised as 'low risk' afterwards you've got a very, very good chance of a completely normal birth with the second baby. With a c/s of course the risks a really serious complication like hysterectomy or placenta accreta go up with each pregnancy, not down. Obviously not a concern if you only want one!

Was looking at the stats for London the other day and I see that the Edgeware Birth Centre had a normal birth rate of 98% in 2010. That's amazing!

[RedToothBrush]

Shag, you are missing something quite important from that though.

What if you aren't that healthy.
You aren't looking at age and how that effects your chances.
You aren't looking at self selection and how that could play a part.

When you look at certain hospitals in London, they have a particularly high ELCS rate. They are criticised for this. And yet delve deeper and the demographics of the area are rather interesting. A significantly higher number of first time mothers over 35 than other areas and many actively choose that hospital because its known for its favourable policy.

A normal birth rate of 98% is something I look at with an eyebrow raised too. It doesn't tell the whole story. Does it tell you the numbers of complications resulting from those births? Thats something I would interested to see, in comparison to other places. I'd be interested to see the demographics of the area, and just how they pick women who are allowed to birth there in the first place and how many they turn away. I'd be interested to see what happens to women who wanted to birth there and were told no. It doesn't tell you how many women wouldn't even consider going there, because it has such a high normal birth rate. It doesn't tell you what 'normal' means either - there are quite a few places that are now presenting 'normal' to include forceps and induction when previously they didn't.

Choice is very important here, and the fact that in London in particular you get such a wide variation in what women are doing is, quite telling when you consider women in London, provided they can book in quick enough, have much more of a choice than women outside the capital.

It would be foolish, to simply ignore this strange difference in stats.

[cakebaby]

Holy shit miaow, I could have written your post as my near worst case scenario. Glad you are both OK. Sadly it's nowhere near an extraordinary tale, my friends/family/colleagues can recount similar experiences: I'm sure the doubters will say I've only heard the bad reports, so why are the majority of experiences I canvass so similar?

Red, clearly we're on the same wavelength!

So is a 'normal birth' one that does not involve instruments or any trauma other than a graze?

Also, why is the uk still using forceps when so many other countries abandoned them more than a decade ago?

[RedToothBrush]

Hmm well that not taken me too long to have a bit of a nosy at those Edgeware stats.

This is interesting:
www.intermid.co.uk/cgi-bin/go.pl/library/abstract.html?uid=45775
Information was available for 5099 women who intended to deliver. Of this group, 29.9% of women were transferred in the antenatal period, 13.96% were transferred in labour and 5.09% transferred in the postnatal period. During the study period 3573 women were admitted to the Edgware Birth Centre (EBC) in labour and 2861 (80.07%) delivered at the EBC. The overall intrapartum transfer rate was 20%. Transfer rate was eight times higher in the primigravida cohort (35.9% vs 4.61%). Approximately 6% of women were transferred in the postnatal period and 3% of neonates were transferred. Information on modes of delivery was available for 3476 women for women who were admitted to the EBC in labour. Of this group 89.35% had a spontaneous vertex delivery, 5.60% had an emergency caesarean section and 5.03% had an instrumental delivery. The perinatal mortality rate for women admitted to the EBC in labour was 1.1 per 1000 total births. The study concludes that approximately half of all women deemed at low risk of obstetric/medical complications require transfer to consultant obstetric services at some stage during their maternity episode. Intrapartum transfer rate for primagravid women is significantly higher than for multigravid. Overall 95% of women who were admitted to the EBC achieved a vaginal birth.

Having read that, and what their 'normal' rate is, I find it a little misleading to just say that 98% of women achieve a vaginal birth. I assume the 98% rate was calculated in a similar fashion to the above. (So if thats the case it does look like instrumental deliveries would most likely be termed a 'normal' delivery for the purposes of stats).

29.9% of 5099 were transfered during the antenatal period.
Thats 1525. We don't know what happened to them.

Information on modes of delivery was available for 3476 women for women who were admitted to the EBC in labour. However 3573 were admitted. So what happened to those other 79 women?

The 95% relates only to those ADMITTED AND they have figures for. So thats another 174 who don't get a vaginal birth after admission.

