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.

[radiostar]

Thanks for posting this cakebaby, I'm so with you on all of this. I'm not even close to having kids yet, but for this reason I will be in your age group when I do. This is partly to do with my own fears about birth, but it upsets me in a way that women like us are labelled 'phobic' when actually it is completely rational to be very anxious at the prospect of giving birth within the UK maternity system as it stands.

In my case, I would be looking to have an elective simply because I cannot accept that fact that appropriate pain relief during labour seems to be somehow considered "optional" by medical staff. I've done my research: epidurals aren't foolproof, but they are extremely effective at managing pain in the vast, vast majority of cases and knowing that i could have one would reduce my anxiety from 100% to negligible and I would happily have a natural birth that way. But can you guarantee one, or will you just be told 'oh, they might slow things down though. Would you like me to run you a bath?"

So, I will most probably have to be diagnosed with "tocophobia" to instead get an elective on the NHS, a term I don't even recognise. Just look at the insanity of this for a minute: I will willingly hand over thousands of pounds OR be labelled insane in order to have major surgery I don't want, just because we are brainwashed into thinking it's normal or even preferable to avoid safe, effective pain relief during the most painful experience of our lives.

How did it come to this?

[RedToothBrush]

OR be labelled insane

So if you ARE phobic, you are 'insane'? Nice.
That doesn't help the stigma of coming forward if you do have issues either.
I get your point, but thats a touch insensitive, too.

[KatieMiddleton]

Can I just say not every woman finds labour and birth excruciating? Yes it is very painful for the majority of women but that pain can often be manageable without epidural. That said, for some women it may be unbearably painful and they should have access to good pain management.

Many women are able to labour and deliver with little or no intervention. There are greater risks of intervention for some groups. There are also exceptions where low risk will become high risk/emergency and high risk straightforward.

Nobody needs to fake a phobia. If you want a c-section ask for one. It is your right.

I've read a few things recently (not just on MN) that insists birth must be a medicalised process. That sort of statement ignores the experiences of many women who have successful births without any or very little intervention. It also does a disservice to those women who are choosing a c-section for valid reasons because it ignores the specifics of their case. What I'm trying to say is that any blanket statements are harmful because they fail to consider the individual and her needs.

[radiostar]

RedToothBrush>

So if you ARE phobic, you are 'insane'? Nice.

Sorry, that was really bad wording on my part and I can only apologise. You weren't to know but I actually do suffer from serious phobias unrelated to this concern. I've been diagnoses and had therapy for them, and I wouldn't normally throw the word around in this way.

I think that's what made me angry though: I know from first hand experience what a phobia is and this is emphatically NOT one of them: it's just a natural aversion to pain and a reluctance to experience it when there is no need to.

Sorry again for using the word 'insane' in this way and for anyone else I offended, this subject just really upsets me.

[RedToothBrush]

What I'm trying to say is that any blanket statements are harmful because they fail to consider the individual and her needs.

Its very very true.

I know, from myself, and from comments made throughout this thread and on others, that one of the themes that comes through loud and clear isn't control or pain or complications or any of the other arguments for and against VBs and CSs.

Its simply being listened to and respected properly regardless of the decision made in the end. Simply treating women as intelligent human beings capable of understanding complex and emotional decisions, rather than treating them as children who 'don't understand' or the automatic assumption that they 'haven't considered X,Y or Z' or they 'listen to too many horror stories' or 'don't trust their own bodies' or 'too easily influenced by the media'.

Which is very, very sad indeed.

[KatieMiddleton]

Yes. I quite agree. I understand there's a fair bit of evidence that shows women who felt listened to, respected and in control have more positive experiences of birth regardless of how they labour and deliver. I haven't looked up the research myself but I have spoken to a few researchers who have.

Official* Birth rights, AIMS and NCT objectives all come back to that point.

*Note I said "Official", not what Beverley the local member or teacher "feels" or thinks

[higgle]

I'm very interested in this thread, OP, because I felt very much like you when I was pregnant - kept getting rubbish advice, always kept waiting, worried about not being in control. I don't like doctors or hospitals and have a grave mistrust of anyone treating me who is not qualified to the hilt. My way of coping with this was a private hospital first time around that specialised in natural childbirth and a home birth second time round. It all worked very well for me, but I was totally ignorant about everything involved and just assumed my body would get on with what was required. If you are finding delays at scanning appointments and lack of proper discussion worrying at this stage you might very well find things get worse if you buy into a birth with an ECS or lots of interventions. Even if a homebirth was not something you wanted to consider I think you can ask for ante-natal appointments at home. I did this second time around and it was much more relaxing. I also paid for the scans privately so I didn't have to wait and it fitted into my working day - that was relatively in expensive.

