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.

Smudging Those kinds of studies showing associations are such a menace and so far on the asthma connection they're conflicting. It's a similar story to breastfeeding research. They can't show causation because they can't do RCT's. The gut bacteria thing is the latest hypothesis but there are many other equally possible ones. For example, it seems to be impossible to separate the reasons why the CS was indicated (since most are medically indicated) and the outcome for the baby. Or the fact that babies born prematurely by CS are more likely to suffer from 'wet lung' which in turn leaves them more susceptible to infection in the first year which may in turn leave them more susceptible to asthma. Epidemiology worked well with tracing the sources of infectious disease but it's causing havoc in non-infectious and more complex areas of health.

Another reason to be wary is that there are commercial interests in the baby formula industry who are supporting research into connecting gut flora differences with many diseases. The goal is to add cheaply manufacturable probiotics and prebiotics to formula and to sell specialised products to neonatal units.

The other issue is that of course you have to weigh up any such risks against the risk to the baby of a VB, including the risk of EMCS.

Eek! My, how the tone has shifted. Whilst I don't think we've descended into a bun fight yet, we managed 6 pages of reasonable, adult debate, indicating to me that the vast majority do find this type of discussion useful.

working I'm so glad you feel CBT worked for you, as you will now be aware, it may not work for everyone and although you obviously had a great birth experience, your stated current position, which which you have my sympathy, does little for your evangelism for the use of CBT in my opinion.

My way of working through any 'ishoos' IS to canvass opinions of the experienced AND professionals AND examine data, THEN draw my conclusions. I know it won't be right for all of us, but it's served me well for many years!

I'm not catastrophising, I'm taking an objective view, which HAS to include both worst and best case scenario. I heed your advice about careful use of these threads, but I am finding it REDUCING any anxiety and am extremely thankful to all contributors.

There is no evangelism. I think basically I'm saying something that some people find uncomfortable. I think that because somehow my opinion and experience are being read as aggressive when that was never my intention. My experience is being read as somehow some sort of challenge, it is not, it simply is what it is.

As for my birth being what I wanted it to be... but yes.. but that was chance. My first birth wasn't at all, but I have learned to accept that was also chance. It took a long time to recover from my first birth both psychologically and physically but there is no preparation I could have taken to have it otherwise. I guess I could have opted for ELCS but that never entered my mind so a bit pointless to second guess that now and I guess it has its own risks.

I think we live in an age where we are taught if you research risk enough and find the 'right' course of action, either from research or through instincts, following that path will free you from potential harm. Sadly it doesn't work that way and especially not with birth.

I think it is really normal to be terrified of birth. It isn't a disorder. Most women who have severe anxiety have bloody good reasons to be anxious whether that is seeing family members and friends harmed by birth, a history of abuse or of overwhelming experiences of pain in hospitals, either themselves or of loved ones etc. There is nothing irrational about it.. It is also pretty primal. For Milennia women have had to go into birth afraid it will kill them or their babies or both. We still carry that fear because actually it can happen even though now it is rare.

I think you do what you do to get through.. but the reality is there are two basic outcomes here. You walk away from birth healthy with a beautiful healthy baby or you don`t. The odds are hugely in our favour as western women that we will have the best outcome no matter how we birth.. but the second possibility is there no matter what you do. You can think about the best and worst outcomes until the cows come home but there is always going to be a risk of death and injury to you and to your baby in whatever you choose. This has always been and it will always be. It will also always include pain.

If you feel comfortable with that and can stare that fear in the eye without falling to pieces, then you are in a better position to research and make a decision and negotiate that with the NHS. For some the fear is about being overpowered or overwhelmed and so that is perhaps easier as an elcs can remove that to an extent... but to be able to argue for that you need to really work on your own inner strength to deal with the horror stories you will be peddled along the way based on your primal fears of death and injury to you or your baby that we all share.

I'm just saying that whatever you choose or whatever your reasons knowing and accepting your fears is a solid foundation for decision and action. Fear can't be resolved rationally. Learn to live with the fear and then you can resolve the causes of fear that are in your control by e.g. booking elcs or hypnobirthing or whatever you then feel will float your.boat.