So of that 5099, thats 34.8% or 1778 who we don't have accounted for or didn't get a vaginal birth. Many of them probably did get a VB birth. I'm not convinced that figure of 95% looks quite so shiny and good now. Those ARE a lot better than a lot of other places BUT its not as good as they are trying to make out. And that is a major worry for me. Those figures DO seem to be misleading.


And don't forget, they might get their VB (from the information above those admitted but transfered are included in the stats) but:
35.9% of first time mothers end up transfered in labour.
4.61 of second or more time mothers end up being transfered.
And 6% of all are transfered AFTER giving birth.

That might be something that hugely concerned someone and be something they want to avoid.

Also note: we don't know how many women allowed to give birth at Edgeware were first time mothers; there could be a disproportionately low number.

[MyDarlingClementine]

Yes I too would love to know the def of a normal birth - mine was so called text book and its taken me years to recover from it.

Also when I was about to leave hosp second time round - someone came round to ask me " questions" for stats purposes I suppose.

The questions were leading and I could not give the answers I wanted to give. I asked her to note that down but probably no room on her stats sheet for that.

I guess those wil be funnled into some test results now - to produce stats!

I'd say once women feel safe to say - actually that was pretty mentally horrendous etc...you gonna find alot more births marked down as physically so called normal, mentally - horrendous.

[rainrainandmorerain]

miaow, I'm sorry you had such an awful time.

Like I said, CS rates are a very blunt instrument for measuring anything.

We don't know the true cost of a birth, and never will until postnatal care costs, for physical and mental health, are taken into account.

Birth costs atm mean nothing little more than 'on the day' costs to an individual hospital. You're basically only looking at what hole a baby comes out of, and how many staff are used to get them out. And how long a mother needs a bed.

It is hypocritical and shortsighted to focus on women wanting c-sections rather than focusing on the holistic care of mothers and babies, and what happens to them after they leave hospital. Even if your only concern is cost. Clementine's post is relevant. if any definition of a 'normal' birth is one which includes women left with lasting mental or physical damage, just so long as it was a vaginal birth, then we are right to be even more sceptical about the stats.

[RedToothBrush]

Bit more number crunching for you on those Edgeware Stats as I find this incredibly interesting, and I think perhaps shows up something rather interesting about that marvellous 98% stats that Shag is quoting and raving about.


From the official HES NHS maternity statistics.
Percentage of unassisted deliveries 2010 - 11 by area.

England 46.4%

London Strategic Health Authority 44.6%

Barnet and Chase Farm Hospitals NHS Trust which is made up of Barnet Hospital, Edgeware Hospital (Edgeware Birth Centre) & Chase Farm Hospital 44.9%

Barnet Hospital 40.0%
Chase Farm Hospital 45.4%
Edgeware Hospital 94.8%

Notably, Barnet and Chase Farm Hospitals NHS Trust is only just better than the average figure for the whole of London and ranks 10th out of 23 Trusts.

Barnet Hospital has the 3rd worst (27th out of 29) for unassisted deliveries by London hospital (Queens Hospital & Imperial College are the only two that are worst)
Chase Farm is 13th out of 29
Edgeware is 1st out of 29.

Edgeware represents only a very small number of births across the Trust.

Barnet hospital's particularly low rank is very, very interesting.

What these figures seem to suggest that, actually, the only thing seems to be happening in Barnet & Chase Farm Hospitals NHS Trust is that there is more selection of patients based on risk more than anywhere else in London. NOT that they were actually improving the rate of unassisted deliveries.

Food for though that one.

[bamboozled]

Stand your ground and insist on the elective CS. For various reasons, have met a hefty number of the senior obstetricians and gynaecologists in London and guess what the overwhelming majority of their wives have .... CSections of course...

[RedToothBrush]

Oh and the figures are less favourable for 2011 - 12 for Barnet. It was the second worst hospital in London with even fewer unassisted births than 2010 - 2011.

[bamboozled]

Shag, you know that when the shit hits the fan in a birthing centre, the mother is shipped to a hospital in an ambulance and then becomes the hospitals statistic, not the birthing centre's - dont you.. that's one way of crunching the numbers...

