I'm really frustrated by this. The BBC article is an abbreviated version of a full FOI request investigation by birthrights.org.uk
Frustratingly the article states simply that
It costs about £700 more to have a Caesarean, compared with a vaginal delivery.
when the full report by birthrights accurately quotes the NICE guidance in full which notes that after you take into account the cost of urinary incontinence the difference in cost drops to £84. (And that doesn't include other possible side effects). And the crucial point that NICE concluded that this difference was not enough to justify preventing maternal request CS.
The birthrights article on the subject is here
It links through to a full report which you can read here:
www.birthrights.org.uk/wordpress/wp-content/uploads/2018/08/Final-Birthrights-MRCS-Report-2108.pdf
I've got to be honest, that I find the report itself a bit arse about face with emphasis perhaps put in the wrong places - almost to produce a shocking figure for the lazy journalists at the BBC and the entire British Press - because they are fully aware that not one of them will bother to actually read the report much less realise what the real issues are.
The headline might scream that only 26% of trust allow maternal requests but thats a bit misleading. 70% of Trusts do offer CS with some concerns and the reports own methodology is important to note:
^However, only Trusts with a written guideline on maternal request caesarean have been classified as “green”. We felt that
this provided some evidence to an ongoing service-wide consistent approach on maternal request caesarean.^
^For Trusts of a reasonable size (over 2000 births) who said they offered maternal request caesarean, or weren’t clear about
whether they offered them or not but told us that they didn’t perform any between April 2016 and April 2016 then the zero figure
provided has been taken into account when deciding on the category.^
What does this mean in practice?
This means that a Trust like Liverpool Women’s which seem to have a very good pathway for maternal request caesarean but has no formal written guideline that references its approach has been classified as an amber.
^Similarly the Princess Alexandra Hospital in Harlow, Essex would have been categorised “green” based on the policies supplied, but
also said that it carried out zero MRCS between April 2016 and April 2017. It has therefore been categorised as an amber.^
Gloucestershire, Ashford and St Peters and County Durham and Darlington have all been categorised as “green” despite using the phrase “maternal request caesarean is not on its own an indication for caesarean” because they all went on to quote the revised NICE guideline (CG132) process in full including having a written commitment to ensuring women were referred to an obstetrician who “will” carry out the CS.
In other words the 47% of hospitals who did offer a CS under certain circumstance really were a mixed bag which ranged from simply not having a written policy to those who required a lot of hoop jumping. And even those who did make the grade, might not have a better policy than somewhere like Liverpool!!!
So its much more of a case of rather 'only 26% are allowing CS', only 26% ticked the right boxes on birthrights survey.
The key point in the report for me was actually this:
Without agreed definitions of maternal request caesareans and no comparable national data it is difficult to develop an accurate understanding of numbers and hard to develop a better evidence-base on the short and longer-term outcomes in these births. We hope that NHS England will take up this issue as it reviews national data collection.
This is something I have been banging on about for a long time. My notes state MENTAL HEALTH repeatedly in bold caps and then there is a little tick box for the reason for the CS being 'maternal request' which is quite frankly nonsensical. My mental health is not something I choose!
The report also stated this, which I do think is very relevant to a lot of women and is very different to myself:
However some Trust policies on maternal request caesarean appear to be based on the assumption that all maternal request caesareans are motivated by a fear of childbirth, as opposed to a rational reading of the evidence and how they apply to an individual’s circumstances, or concern as to the impact on another physical health condition, for example. Some women have told us that they are surprised and concerned to be treated as if they have a mental health issue, if this is not what is driving their request.
It then went on without irony to state:
Furthermore, while a debrief of a previous birth is often helpful, for women with post-traumatic stress disorder following a previous traumatic birth, interventions that focus on re-living the birth risks further traumatisation. Some women with a history of trauma may not feel able to disclose the reason for their request, despite those reasons being compelling. Therefore a one-size-fits-all pathway is not appropriate for maternal request caesarean
Despite the report advocating for written policies on maternal request CS and then down marking Liverpool for not having a written policy. Which is somewhat contridictory.
I'd rather a good pathway based on good understanding of staff, rather than a written pathway which is too monolithic supported by staff who lack a basic knowledge and common sense relating to understanding why women are requesting a CS.
I also think the following is very very important as it the thing that most highlights the need for research in this area. We are denying women access to care without the necessary evidence to understand on what grounds women are requesting a CS in the first place. How can you adequately support them - regardless of how they ultimately give birth - if you don't know this:
The reasons for women requesting a caesarean are not always well understood.
Our own analysis of our advice service enquiries on this issue between November 2016 and May 2018 reveal that a third of enquirers (33%) want a caesarean due to a previous traumatic birth.
^The second most common reason (28%) for wanting a
caesarean birth is an underlying medical condition such as symphysis pubis dysfunction (SPD) - a common problem with the pelvis during pregnancy -, vaginismus or fibroids. These conditions do not always meet the threshold of requiring a caesarean for medical reasons but the impact of these conditions on the women affected is significant, and the thought of having their condition exacerbated by a vaginal birth can be a cause of huge anxiety.^
^The remaining third is made up of women who simply believe it is the right option for them (16%), often after extensive research into the evidence, or who have primary tokophobia (8%) or who have experienced other trauma in their lives such as sexual
assault (6%). 10% did not give their reason for making this request.^
How do these women all fit into the same box?! The answer is they don't. The term 'maternal request' simply isn't fit for purpose and thats REALLY what is driving a huge inconsistency in care across the country, with hospitals each interpreting the guidelines as they want because the entire term 'maternal request' is so problematic - the hospitals just don't understand the complex and wide range of issues of the women who end up in this catergory purely because they fall through all the cracks of policy.
Maternal request as a term, is simply a way of catergorising women into a box which can be written off as 'not deserving understanding' and 'lazy/irrational/self centred/hysterical/stupid'. And thats the bottom line.
The other point is that every one of the times who are denying women a maternal request CS are failing women who have post-traumatic stress, co-morbid physical issues, severe mental health issues or are particularly vulnerable due to a prior experience. Failure to acknowledge these as a potential legitimate reasons for a CS is an abdication of their duty to patients. It also puts more pressure on neighbouring trusts who do fulfull their most basic obligation to patients to simply provide the most appropriate care for their needs as outlined in the NHS charter. (Which actually has more weight and power than the NICE guidelines on maternal request).
There is an interactive map which has the green, amber and red coding which can be found www.birthrights.org.uk/maternal-request-caesarean/
I'd urge anyone looking at it, to take it with something of a pinch of salt if green or amber and to take the time to click on any trust you are interested in and to read their FOI return to get an idea of why birthrights gave them a green or amber rating.
There is also a full list at the end of the actual report itself (which is easier to read). I'll name and shame the red trusts in another post shortly.