CBT is a gold-standard of treatment for anxiety if you believe and place your faith in research. Of course it doesn't work for everyone but that just highlights the fallibility of research which sort of brings us full circle. ACT acceptance and commitment therapy and Mindfulness are also recommended and both would also place the focus in the present instead of worrying ad infinitum about the 'what ifs' of birth. Buddhist psychology, which is pretty much as far from CBT as you can get, takes a similar position in terms of how you can lose the beauty of the present because of your made up fears about the future. I think when lots of different traditions and schools say there same root thing, it is worth paying attention to. I'm sure there are others.

Look, pregnancy is so special and so short lived. I really missed out a lot of the joy of pregnancy with my second because of fear and endlessly reading horror stories and guidelines and research and stats. I am sorry about that and I will never get it back. I posted for that reason and that alone... I had compassion for your position. Somehow you think there is something else to it, but there isn't. You have a great opportunity to face your fears and get what you want agreed whether that is elcs or whatever. It may be wrong that the system will prey on your primal fears to dissuade you from elcs but it is what it is and if what you want is to overcome that, you need to be strong and fearless and resolute.

Whatever birth you want to agree...

Working,

I also find your opinions to be a little evangelical, but not uncomfortable.
I personally don't believe that women who are afraid of VB are very, very reasonable and there is no phobia or irrational fear that should be brainwashed away from them to force them into VB. I admit there are those that really suffer with nightmares and anxiety and I admit there are women who are revolted by pregnancy itself, including pregnant women. For these women some kind of therapy could be helpful, if they find it necessary and useful. However, CBT as you describe sounds like full-blown brainwashing, very, very fishy to try to change rational opinions of grown up women and try to make them into tree hugging homebirthing hippies by a so-called therapy. No therapists should do this and I find it unethical.

If men were to give birth, do you think that anyone would try to persuade them that "pain in childbirth is a good pain" (such b*locks) or that if they scream in agony they should just relax and pat them on the head? Do you think that men would accept to be subjected to unbearable pain just because some undereducated woman has ideology that she applies on her patients? No, no, no! If men gave birth as well as women, by now it would be close to painless, even pleasant procedure, because men can't fool themselves so easily like women do to one another. Even the funny idea that people shouldn't tell first time pregnant women all the info about what can happen in childbirth. FFS, are they children or half-wits? It's not only unbeliavably patronizing, but quite frankly abominable to treat any human beings like that. Even animals get analgesia at the vet's.

And what is actually so strange or irrational about being afraid of unbearable pain? Of being humiliated by staff and denied pain relief (happens everyday as you can see on these boards)? Of being incontinent or so destroyed down there that you won't be able to enjoy sex for the rest of your life? Would men accept this as irrational fear? I think not. Only we women still insist on being irrational and thinking that this is the way we should suffer to be real women. I don't understand where all this suffering religion comes from and where all the midwives denying women pain relief come from, the only explanation being pure masochism and sadism, imho. I don't believe for a second that a rational being could really believe that pain is good without being completely brainwashed or secretly kinky.

I choose ELCS for myself too, if I ever was to have children. And no amount of so called therapy or arguments could change my mind. This is my body and I DECIDE WHAT IS GOING TO HAPPEN TO IT, no some random stranger that thinks that she knows what's best for me.

I know this will ruffle a number of feathers, but I just couldn't help it.

Sorry
*I personally don't believe that women who are afraid of VB are very, very reasonable

of course, I BELIEVE

CBT is a gold-standard of treatment for anxiety if you believe and place your faith in research.

If thats the case, WHY did NICE say under research recommendation:

RR15 What support or pyschological interventions would be appropriate for women who have a fear of vaginal childbirth and request a CS?

