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.

Redtoothbrush - can you point me in the direction of your research you've been reading because what I've been reading is very swings and roundabouts, you find one study that says first time mothers over 35 basically shouldn't have homebirths and and you'll and another that says the complete opposite - basically for me confirming my belief that pregnancy and birth is risky, has always been risky, and always will be risky and you often cannot predict nor control the outcome - all you can do is your best.

I feel it's worth pointing out that some people do have absolutely straightforward vaginal births, so there should be no need for treatment afterwards.

ELCSs seem to be presented as a walk in the park, but they are operations so, of necessity, medical events. This leaves me too being a bit puzzled by why the OP, if she has a fear of hospitals, doesn't explore home birth or MLU options further, or failing that investigate getting a doula. Having a doula to support her and speak up for her could give her back some of the autonomy which she rightly fears will be lacking.

Chunderella - I do not believe women's birth choices should be dictated by cost alone - I believe it should be dictated by what is the safest option. From what I've been reading I do fear that a lot o the decisions made with treatment from the NHS is cost and not best practise based - which sometimes makes me question my own MW's support of me wanting a homebirth and whether that is the safest option for me. In all honesty, I did actually believe that CS was ALWAYS far more expensive than a VB, it's something that I haven't researched for a long time - if that is not the case then I can't see why women shouldn't be allowed to choose ELCS if that is what they want and they don't have a condition that for some reason would completely contraindicate ELCS.

If I came across as anti-choice than I'd like to assure you I am not - I am vehemently against how some women are treated when it comes to birth choice - fobbed off, laughed at, told to suck it up - I think that's appalling - my only point was that it wasn't fair to expect an expensive procedure coming from a limited pot when it's not medically indicated - and if CS costs are no more then that point is/was moot.

Congratulations on your pregnancy :)

You say you get anxious around hospitals (understandable, and I'm sorry for your loss) - you will end up spending more time in hospital having a c-section. So actually, if you don't want to be in a hospital setting, you would be better at looking at the option for home birth or a birthing center. You can be discharged and heading home within a few hours of a straight forward hospital birth, too.

CS are portrayed as the 'easy' option, when they're really not. I'm currently recovering from minor abdominal surgery, and feel like utter shit, never mind major surgery AND adjusting to looking after a newborn.

Unfortunately having a baby is all about letting go of control They eat when they want, sleep when they want, poo when they want... But more seriously, if you want to be in control of your birth - again, understandable - then things like hynobirthing, avoiding induction, keeping active during labour, and trusting your body will put you more in power than a group of surgeons.

trustissues,

ELCS on maternal request can be not only budget saving (as it is not usually followed by years of treatment of mental issues or years of physio and reconstructive surgery), it is also time saving because ELCS is planned and the time of HCPs it requires is much more predictable whereas VBs are as a rule unpredictable as for time it takes and outcomes.

Is it really the case that the additional costs for giving elective cs on maternal request is the same as the current costs put into treatment for women following vb? I am amazed by that but if it's a fact, it's a fact.

I think the whole issue of research in this area is so problematic. I really genuinely believed from trawling through research that a) the fact I was anxious in pregnancy would create an anxious baby; b) that anxiety, as it was severe, would prevent me having a normal vaginal birth as it would slow down labour and increase likelihood of induction and c) that I would be in immense, uncontrollable pain and no one would listen but would instead shout at me and disregard my wishes.

Now, as it so happened, none of these "beliefs" I had sought evidence for again and again (and for which there was actual statistical "evidence" for when it came to a and b) bore any relationship to the truth of my experience. It is so complicated.

Again, I fully support the OP's right to request an elcs BUT I think ELCS or not, the anxiety needs to be dealt with. I also think in general when you are having kids, your old "ishoos" come up and it is a powerful and productive time to deal with even the darkest shadows and skeletons in your cupboard.

You've name changed too haven't you, working. I have a fairly good idea who you were. I did wonder, if it was you. I hope things are getting better as I know what a state you were in at the time.

I've actually got an appointment booked with the GP for Friday. Which I'm trying to prepare for atm. I've got to sit down and talk to my DH about it all properly later today. We've been talking about it for a while, but for various other reasons its not been top priority (DH's job had a job that was going to take him out of the country for sometime and we didn't want to seriously start doing anything until that was over, as frankly I need the support).

I actually saw the GP in October. Long story involving side effects of mini-pill.
Naturally my general anxiety over doctors came out in the process too. She went on and on about 'building up trust', 'taking it seriously', 'building up a relationship' etc etc and said she would refer me for counselling over it. She went on about the counsellor being someone who "wouldn't be someone wearing a white coat" in the most patronising way imaginable and I did challenge her on this as I got more and more upset and distressed over her not listening and just assuming what my fear is about.

