Guest post: “We must support women’s decisions in birth and make respectful care a reality for all”

[MumsnetGuestPosts]

Women’s rights in childbirth have occupied a dusty corner of the feminist movement for too long. As CEO of the human rights in childbirth charity, Birthrights, I’m working with a small team of staff and an expert board of midwives, obstetricians, lawyers and maternity service users to change that.

We believe that all women matter in childbirth and that we need to be treated as the same, reasonably rational human adults we were before pregnancy at this transformational time in our lives. We’re using the human rights framework (with its focus on dignity, respect, choice and autonomy) to push for a system, services and practice that protects women during birth, offers them safe, equal and compassionate care and listens to their feedback. To do that we provide advice, training for NHS staff, conduct research and feed the resulting knowledge in to maternity policy - always with a focus on vulnerable groups.

Women contact us for free advice on a range of issues. From accessing their chosen place of birth and help with making a complaint about care to dealing with issues around informed consent or entitlement to maternity care in the UK.

Over the past two years a worrying third of our advice service enquiries have come from women trying to access a maternal request caesarean and finding themselves battling, jumping through endless hoops and waiting for months for answers. Some women whose reasons are not deemed compelling enough have even had their care withdrawn completely in the last weeks of their pregnancy. These enquiries have been some of the most distressing we have handled and we’re determined to do something about it.

Whether they are choosing a caesarean, a homebirth or any other birth option women have very compelling, thoughtful and sometimes private reasons for making their decision. From the 83 women hoping to have elective caesareans we advised in an 18 month period 33% had experienced a previously traumatic birth. 28% wanted a caesarean birth because of an underlying medical condition such as symphysis pubis dysfunction (SPD), vaginismus or fibroids. 16% of women simply believed it was the right option for them (often after extensive research into the evidence), 8% cited primary tokophobia as their motivation while 6% explained their request was based on other trauma in their lives such as sexual assault (6%). 10% did not give their reason for making this request. Nor should they have to given our growing realisation that many more women have experienced trauma and violation in their pasts than we’ve previously assumed.

Through a series of Freedom of Information request we have created this map of Trusts showing the 26% who offer a respectful pathway for women to request a caesarean (in line with best practice guidance) Trusts whose policy effectively bans maternal request caesareans (15%) and the many in the messy middle ground that women are expected to muddle through. We’re now working closely with national policy makers, the Royal College of Obstetricians and Gynaecologist and the Royal College of Midwives to push for clear national recommendations on this issue and to encourage Trusts to abide by them. And we are considering legal action if Trusts’ policies are shown to be unlawful.

Women make decisions on what kind of birth is right for them based on a range of medical, social, cultural and experiential factors. For me a safe birth meant being at home, for others it requires access to an epidural or the presence of a trusted midwife. And for a small percentage of women electing a caesarean is an important decision in a positive journey to motherhood. We must come together to support women’s decisions and insist on a system that makes safe, respectful care a reality for all.

If you need information on anything concerning your rights in pregnancy and birth head to our website and this series of Mumsnetters FAQs, such as “Can I be refused admission to a midwife-led unit” and “Do I have the right to access my maternity notes?”

I’ve used this radical idea that pregnant women are human beings as the basis for my new book, Your No Guilt Pregnancy Plan: a revolutionary guide to pregnancy, birth and the weeks that follow. I’ve focused less on the ‘you shoulds’ and ‘you shouldn’ts’ and more on the concerns that came up for me when I was first pregnant a decade ago and asked for support on a Mumsnet due date thread. So there aren’t endless comparisons of your baby to the size of a vegetable but I do cover the huge shifts happening in our relationships, bodies, work, sex and emotional lives as we become mothers. And of course a firm focus on rights and mental health.

//birthrights.org.uk
//rebeccaschiller.co.uk

[Mugglemom]

I could not agree more.

I was an ELCS after several failed attempts at induction. I got so much pushback for the choice and the consultants attempted to scare me into not going for a c-section by telling me all of the many risks associated without properly talking through the risks of any other choices (such as the induction itself).

At one point, after 2 pessaries had done nothing and my elcs had been confirmed for the following day, a consultant came to speak with me at midnight and wanted to check my cervix. It was incredibly painful, so I was put on gas and air for the sweep. The consultant then said she was confident she could break my water and tried to get me to concede while still lightheaded from the gas and air, and without my DH present to discuss it with.

I was incredulous and of course said no. The following day, I was not seen all day even though I'd been fasting all night and day in preparation for the surgery. At 5:00PM, I was informed the surgical staff had been too busy with emergencies and my elcs would not be that day. This was when I was 17 days overdue. My DH was furious and spoke to the head of the unit who sorted it for me to have the c section that day.

But it's a good thing I did, because I'm sure I would have ended up with an emergency c-section, as my little one was 10 lbs 9 oz!

[Miyah]

I just think it’s crazy how my traumatic long induction ending in emergency rotational forceps in theatre leaving me battered and bruised, my baby battered and bruised, me with an episiotomy extending into a tear, PTSD and now long-term mental health problems as well as long-term physical health problems (incontinence issues, scar tissue problems, pain during sex) is seen as a success just because my baby came out vaginally. If women are warned about elcs risks then they must also be warned about induction and forceps risks as these are also interventions. I’m struggling to see how this is anything other than trying to control women and prevent them having choice and agency. I just can’t see how it’s supposedly in our ‘best interests’.