Intervention for evaluation could include
- support from a named member of the maternity team
- continuity of carer
- formal counselling
- cognitive behavioural therapy

It goes on a bit about outcomes and why this is important

It then says:

All of these intervention have different resource implication and there is no clear evidence to suggest that any are of benefit. The proposed research would compare in a randomised controlled trial two or more of these interventions in women requesting a CS. In the absence of any evidence, there is a case for comparing these interventions with routine antenatal care (that is, no special intervention).

This research is relevant because it would help to guide the optimal use of these limited resources and future guideline recommendations.

Just because sometime works with one thing, DOES NOT mean it is the gold standard for something else. Anxiety has lots of different forms and they stem from different reasons.

One of the reasons that is very frequently listed is anxiety over resources and staffing; so how is CBT actually going to help that? Wouldn't it be better to put the money actually into solving the root cause? Counselling would be like putting a sticky plaster over a broken leg in those cases.

Anyway going back to NICE, they back up what I've just said elsewhere, when it says:
The GDG's experience of caring for women requesting a CS was that anxiety about giving birth vaginally was often at the root of the request; for example as a result of a previous poor birth experience. The GDG believed that when women are given the opportunity to discuss these anxieties in a supportive environment, the anxieties can often be reduced to the point where the woman is able to choose a planned vaginal birth. The GDG agreed this was the preferred approach. It was not felt to be necessary for the person providing this psychological support to be a mental health expert unless clinically indicated, but it could be provided by a member of the maternity team, such as a midwife or obstetrician.

It was felt that the extra resources required to provide this support would be offset by resources saved where a request for a planned CS was appropriately changed to a planned vaginal birth as a result of addressing a woman's anxieties or concerns antenatally. However in situations where a woman persists in a request for a CS following provision of the opportunity to discuss and explore her reasons for the request, the GDG believed that the potential for psychological harm caused by denying this request was sufficient to warrant this unacceptable in terms of the woman's health: it also has the potential to be costly in terms of long term need for psychological support. It was concluded, therefore, that if a vaginal birth is not an acceptable option to the woman after discussion and the offer of support, she should be supported in her choice of a planned CS.

There is also the VERY IMPORTANT issue of the ticking clock. CBT does not work immediately and takes time - even where it does work. This is something that it limited during the course of a pregnancy, and ultimately depends on when a woman comes forward to try and seek assistance and how long it takes to get a referral. This is one of the very major problems.

At present since this issue is taboo, women usually don't come forward before becoming pregnant and even then tend to bottle things up until some time into the pregnancy as well.

And then even if a woman did come forward before becoming pregnant, there are no guarantees of anything. At present there is nothing in any guidance about what to do with a woman who isn't pregnant. The problem is poorly understood by a lot of healthcare professionals within the field and perhaps less so by GPs as this isn't their speciality. It means that unless there is no formal pathway to direct women down, particularly if they have never had children and therefore can be classed as having a trauma, so it can be hard to access the appropriate support.

I think it is clear from reading this thread that some people have rather fixed beliefs, and will only listen to others who affirm those beliefs. OP I think you have been given some great advice by working and you are doing yourself a disservice to ignore it. If you are not offered a cs on thenhs what will you do? You really should look at ways of managing your anxiety.

That's what I said Raluca.

I find it strange that there is this resistance to the idea that perhaps the totally normal primal fear of childbirth (and here I include any way of bringing a child into the world, I am not advocating that this means that you have to have a "natural" birth, just the fear that comes with the uncertainty of bringing a baby into the world and the fact that you will suffer pain/could face death of yourself or your baby no matter what birth route you choose) is worth doing some thinking/reflecting about.

I'm not saying everyone needs CBT (as above, again...). I'm saying that in my opinion (sharing opinion/experience is not "evangelical" though it is an interesting way of trying to dismiss it!) it is worthwhile to find a way to cope with this deep primal fear that all women share in some ways.

I think if you want an ELCS, it's perhaps even more important unless you can afford to pay to go private as every step of the way you will be bullied told horror stories which capitalise on this primal fear.