And guess what. I've heard absolutely bugger all since. I've no idea if its because the waiting list is so long, or because she didn't fucking bother to refer me, or because the system doesn't tell you if your referral is rejected.

So I feel very let down, betrayed and frankly lied to already. This isn't exactly helping and in fact is doing exactly the opposite by helping to reinforce my feelings and other previous experiences. I already feel like they don't have a clue what to do with me, or how to deal with anyone like me.

As it stands, finding the strength to have an ELCS would still be an enormous achievement for me given my personal circumstances. Which is one reason why I want to have it all sorted and agreed before TTC.

If then, by some miraculous thunder bolt hits me (which I sincerely doubt will) I have the knowledge that I'm free to change my mind without pressure. But I need the pressure removed and not to have to deal with a fight to be able to do that. The more I am pressured, the more I simply am alienated from anything anyone says to me, and I'm fully aware of this. I need breathing room, I feel happy with and on my terms.

I have confidence that, with the right support, I could over come things enough to have an ELCS - but given how deep seated this is, and what it is related to at its very heart, I'm realistic that miracle working isn't likely to happen. Not with the time I have left to deal with this. I can hear the ticking clock in the background.

I genuinely need supportive health care professionals to help me achieve that not judge me. Not put words in my mouth. And not reinforce pretty much everything I've already experienced and feel. I do feel that all these conflicting agendas out there, which I am only too aware of, have anything but MY best interests at heart and no one really wants to listen to me and help me. Truthfully I do think everything is set up against me, quite sadly.

I do not feel for one single second that I am alone in this. Or that others don't have different, but similar enough problems.

It has to change.

Is it really the case that the additional costs for giving elective cs on maternal request is the same as the current costs put into treatment for women following vb? I am amazed by that but if it's a fact, it's a fact.

i am not sure that it is a fact - I don't think anyone can properly quantify it. Many women don't have problems until they hit the menopause. Now most of those currently having such surgery will have had a VB because even about 25 years ago the CS rate was only about 8%. Fast forward 25 years, with our 25-33% CS rates will gynae repair ops be a thing of the past? I don't know, but will watch with interest.

RalcucaV - budget saving even? I was not aware. Let's hope when the NHS actually latch onto this they then swing the opposite way and pooh-hoo women out of choosing to have a go at natural delivery...

Also KatieMiddleton - please do not swear at me - you accuse me of being rude and yet in your first sentence you swear at me, twice! I have no problems with swearing over something but swearing at me steps over the line of basic politeness.

That was meant to read ..."they then DON'T swing the opposite way and pooh-hoo women out of the chance of a natural delivery."

working,

I agree there are some beliefs and myths surrounding childbirth that are taken as facts by the public, but unfortunately by some HCPs as well.

a) I believe it is a possibility that mental state of the pregnant woman does influence the baby, but I wouldn't swear on it. It has never been proven sufficiently for me to take it as a fact.

b) This maybe wasn't true for you, but it can be true for many other women. Panic attacks can't be good in labour, however you look at it. And as I'm very likely to panic, to become aggressive or suicidal in pain (I know I do when I have migraines.), I don't even want to try. It's simply too dangerous a gamble for me.

c)Unfortunately, it is also true in most cases. Most women describe the pain of childbirth as unbearable pain, wishing to die, great shock, made worse by cruel staff (some have epidural, so it becomes bearable for them). There are only a minority that describe it as manageable and even pleasant. Also, great gamble for me, so unacceptable.

I don't see it as very complicated to decide what's best for me. If I am to have high probability of b and c, I will do good if I simply avoid VB if I can. That's just risk assessment, not anxiety per se. I don't have any skeletons in my cupboard to be investigated by a therapist, no abuse nor nothing. I just don't enjoy pain and being bullied and humiliated and I think that's quite normal, not an irrational phobia or anxiety.

Chunderella - I'm completely with you on that one - the safest option is subjective and relies heavily on the parents, especially the mother, being informed with proper, unbiased, easily understood information so she can actually make an informed decision based on her personal context - I'd hardly want to see hospitals going ahead and sectioning a woman because the Dr's are adamant that the safest option is a C-section for her because if she doesn't have one her baby has a marginal increased risk of dying - that is up to the mother to decide based on information she is given. There is nothing more infuriating than being co-erced into something by being given one sided information - I ired my first OBGYN for that when she told me I would give my son penile cancer I I didn't have him circumcised and gave me a list of what was going to be "done" to me over the course of my first pregnancy.

To everyone here.

Can you not see that all this need 'to prove your case' to argue your 'validity' IS the problem.

I can find all this research. And yes I can find stuff to the contrary. I've made an effort to do so, so I have a picture of the opposite as I understand that you can seek out stuff that just says the opposite.

Which is why on balance and generally, I DO feel there is little in it for a VB or a CS in terms of safety.