[Viviennemary]

It is very much an individual thing and what your perception of childbirth is. When you haven't given birth that is. For me, I had a total and absolute dread of having to have a Caesarian. But the midwife you saw doesn't sound a very sympathetic one who would sit and listen to you and talk you through various options. I'd ask to see somebody else. And we all hear totally negative stories. I was terrified the first time and it wasn't bad at all. Good luck in whatever you decide.

[RedToothBrush]

I also forgot to mention - What happens to all the women who need to have an ELCS who initially booked into Edgeware? Since it doesn't have the facilities to carry out a CS then of course its stats should be bloody high!

The HES NHS official figures have two separate definitions:
Normal Delivery:
A spontaneous vaginal birth where:
? labour is not induced
? oxytocin is not given to the mother
? method of delivery is spontaneous vaginal (excludes caesarean, use of forceps, vacuum extraction)
? no artificial rupture of membranes
? medicated pain relief assistance (ie narcotics, regional anaesthesia, perineal infiltration) is not given to the mother
? episiotomy is not carried out.

'unassisted deliveries':
? spontaneous onset of labour
? method of delivery: spontaneous vertex/cephalic
? episiotomy is not carried out.

The problem is these terms are being used in a way to confuse and mislead and not using these definitions by various groups. It is very important that women properly know and understand the difference when ploughing through statistics and talking about birth.

[KatieMiddleton]

The idea that obs and gynies and the wives of obs and gynies only have c-sections has been bandied around as fact before. There is only anecdotal evidence this is the case. If we're going for anecdotes, then the two obs who I have discussed birth with went for vb (one at home) and one of them suggested that some of their colleagues have very fixed ideas about c-section because they don't see any straightforward cases.

Returning to facts, women of my age with my obstetric history are more likely to achieve a vb without intervention and this becomes more likely if we labour at home. However, I'm not the op and what was suitable for me is not going to be suitable for her just based on what's been posted: 1. Her age 2. How she feels about birth and labour.

There are no easy options with birth, there are only better options for individuals. I don't talk about my positive home birth experience in RL unless directly asked because I worry I may be seen as smug or insensitive. This is completely at odds with what I think about other's birth choices and experiences so perhaps I should get over this! Nobody should feel ashamed or embarrassed for how they give birth. Frankly any woman who does is awesome and courageous.

There are some great evidenced posts here but there are also some very narrow minded ones. I am still agog anyone would think mortality is the best we can hope for! Every woman deserves the very best, personalised care.

[Wishiwasanheiress]

From my experience an emcs was awful. Painful and shocking. An elcs is far different. Frickin easy! I feel bloody marvellous! Yes cost but I think they just don't want average joes to opt this way. Making it out to be awful stops that.

Like having an abortion. It's always painted as being dreadful. For many it's the opposite. Keeping it bad keeps people away from it. Both are often controlled by men. No idea if correlation, just saying....

[Sioda]

Shagmund Sharing anecdotes is fine. Using one the way you did isn't. Throwing what you know perfectly well is a rare and serious risk out there as an illustration of how the rest of us somehow ignore the risks of CS is ridiculous. I don't believe you are really concerned about whether women are being fully informed of the risks of CS or not because you know that ultimately that's the obstetrician's job. There's no such comparison with VB as no informed consent is required. Anyway, our views are generally so far apart that discussion never goes anywhere, so I'll leave it there.

[bamboozled]

Katie - I'm not flapping around anecdotal facts - I am the wife of an ob/gyn..

[pixi2]

I have had a viginal delivery and an elcs. There are pros and cons to both but the vaginal birth you heal from much faster (that's from someone with a 4th degree tear and blood haemorrhage AND bowel incontinence afterwards).

There are parts of my lower abdomen and bikini line I have no sensation in any longer following my c section as I am too high risk for another vaginsl delivery. I am very expensive as anaesthetia does not work and I need at least double the does for the normal effect.

I still remember being stitched back together after dd's delivery, the feel of not being able to breath because of the pressure was horrendous.