Is that right? No. Unfortunately when you are pregnant it is really hard to fight this fight and stay strong without support and a time/place in your life to reflect on and have unconditional support for your right to make that decision.
While women who are not pregnant can "fight the fight" for how this isn't the best way for a woman to be treated about her birth choices, it is in practice very difficult to manage while you are pregnant and unfortunately sort of prey to being buffeted about by the system.

Should you need this? No. Should you be bullied? No. Should women as a whole accept this? No... BUT it is a reality that this is the way the system is here right now. I would have loved to pay for better treatment but there were no private options available where I live, even if I won the lotto.

There is no shame or weakness in dealing with fear. It is actually more brave to face your fears than to deny them... but somehow, what I am saying is being again and again read as something it's not. Not sure why. If I'm an "evangelist", I guess I am a pretty bad one!

Redplastic,

please explain to me what is anxiety in your opinion?

Because I frankly do not understand what you mean by that.

Working,

that is true in a lot that you say.

"Unfortunately when you are pregnant it is really hard to fight this fight and stay strong without support and a time/place in your life to reflect on and have unconditional support for your right to make that decision.
While women who are not pregnant can "fight the fight" for how this isn't the best way for a woman to be treated about her birth choices, it is in practice very difficult to manage while you are pregnant and unfortunately sort of prey to being buffeted about by the system."

This is why I agree with Redtooth that it is necessary that these things are discussed in the open so that women get to think about what is right for them and get useful tips on how they can stand their ground while they are pregnant.

However, I still do not get, why would anyone need to fight quite rational fears based in statistics and research. Does CBT help you to live with destroyed undercarriage? No, so then I do not see the point of undertaking it.

If you are not offered a cs on thenhs what will you do? You really should look at ways of managing your anxiety.

But this is the issue isn't it? This is why the guidance said the NHS should be allowing a CS as to not do so has the potential to cause psychological harm if a woman is that determined to have one. Because there are women who can not manage their anxiety and even if they do look at trying to do this and did try and go for counselling, there is no guarentee they would get that either or that they would have enough time for it to be effective.

Trust in the system and trust that you will be able to get SOMETHING is part of the problem. All the talk of resources and CS's costing more money has actually made anxious women dubious and suspicious about counselling.

You HAVE to bare in mind that a lot of women in this position, are like this, PRECISELY because they feel like they have been betrayed or let down by health care staff in the past. They are going to be more resistant to counselling from the word go, so need a range of options rather than to rely on ANY one - which actually includes trying to manage your anxiety.

I am annoyed, because this was started by someone telling people to do something in a manner that was quite confrontational and wanted to close discussion; rather than suggesting CBT as a possible alternative suggested that looking for support and information was a bad idea. It was the tone, rather than the suggestion that was the entire problem.

"If you are not offered a cs on thenhs what will you do?"

If you are not happy with the service, what will you do? Go somewhere else and you don't have to put up with being fobbed off. No one has to.

1st birth - so called all went fine, but lived with physical niggles and minor problems for a long time after the birth, talked about it to anyone who would listen, found it horrific and that was with great support from DH and mw's.
Denied epirudural and felt there was a veil of secrecy over birth in general.

2nd - discovered MN realised con over epidurals - already knew loads of nasty birth stories - felt that viel was lifted and that gave me un measurable reassurance and when i had to face a consultant with a possible agenda - i had my own agenda well shored up in case of conflict. it gave me confidence.

I did speak to a head MW and she seemed totally brain washed to me - she didnt seem to listen to me at all - and indeed - her attitude made up my mind that an ELC was the right thing to do.

It wasnt easy - and again I was prepared for this by reading these boards, I was scared, I had moments of nasty pain. I was terrified about infection and also norivirus with an open wound!

it wasnt an easy option for me - but it was an option and I took it and now i dont even think about it and ( five months on) and my body is in a much better state than after the "normal" birth. Mentally and emotionally I was a different woman, my reserves of everything were not depleted and I was able and still am able to concentrate happily on baby.

It was absoluty the right thing for me, and my family. Luckily I was granted one at 20 weeks - and I didnt have to fight for it.

If you are not offered a cs on thenhs what will you do?