BUT, the things that matter MOST to ME are better for an ELCS. I find aspects of a ELCS worrying and scary, but ultimately I think that could be manageable. I don't feel that for a VB for a whole multitude of reasons.

I understand what is rational and irrational. But they are ALL labelled as irrational. And not 'valid' enough.

Quite frankly, if there evidence is, that both are as safe as each other, I don't want any more children and the cost argument is a non starter, why is this even a debate?

I have to PROVE it to everyone else, rather than everyone else bothering to respect how I feel and start listening in the first place. They already know it all and put words in my mouth. Its a process of having to justify everything.

NOTHING is on my terms and nothing is about me being an individual. Its all about making me fit into a nice convenient box and complying. Its about ignoring what my greatest concerns are.

Nothing is about giving me the confidence in my own decisions and supporting me in them as being fair decisions based on everything out there.

How is this selfish? How is this even purely about control. It is, but its also about seeking respect and being treated as a human worthy and capable of making informed decisions.

I am struggling to get access for anxiety problems. I have a lack of trust in the system because of previous experiences. Previous experiences that are the fault of other people - not me. You can not expect me to just change that or forget it. I am a product of the system!

And yet you do.

Yeah Redtoothbrush, funnily enough I have only this week returned to my pre-all of this nickname, because I have let go of a lot of the shame and paranoia about being "found out" in rl.

I most definitely was in a state, that much is true. I won't pretend it's been an easy year or that the birth magically removed all my fear, I wish it had. I was on a massive high for a while after it, but as you may remember, the difficulty with my diagnosis was that anxiety was always going to "jump ship" and it did.. he lost a lot of weight and so the mh care team advised not to focus hugely on it, but actually it didn't get followed up very well and lo and behold, my poor darling ds actually became "wasted" in the GP's words.. all the while I thought it was just my anxiety thinking he was too thin because none of the health professionals checking on him actually followed up... grrrr.... so believe me, I totally understand this distrust and fear of health professionals and realise it is not always irrational or anything like it.

On the other hand, being a bit more objective about it at this stage, I will say it was very hit and miss... some care was actually superb and obviously for me, the CBT was incredibly useful. The therapist really supported me whenever everyone else cocked it up and stood up for me in a MDT whenever all the other professionals were basically trying to fob me off, and also created space for me to stand up for myself when I was getting overwhelmed. I appreciate that part of this might just be that he is a good therapist too, I imagine there are also some shit ones.

I really think in your situation Red that you will be granted an ELCS but sadly I also think that if you don't take steps you shouldn't have to take to manage it, the process might be hard... I think if I were you, I would try and find a good therapist first because so many of them are, frankly, crap (you may remember I had a numpty myself before I got my NHS one)... because in your situation I think it would be important to go into the whole thing with your issues clearly outlined and then just have someone supportive with you to prevent the endless "presentation of risk" aka bullying and fear provoking etc so that you don't have to suffer it.

It is shit. I don't agree with the system at all. I just hate to see women getting swallowed up in it because I remember it, it's still actually very raw for me. I am trying to be really balanced and "mindful" about it and realise I also had great moments this year, but there were times that I was very low after the birth indeed and I am sort of at the stage now of just coming to terms with that. I wish I could go back and shake myself out of my anxiety but of course I know it's not that simple...

I really hope you can get it sorted. I would hate to see any woman not have a child because of this awful fear.

i am not sure that it is a fact - I don't think anyone can properly quantify it. Many women don't have problems until they hit the menopause. Now most of those currently having such surgery will have had a VB because even about 25 years ago the CS rate was only about 8%. Fast forward 25 years, with our 25-33% CS rates will gynae repair ops be a thing of the past? I don't know, but will watch with interest.

In 1990 the percentage of CSs was about half what it is today. (I can't be bothered to check the exact figure, but it was close on it).

In the twenty years since, the total number of women giving birth over 35 has tripled. They now make up about 20% of all women who give birth. In 1990 it was about 8%. The average age at which women have their first child has gone up considerably. The human body wasn't designed for this and doesn't react to well to it. We also have the impact of obesity.

Its perfectly feasible to suggest that actually a 35 year old woman giving birth today (assuming the same BMI) actually doesn't have any more or less of a chance of having a CS than she did had she been 35 in 1990 on the basis of her personal medical history.

I'm not sure there is a compelling case to say that the number of CSs that are really needed has increased as significantly as people initally believe.

Raluca, I absolutely agree that fear of birth can be completely and utterly rational. I suppose my point regarding those three things I mentioned isn't whether they are valid or based in research or not per se, just that I have learned that research in general isn't always applicable or anything like it for many of us.

For example I was told that research shows that people don't panic in labour because the part of the brain governing labour sort of shuts down panic.. but as I said at the outset of this, no one had ever researched me giving birth for the second time in the same way they haven't researched you.