[KatieMiddleton]

Sorry I do agree with that. Perhaps my use of bearable was sloppy. I think any woman who wants pain relief should be able to access it. I used bearable in the sense that if I have a mild headache I might not immediately reach for the pills but if it got worse I'd take something, even though the pain is "bearable" I choose not to suffer.

My definition of pain relief is quite wide and includes everything from paracetamol to G&A to water to pethedine to epidural to GA... and everything in between!

[KatieMiddleton]

Perhaps "tolerable" would be a better word. Or "acceptable"?



I'm a bit sleep deprived - due to poorly baby and a tad hard of thinking today!

[RedToothBrush]

Katie, I've read quite a bit of research along those lines and that is actually part of my reason to want to have a ELCS rather than a VB in my particular circumstances but why I also fiercely support any woman who wants to go the other way, if she wanted. Women know their own boundaries best.

Radiostar, I don't want to be too confrontational over what you said, so I hope you don't think I am. Like I say, I do understand what you meant but I do think its incredibly important to be cautious about language around childbirth. It seems to be filled with emotive phrases and words that are often very loaded with judgmental associations. Words like 'normal' or 'natural' or phrases like 'failure to progress' etc. I could go on. Which I think are actually creating some issues around birth for some women.

I think its perfectly legitimate to worried about pain as it goes. Its not phobic, it may be considered lower level anxiety or may be considered not anxious at all, but it doesn't really matter, its legitimate.

And actually the wording of the NICE guidance does not require any level of anxiety to be deemed legitimate. Doctors are not really supposed to differentiate and place value as to what is a 'sufficient' level of anxiety when making decisions over this.

What it actually says is:
34 When a woman requests a CS explore, discuss and record the specific reasons for the request

35 If a woman requests a CS when there is no other indication, discuss the overall risks and benefits of CS compared with vaginal birth and record that this discussion has taken place. Include a discussion with other members of the obstetric team if necessary to explore reasons for the request and to ensure the woman has accurate information

36 When a woman requests a CS because she has anxiety about childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her anxiety in a supportive manner.

37 Ensure the healthcare professional providing perinatal mental health support has access to the planned place of birth during the antenatal period in order to provide care.

38 For women requesting a CS, if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not acceptable option, offer a planned CS

39 An obstetrician unwilling to perform a CS should refer the woman to an obstetrician who will carry out the CS

The wording IS heavily weighted to offer most support to those with anxiety HOWEVER if you look at 36 it also makes it clear that not all requests will be on the basis of anxiety presenting it as a possibility.

If the guidance is being followed properly you shouldn't have to 'prove' you are anxious or phobic as its simply not a requirement. I know the reality on the ground is that this is how it is being interpreted and implemented by doctors. And thats the problem. Its getting people to understand this and that personal choice alone, is considered legitimate under NICE's guidance and forcing hospitals to recognise this.

The thing you are most likely to fall foul of, from what you've said is, actually the last sentence of 35, where they say to "ensure that women have accurate information" as the hospital will say they do provide proper access to pain relief when in your opinion, you don't feel this to be to your satisfaction. They'll probably argue the toss over that rather than recognise you have a concern that they need to deal with effectively.

If it were me, I'd be looking for some way to back me up or make a case with - such as staffing levels either as a way to perhaps identify somewhere more likely to deal with pain relief or to use as a justification for my case. (Not that I like to find cracks in this policy stuff at all!)

[KatieMiddleton]

Katie, I've read quite a bit of research along those lines and that is actually part of my reason to want to have a ELCS rather than a VB in my particular circumstances but why I also fiercely support any woman who wants to go the other way, if she wanted. Women know their own boundaries best.

I chose homebirth for same reasons (I did read lots of primary research about that myself!) and I would also fiercely support anyone who wants an elcs or a vb with epidural or any other actively managed birth if that is what they want. We need unbiased, evidenced information available so each woman has the best chance of making the right decision for herself.

So nice to read supportive posts from people who have made a different final decision based on personal circumstances but can empathise and support others who reach a different personal decision :) Too often on MN people take offence at something different as if it's a negative criticism of their personal choice. So refreshing to have a debate rather than a bunfight!

[RedToothBrush]

I had a couple of friends who I don't see very often and managed to discuss my issue with last time I saw them about a year ago as the dreaded question 'do you want kids?' came up in conversation.