[shallweshop]

Pixi - your experience of an elcs sounds awful but does not sound like the norm. My own experience of 2 c-sections is completely different and I was back on my feet within 24 hours of both and back to driving etc. within 2 weeks - bits still fully intact.

One of my bf's has recently undergone major re-constructive surgery on her undercarriage after suffering the after effects of 3 'normal' vb's - her youngest is 6!

Bamboozled - I was treated by Prof Lesley Regan at the Miscarriage Clinic and when I mentioned to her about wanting a c-section, she was clearly in favour.

There is still a part of me that feels sad that I missed out on the experience of a vaginal birth though :-(

[myrubberduck]

Re discussing e risks of VB vs CS of visa versa there really has to be some consideration not just to the seriousness of the risk but also the liklyhood of the risk materialising.

As I understand it there are risks of serious complications assiocated with CS and VB but maternal injury cause by VB is much much more common.

I was left with serious incontenence issues following the birth of my DS which required fairly hefty surgery to fix. My Uro-gynae consultant told me that 1 in 3 women are left with significant contenance issues following VB and of those 1 in 3 (Is that 11.1%? my maths is crap) will continue to have significant contenance issues 1 year post delivery . I mean serious contenence issues which require treatment; i do not mean a bit of a leak when you sneeze.

Apparently this is common knowledge in the medical profession; seems to me they keep it very quiet!

[HotSoupDumpling]

I would very much like to say the following to the GP, midwives, consultants involved in my pregnancy.

Dear Sir/Madam, when I ask you about an ELCS:

• Please don't make furrow your brow and make generalisations about why you think women want a ELCS, without even asking me why I, personally, want a ELCS
  
• Please don't make fob me off with airy statements about 'major abdominal surgery' instead of discussing specific risks and hard stats. If you don't know the specific risks and the stats, just say so.
  
• Please don't assume that if I request an ELCS, I am clearly ill-informed or simply irresponsible, and require more information or counselling to relieve me of my temporary insanity/selfishness.
  
• I really couldn't give a damn what you would do if you were in my position. Because we are different people.
  

I've got nothing more to add that eloquent posters who share my opinion have already done in this thread. Redtoothbrush, Sioda, Chunderella, and many more, thank you.

[janey1234]

I too am considering an ELCS, simply due to my age (38) and the increased risk I face of an EMCS (with its typically more difficult recovery than from an ELCS) or an instrumental birth, and the complications that tend to follow that. In addition, I'm very very worried about the increased risk of stillbirth due to my age if I go over term.

My own GP cousin dismissed my concerns and told me to 'just push it out' like she did, until I told her to look into the stats. She did, and the next time I saw her took me to one side and was adamant she wanted me to have an ELCS and didn't want me 'going anywhere near term'. There are two paediatric consultants in the family too, both of whom said in my shoes they'd have an ELCS.

Statistics seem to vary, but lots seem to point towards over 35's being around three times more likely to have an EMCS or forceps, and twice as likely to have a stillbirth.

For me it's all about the least risky option for me AND baby, and that looks like and ELCS.

The first midwife I saw was lovely and said that NICE guidelines had changed, and if I wanted one I could have one. The second was very dismissive, but has reluctantly referred me to see a consultant midwife, who should then refer me to a consultant. Once I'm in front of the consultant I intend to have a frank and educated discussion about the risks, from which I intend to make my decision. I will of course be totally open to hear his arguments, and the true statistics, but if ELCS still looks to be the lowest risk to us both, that's what I will ask for.

Oh and if they say no, but I want an ELCS, I will simply ask to be referred to someone who will give me one - as per the NICE guidelines.

[redplasticspoon]

Ushy , I realize this is a late reply, but you might still be around.

The reason counselling is suggested when mothers request Cesareans for non-medical reasons is there is no other situation when having surgery for non-medical issues is considered acceptable.

Incidentally, if as you have given an example of, women are also making unwise health decisions regarding home birth because of psychological issues, I think that counselling would also be beneficial to them.

To me, requesting cs when there is no medical reason for them just seems like putting a band aid on a gaping wound, ie rather short-sighted.