I think we are living in a time when "evidence" is prioritised in such a way it dismisses real fear. I was told I could take antidepressants in pregnancy and that there would be a "small chance" (1 in a 1000) of it causing a serious but fatal birth defect... erm, yeah, that's okay but clearly eating certain cheeses would be irresponsible when there is a 1 in 18 million chance or something crazy like that of it causing harm.. Go figure.

Oh and sorry - you might not have "ishoos" but a lot of people do..

Redtoothbrush - I completely agree with you that having to argue your case IS a huge problem - I went into my first midwives appointment expecting to be pooh-hooed about wanting a homebirth and was more than surprised by the rresponse I got - based on previous experience I was expecting resistance (which now brings it's own set of problems because I'm now wondering if they're blithely disregarding and risk actors I| may have in the name of saving money)

Wourds like "allowed", "mustn't" "shouldn't" and the likes need to be banned from the practise. Staff who think women, especially pregnant women, are neurotic and irrational should be weeded out.

I have no idea who is calling you selfish because you want an ELCS. My only original point, which was based on research I did years ago and which I should have checked up on since it was years ago, was that ELCS is more expensive and that's a little unfair if you're not willing to at least make up the financial difference. There's nothing selfish about wanting your birth your way.

And I do sympathise, Redtoothbrush - I have bad anxiety and PTSD symptoms that need to be addressed...can I get access to treatment for something that is affecting my life and won't just go away because the trigger is and will always be attached to my life since he's my sons father? Can I chuff!!!

Working,

:) exactly. It is almost impossible that in this day and age there are still so many things surrounding human procreation veiled in the mists of mystery. Anyway, it still doesn't mean that we cannot make decisions for ourselves according to what suits us better. Risks are not only numbers, but real things that might happen and there are simply risks that I do not wish to gamble.

"For example I was told that research shows that people don't panic in labour because the part of the brain governing labour sort of shuts down panic."

You are right, there is no credible research for this. To me it's hippie bull*t if you ask me. Hm, not panic while being in such a pain that one wishes to die, hmmm, if this is not panic, then I want to know what is. There are also many anecdotes about women that decided to go away from the hospital when the head was already out because they felt utter panic and helplessness. But yeah, brain shuts and doesn't feel panic...that's why there are so many women with PTSD after labour, right?

trustissues - I so agree, words like 'allowed','must', 'got to' should be banned, plus comments like 'if you don't care about your baby', 'if you were me/my wife' and so on.

I also think it shows how you process fear, evidence and risk and just how important psychology is to the birth process.

I've been keen on not picking an choosing and made myself read stuff I didn't want. It has made me see the value and real case for things like homebirth. I think for some people it really does work. Like I said upthread, one of my friends went for it, and it had been secretly what I had been hoping she would do without ever talking about it to her. I was very pleased she did and it turned out well for her too. Its why I support a multitude of options - satisfaction with birth isn't linked to what ultimately happens, it is much more linked to have involved you are with the process and how you have been treated during it. Even if it doesn't go to plan, its the process that you've gone through to get there that more important. Its nuts.

But I've also seen how what is close to you, often has more impact than logic and evidence too.

Whilst I fully understand that the experience your mother had has no baring at all on what happens to you. There is no evidence for it. None. Nothing. Zip zilch. Far more evidence to say its to do with the position of the baby and the position you labour in.

This IS reassuring to me. I'm sure its reassuring to other women.

But it doesn't take away the fact of how it might have affected you mother and in turn you. Or how it clouds your vision. Instead of it being a hypothetical situation, it becomes a real one that has occurred. Statistics become rather meaningless, if you or someone close to you are the ones affected.

This IS important to understand as its part of human psychology.

You place the value of one higher than the other, despite knowing which is more important and which is more valid.

And this DOES effect the body in physical ways we are only just beginning to explore. For example, anxiety raises blood pressure. Its only been recently that doctors have been advised to monitor blood pressure over 24 hours away from them, as it was proven that anxiety at the doctors was effecting reading to such a significant extent.

If you understand these principles you can improve care, in both a home and hospital environment for a whole pile of things not just maternity. But at the moment they are so poorly understood we can't manage it effectively.

Of course this is feeding a cycle we can't break at the moment too though. But until we actually recognise that irrational fear also has rational basis and rational basis can create irrational fear then you won't actually get anywhere either. The two are both important and both 'valid' for mental AND physical reasons. Your body and mind are not separate and yet, this whole thing over maternal request seeks to do this.

It is no good to make people 'hoop jump' and prove as its feeding this.

Is it good to have health professionals out there so ideologically compromised that they ignore this? This is true of both midwives and consultants. The distorted figures for how they give birth are frequently used; but what they show is really nothing more than how important it was for them to be free to make that decision on their own terms and based on what is important to them.