One was pregnant and, as it turned out, was planning a homebirth. I was thrilled for her when I found out. I had been dreading seeing her as I knew the subject would come up, and had been secretly hoping she'd done some reading and would go down that particular route, as I knew her personality and genuinely thought it would probably suit her best! That probably sounds completely bonkers but its true.

Ironically she was somewhat relieved that I didn't think she was mad or endangering her baby (apparently she'd come across a few negative reactions) and was equally supportive of my feelings on the subject when I explained the reasoning behind my point of view.

They were the first people in RL apart from my DH, that I'd been able to tell and it was such a relief to have a positive response from someone over it. It makes a difference. I think some of the anxiety over this issue is in part purely down to this element of judgment. It'd do us all a favour if that was removed - the people perhaps being most guilty of it, being the professionals, because of their position of power.

I really do think it just depends on whats most important to you, how you cope with certain situations and what your risk factors are. I do think the arguments for and against various births are generally pretty finely balanced unless there is some very real medical problem that is apparent before your due date or if you want a large family and can be argued either way. Which is why there is so much argument on the issue at present. 'Better' is a word that is so subjective.

[cakebaby]

Janey don't worry I knew the stillbirth risk in our age group, just hadn't mentioned it in thread for some reason!

red absolutely agree, the pain aspect is at the bottom of my list of concerns.

It's about not being fobbed off like I'm a complete dimwit who is being a lightweight, is ill informed and has not thought this through.

It's about not being treated like I'm a cat at the vets, having things 'done' to me without explanation or sought consent (not that I'd ever permit that, but it's been on the cards already).

It's about an acknowledgement that I, after nearly 40 years of knowing myself, just might know a little more about myself than the professionals (4 different ones so far), who have clapped eyes on me for no more than 10 mins each.

It's about health of baby and safe arrival, my physical and psychological health and coming out of the experience as well as possible with as little likelihood of lasting injury or trauma which will impact on my ability to function as close to how I do now, including continuing my job in due course and keeping a roof over our heads.

[MyDarlingClementine]

Has Shag come back yet to explain her Edgware stats?

[working9while5]

Redtoothbrush and OP, you really missed my point about not engaging in this discussion.

I have no issue with the discussion for my own sake, I could happily talk about it all night. I simply know from having had CBT about this issue that anyone who is anxious about these things would be advised to avoid this type of forum for discussion of this type of topic as it is, essentially, reassurance seeking.

In a formulation of anxiety, reassurance seeking is a compulsion and to reduce anxiety you asked to avoid it as paradoxically it increases anxiety over time instead of reducing it. The reason is that you are trying to problem solve a hypothetical situation as opposed to an actual one, and as such you have very little control over it so no matter what information you are presented with you trust, you will automatically realise that the counter is as likely to happen (e.g. you can totally believe a natural home birth in water would be best but you have no guarantees so the risks of induction you read about for months may end up being what you face when you are most vulnerable).. So the more you research and the more frightening stories and horror statistics pile up, the more "what if's" will creep in to sustain your anxiety.

It's difficult, I appreciate. I spent a lot of time on these boards and I suppose initially if someone had told me it wasn't helpful I would have scoffed... but now that I have had the benefit of CBT myself and I am "out the other side", I can see that really it wasn't helpful and it did fuel my anxieties.

I guess basically, I would read NICE and then spend a good deal of time reflecting on what you actually WANT (perhaps getting counselling if you feel it would help) and then find out the evidence about what you WANT. You don't really need a load of statistics. What you need is to get in touch with your gut and ask yourself: is this fear something I can overcome if I get more information e.g. if I choose to get a doula or do hypnobirthing or whatever... if it isn't, will information on getting an ELCS be helpful (in which case you wave around the NICE guidelines a lot and still perhaps seek counselling to enable you to stand to your position and not waver in the face of those who will try to blind you with science).

It is your choice to get involved in discussions. If you know you are anxious, you probably know if looking at these boards is going to help or hinder you too. - lovely the empathy here, I had to laugh, especially as I posted only because I know from nearly a YEAR of CBT for anxiety that generally, people with anxiety DON'T know if looking at this information will help or hinder them. I had even dealt a lot with anxious people at work and thought I knew something about it, yet I never realised the extent to which reassurance seeking and this sort of ruminating over your anxiety sustained it... I'm not "denying" anybody any "right" to ruminate and compulsively trawl through risk statistics for their entire pregnancy, just saying that it might not be the most helpful approach to the underlying fear.

[working9while5]

And OP, you see this:
".... as little likelihood of lasting injury or trauma which will impact on my ability to function as close to how I do now, including continuing my job in due course and keeping a roof over our heads. "

This to me says that you are catastrophising, which is a completely normal thing to do when you are anxious. The likelihood of birth resulting in the end of everything as you know it in such a disastrous way is extremely small, but there is a small risk that it will and there is nothing you can do about that.