Start campaigning for all women to have choices across the board and the right help and assitance for thier needs, and for all consultants to be made aware of birth trauma and womens needs. To go on courses and be educated in this and remeber that they are dealing with peoples lives not ticking boxes.

The MW ( who was lolvey) delivered by first child a long time ago - it was a baby to her - it came out - job done. That birth has lived with me and troubled me deeply for a long time.

"I am annoyed, because this was started by someone telling people to do something in a manner that was quite confrontational and wanted to close discussion; rather than suggesting CBT as a possible alternative suggested that looking for support and information was a bad idea. It was the tone, rather than the suggestion that was the entire problem. "

No, that's not what I did. I said that I realised in my experience that rendlessly trawling through risk stats etc online was damaging to me and I have since learned that this happens to a lot of women.

It's not about "support" or "information", it's about being faced with rafts and rafts of conflicting voices and information when you're not really sure of anything yourself because how can you be?

Where is the "conflict"? What is the conflict? I was posting that final point really hastily, I have two toddlers here and I was coming to the end of the time where I could be online and I can see when I reread it that it might have come across as me saying it is "wrong" to post when what I was saying is that looking back I - who was in exactly the same position as all of you - realise that this was not the best place to have these deep discussions because inevitably it does become some sort of debate. I really don't care if anyone does CBT or ACT or dances at the crossroads at midnight or campaigns for ELCS, that's not my agenda here. I shared my experience and my thoughts because I remember what it was like to live in the grip of that fear. There is now this imaginary "confrontation" and all sorts of words like evangelism and other sorts of things being bandied about when I made a simple point:

If you are afraid, it is horrible and it can suck the joy out of a precious time in your life. If you want to deal with that fear, there are means of doing that which you may find helpful. This will support you no matter what you end up having as a birth plan.

Is that clear enough?

"Trust in the system and trust that you will be able to get SOMETHING is part of the problem. All the talk of resources and CS's costing more money has actually made anxious women dubious and suspicious about counselling."

I understand this. I remember that distrust. As I said, I didn't have CBT until after the birth but it was my experience it was about me and absolutely nothing to do with trying to get me to "buy in" to any model of looking at this, we did a lot of talk about this resources issue and my anger was really supported and it helped me make certain complaints. At no point was I told that my rational fears where irrational... it was just the ones where anxiety had become so huge that it coloured everything so that I was so on edge I was then thinking of all the other risks/not trusting advice about feeding etc.

Again, I fully support campaigning for a different culture where women don't have to feel like this. I just think it's really hard to achieve while you are pregnant and you need to put your own wellbeing and that of your baby first. It's not really a great time to be objective about your deepest fears.

Sorry that's not clear either.. I was so stressed and anxious for so long that after birth I treated all advice as suspicious for a while e.g. I was afraid that my baby's cold was pneumonia or that he was really seriously ill and I was being fobbed off.

This is a real problem. It still helps to have ways of understanding and managing your anxiety. They are not mutually exclusive.

Chunderella, you are very right about knowing the system. As a second timer of 34 I was very much robbed off.. but I think your post has made clear to me, there are two questions here.

1. Should you have to be diagnosed with an 'anxiety disorder' to get an elcs when your fears have good clinical grounding?
2. Will counselling for this issue be about persuading you to have a vb against evidence and therefore dismissive of your reasonable fear?

I would say the answer is no and no. Unfortunately if you want an elcs because of maternal request you won't get one. So you 'need' to have an anxiety diagnosis. This unfortunately means labelling your fears as pathological even though they are not. This is pretty misogynistic but a hoop you have to jump through.

This is all true.

However, dealing with your actual, 'normal' anxiety can still be helpful in all sorts of ways, especially in this time when motherhood is often unsupported unless it appears to be glowing and serene. You can engage with counselling in a way that supports you through the system without it meaning you have a pathology that needs to be fixed.

ACT and Mindfulness in fact are about NOT pathologising the human experience, about recognising we all have valid and real experiences of fear that are just part of being human and that it isn't helpful to view this as disease.