I have been where you are and the consequences were not pretty. We live in anxious times and I am about as rational as they come, I had very much the same concerns as you.. and I applied my usual "thinking" brain to solving the problem of primal fear. It just doesn't really do the job you think it does. Try and focus on learning to manage the inevitable fears that come out of a higher risk pregnancy and the total "cosmic gamble" of becoming a mother anyway. Only giving you the advice I wish I'd had from someone in the same position.

[Zara1984]

Hi OP, haven't read the full thread as it looks like it's descended into a bit of a bunfight.

I think you should ask to speak to someone more senior at your hospital about your worries rather than fretting at home about it. You'll either get to chat to someone who can allay your fears a bit about vaginal birth or you might be able to get an ELCS booked. Sounds like your midwife is a bit dismissive of your (very valid!) concerns so you need to go up the ranks.

There ain't nothing wrong with wanting an elective section. I would certainly consider asking for one for DC2 if it looks like I'd be up for an induction again.

From what my friends (who have had between them free range drug-free births, standard hospital births with epi, induction, instrumental, emergency section and elective) an emergency section is worst situation. Next worst is instrumental delivery and inductions. And (in terms of happy non-traumatised mum) a straightforward VB is on par with an ELCS. But that's just anectodally from my friends.

Congratulations on your pregnancy!

[RedToothBrush]

But you want to close discussion. And that stops change. And for that reason alone, thats why I believe it NEEDS to be talked about, as I said before.

reassurance seeking is a compulsion and to reduce anxiety you asked to avoid it as paradoxically it increases anxiety over time instead of reducing it. The reason is that you are trying to problem solve a hypothetical situation as opposed to an actual one, and as such you have very little control over it so no matter what information you are presented with you trust, you will automatically realise that the counter is as likely to happen (e.g. you can totally believe a natural home birth in water would be best but you have no guarantees so the risks of induction you read about for months may end up being what you face when you are most vulnerable).. So the more you research and the more frightening stories and horror statistics pile up, the more "what if's" will creep in to sustain your anxiety

Well if thats what CBT does, then maybe its really not for me, as actually since talking about it on here, I've been able to talk about it in real life which I would never ever have done and would still saying 'I never want children'. I've actually FINALLY got a GP appointment booked about this for next week. I know I would never ever ever have done that but for the support I've found on this forum. But there you go... you know best.

Everyone is different. Not everyone will respond to CBT. That's well known and documented in other areas. Like an ELCS might not be right for someone and a VB might be right and vice versa the same also applies to various ways with coping with anxiety and various types of counselling available.

You might what to think about that, whilst you talk about how great CBT has been for you.

I guess basically, I would read NICE and then spend a good deal of time reflecting on what you actually WANT (perhaps getting counselling if you feel it would help) and then find out the evidence about what you WANT. You don't really need a load of statistics. What you need is to get in touch with your gut and ask yourself: is this fear something I can overcome if I get more information e.g. if I choose to get a doula or do hypnobirthing or whatever... if it isn't, will information on getting an ELCS be helpful (in which case you wave around the NICE guidelines a lot and still perhaps seek counselling to enable you to stand to your position and not waver in the face of those who will try to blind you with science).

Ok... so you know what I've done and what I'm doing then and why I'm doing it? Are you a mindreader?

Bottomline people have to find what is right FOR THEM whatever issue it might be about. No one else.

And other people have to respect that there is more than one way to skin a cat.

[Zara1984]

... and I should point out that I perhaps am not the best/most knowledgable person to ask, as I did not have any fear of childbirth I do now though

[MaxineQuordlepleen]

I usually avoid these threads but going to throw in mine anyway, even though I strongly believe that anecdotes do not equal data... I was terrified and 37 but also severely allergic to anaesthetic, so avoiding surgery was a priority, even though I had an emergency anaesthetic plan. To cut a long story short, I did hypnobirthing from week 25 and it worked perfectly. I had a 12 hour labour and a lovely water birth in a midwife unit attached to a labour unit.

What does that show? Well, nothing conclusively but I think Hypnobirthing can work well. May not be for everyone but worth giving it a try?

[working9while5]

I never said I had any interest in closing discussion! My post was to the OP in terms of my personal experience basically saying my understanding of this stuff - after quite a bit of my life thinking about it! - is that these discussions can really increase the OP's anxiety, so if I were anxious and pregnant again now, I wouldn't engage in a discussion like this because I know it can be counterproductive.