However, to get that red stamp of approval for elcs you sadly do need to at least pretend to buy into the WRONG assumptions of the medical profession because otherwise they will say no.

Again,this is not right.. but it is what it is and it can be helpful to have support to stay strong and someone who can support your application. A counsellor will never tell you what birth to have!

This has been such an interesting and informative thread for me and I really don't want it to descend into a bun fight!

Clearly my OP has been accurately interpreted by some, by that I mean, as I intended it to read, and differently by others. I should have made my points more explicitly perhaps.

chunderella you hit the nail on the head in your 1407 post, last paragraph.

I have no desire to ride rough shod over anyone's experience and thank all contributors, but I never intended this to be a post about CBT! Can we accept some of us have misinterpreted others posts and continue our debate?

On another note, I managed a hospital blood test yesterday, without shaking, sweating, crying, fainting, veins collapsing or vomiting. Yeah for me! It's progress...maybe my thought processing and this thread is helping overcome part of my hospital hatred!

I do have to say, that I'm yet to see someone on here, who wanted an ELCS and perhaps was denied it at first, not be approved in the end. But its that fight itself that bothers me and causes me anxiety. All this hoop jumping is actively creating additional stress. I think quite a few women are going private if its an option to bypass this. Ironically the NICE guidance was supposed to stop this hoop jumping anxiety!

Secondly out of all the people I've seen on here wanting an ELCS, I've seen only one end up having a VB against her wishes because its not gone the way things were planned due to going into labor early and being repeatedly delayed. That said her experience was dated and she came back to post about it over a year after it had happened and it was prior to the NICE update, which have created a greater awareness of how this could be potentially harmful. I think that hospitals would be perhaps more reluctant to allow this to happen as the guidelines spell out the risk quite clearly.

I'm fairly confident about eventually being able to get an ELCS if I wanted, given my personal circumstances. (That might be different for women in other circumstances though). But I would find this process distressed and its all the bullshit on the way that bothers me. It is entirely preventable and completely unnecessary. To me, that in itself, shows the sheer lack of understanding of the problem.

cake baby, I am very sorry that your experiences so far have not left you feeling any better about the choices that you need to make for yourself and your baby. I would imagine (as someone hoping to be a midwife) that every midwife has you and your babies best interests at heart, however if you do not feel that please ask to see another one. Does your trust do case loading at all? you can ask the midwife, that is where you will have a very small team of midwives who you will always see.

As for your choices, they are yours and you sound like you are doing a lot of research, if you choose to have an elcs then you will have to be persistant and speak your concerns until you are heard, try to remember that you are basing all these decisions on stats and hypothetical situations not any set reality over which you will have control.

What always worries me about threads like this is everyone comes on with a bad birth story just to set your anxiety levels higher, you very rarely hear the had baby in 12 hours and went home 8 hours later, but this is for most women the reality.

There is a problem for all women who wish to deviate from the general protocol. Women have to fight for elcs, for home birth, for a vb with planned epidural. It's all "you'll change your mind" "do you understand?" "Isn't it terribly dangerous" "so-and-so did it X way so you should too".

And the the insults: "too posh too push" "too reckless" "must be a hippie" "must be mentally ill" "doesn't understand the dangers".

What do almost all of these women have in common? They have tried to take back control and given thoughtful consideration to the birth they want.

Yes birth is unpredictable but not all of it is. Telling women as a homogenous group they can't make decisions about care smacks of misogyny and is belittling and insulting.

OP you sound like you have a good understanding of your circumstances. Whatever you choose in the end you won't be judged by me as anything other than miraculous because all women who bring a child into the world are. It takes courage, selflessness and sacrifice to be a mum regardless of how they enter the world. Good luck with your pregnancy and I hope you get the birth you want :)

Gah!!!! Because its about how long it takes or how painful it is!

Read and LISTEN to what concerns there actually are on this thread.

You aren't helping by missing the points and concerns people are actually raising here. Its not going to give them much faith that you'll do that in a stressful situation.