There are times for changing the world and all that but when you are feeling highly anxious in pregnancy the most important thing is to take care of yourself and your baby, especially given the fact that anxiety can lead to quite significant PND.

As for this: Ok... so you know what I've done and what I'm doing then and why I'm doing it? Are you a mindreader?

I said what I would do with the benefit of hindsight.. that is what I WOULD DO. That has nothing to do with what you would do, but if you go back and read my posts, essentially both say you need to find what will suit you best but there will never be any certainty, no matter what you decide. That is just a fact of life, sadly, no matter how you skin the proverbial cat.

I have been there and I have come out the other side and my post - and specifically saying, please don't post - is totally based on the benefit of hindsight... not because "it shouldn't be posted", it makes no difference if it is or it isn't.. but because I know that it can be very damaging TO THE OP. The reason I posted was out of empathy FOR THE OP's POSITION. My anxiety about this is long gone, believe me.. I have my two babies, I am having no more, it makes no difference to me what anyone posts about the risks because it doesn't apply to me. I was just trying to be helpful by sharing experience.

[RedToothBrush]

but there will never be any certainty, no matter what you decide
I do realise that. But everyones ways of tackling that are different.

The way you phrase things was worded in a way that was attacking everyone who has shared things here, by telling them they are wrong to do that. Thats going to ruffle feathers and I'm not sure what you expected in response.

I have no doubt that for some these discussions are really the wrong thing to take part in. But for others if won't be. Because we all go on different journeys through this and our stories are all different.

When you talk about fear or concerns about VBs, I bet that every single person on this thread who has them will have a different list and different priorities.

And that just highlights just how this subject can never ever have a single 'right solution' that can be quantified and implemented as a fixed policy - only ever a 'best fit' solution for each individual. Sadly, there are policies for everything now and in spite of promises of more choice actually whats happening is fewer people are willing to apply flexibility to those. Hence why 'the drive to reduce cs' which is in the premise of this thread, is just so fundamentally flawed. It doesn't listen to women.

I know I can talk about stats on this a lot. But then people are always going to pull figures out to 'prove' something - which actually those stats don't prove at all. I think its actually more important to discuss what they really show, so people understand what they are actually reading, not just take them at blind value and are better able to evaluate the quality of what they are reading themselves. What are their weaknesses as well as what do they show. And when it comes to studies on CS and VB, these weaknesses in studies are hideously common, so its important.

And whats plainly become very apparent to me, is birth in the UK is very safe and that theres a case for both a CS and a VB and there really, really isn't much in it. If this was talked about better, I think much could be done to improve the current situation which is scarily more about various conflicting politics and ideology and a break down in trust which has occurred than actually about women stick in the middle of all that trying to understand whats happening and how to cope. The number one thing is lack of communication. Well that and busting a few myths.

The subject of ELCS requests is taboo. It needs to be broken. The subject of fear in childbirth is taboo. It needs to be broken. It needs to be made acceptable to ask without fear of being laughed at, turned down or judged. It needs to be something that people realise is normal, common and entirely understandable. They are not a freak, they are not weak, they are not less of a woman.

Then maybe some of the issues at the very, very heart of the subject can start to be tackled rather than making it into an ongoing war between the pro-CS or pro-VB camps where the only losers are women - and what I really think is causing so many of these anxieties in the first fucking place.

[working9while5]

Listen, there was no attack. None. I really support anyone in seeking any birth that feels right to them. At one point I thought Elcs for myself.

In all fairness, I am not sure where you got I was attacking. I have just been declared unfit to return to work for a minimum of three months, my son is 8 months old and I got my anxiety dx at 28 weeks pregnant, so nearly a year ago, all triggered by fear of birth. So why would I be attacking anyone??

I didn't access cbt until after birth so I didn't learn about the dangers of trying to solve the problem of fear by seeking the most reassuring set of facts until after I had spent months on threads like these. Now I see that was unhelpful. By the time I gave birth I was in an immense state of panic with a home birth and induction booked, having constant flashes of my baby dying.

So think about this, where is the attack? My intention was to share my thoughts about these discussions and to say hey, if I could do this thing over I would avoid looking at it this way and maybe not whip myself up into a frenzy by reading stats but would focus instead on means of managing fear.

Your point that it may be helpful for some is valid of course... but it may be helpful for others to reflect on whether these discussions are making them more anxious and if the answer is yes (and these things are not always obvious to you if you don't stop and think of them, as I know myself) reading my experience might be equally helpful to them in thinking about how to tackle their fear in other ways.