[Slumberparty]

My birth story isn't as bad as some of the ones here, but I did have a horrible consultant who made me feel like an absolute failure. I was induced and after around 30 hours of contractions that were not doing anything (I never got passed 4cm), the baby started to become distressed. The consultant would turned off the drip and the baby would recover but contractions would stop, then turn on the drip and contractions would start and baby was in distress again. This went on for a few hours turning the drugs on and off. The midwife warned me that I would probably require a c-section which by that point I was ready for. However when the consultant came in to check the monitor and ordered the drip to be turned on again I asked how long we were going to keep doing this for and if I would be having a c-section. She acted pissed off and told me that if I wanted to "give up" and have a c-section then fine. It really upset me . I was exhausted and the baby was in distress!
I had a c-section in the end and am pregnant again now and am expecting to be having an elcs. I haven't actually been told yes for sure but no one has tried to talk me out of it.

[Elephantgrey]

I think this is about much more than midw of delivery. It is about women not having individualised care. If a conversation had taken place where the women had the chance to express her concerns about birth and the doctor had made a care plan based on that they are far less likely to end up in dispute with the hospital.
I know people who have had c-sections at the hospital where I gave birth because they have the same medical condition I have. The difference? They had a different consultant. Often the consultant looks at your case on paper and decides before they even speak to you. Often it is down to their personal preference.

[Slumberparty]

I recently had an appointment with a consultant to discuss birth options for second baby. All the statistics given point to a VBAC being the safest option all round. No mention of risks of tearing, instrument delivery etc.

[Miyah]

Yep I’ve heard women’s stories of vbac clinics showing them only a list of the pros of a vbac and the risks of an elcs. How on earth is that an informed choice and informed consent? There’s a massive human rights issue with presenting such one-sided bias information

[BringBackSummerQuick]

Thank you for campaigning on this. Our society has a complete lack of empathy for the impact childbirth has on the Mum. If she feels pain or gets injured she should just shut up and get on with it as that’s her duty. She certainly mustn’t talk about it or request and elcs next time or use pain relief. If she does any of the above we will roll our eyes, tut, and write her off as dramatic. Disgusting that even the nhs trusts can’t see past this and follow the NICE guidelines. How can we best support your campaign?

[BringBackSummerQuick]

I also agree with PP about vbac clinics being very one sided. Ours was all about convincing u to vbac. I had already decided to go down the vbac route and even I felt the bias and pressure. The midwife actually breath a loud sigh of relief when we said we were willing to vbac!

[Laney79]

@Miyah so true! How can it truly be informed consent is information is withheld or glossed over invade you "scare" the women it could happen to? I've been involved in social media debates on this where midwives/experts have actually said that - you don't want to give too much info for fear of scaring people!!! But it seems it's ok to do that about CS...

[ingenvillvetavardukoptdintroja]

I had an ELCS a week ago. I am very lucky to be under a trust that allows maternal request section.
I had previous EMCS ending with my son spending 4 weeks in NICU and also prenatal depression. I have been treated so respectfully and listened to throughout my pregnancy. The birth was a wonderful experience and has made such an important impact on me, both recovering mentally and not having to worry about the birth during pregnancy when I was suffering from thoughts of self harm. Section was agreed at 20 weeks.
It's really upsetting to think of women in the same situation being denied such a positive experience.
Reactions from friends has also revealed common misconceptions about sections - everyone is gobsmacked that I left hospital after 36 hours, that I haven't been in pain and that I'm walking around. Many women are not even considering sections because they are believed to be a highly dangerous option that leaves you incapacitated for six weeks. We are not idiots and should be allowed to weigh up the options ourselves and decide what is best for us.

[Miyah]

There’s a huge difference between being open and honest about the real risks and statistics of procedures and of ‘telling women horror stories/scaring them’
And why is it then ok to emphasise CS risks when a lot of women will also need those for medical reasons so could also be ‘scared’
In other areas of medicine you are told open and honest information about risks, to justify giving one-sided bias info preventing true informed consent with ‘ah but women get scared‘ is just treating women like children who need somebody else to decide the best option for them

[RidingMyBike]

The ridiculous thing I found, having had two lots of minor surgery in the past - both involved meetings about consent and the doctor making sure I understood all the risks involved, including the microscopic chance of death.

Get pregnant and start planning birth and looking into options and all the information, listening to the patient and offering choices disappears out the window. Even though the risks of injury are a lot higher than in minor surgery. Luckily I read around and did lots of digging - knew the risks of being induced and it was indeed horrendous. I knew to refuse an assisted delivery and go straight to c section but I don't know if that would have been 'allowed' if I'd got that far. I was very pro-active about asking for pain relief and got the Midwife organised with getting the anaesthetist in to do the epidural whilst she was handing me the pethidine, as I knew there might be a wait for the anaesthetist. But the midwives were trying to downplay any risks from vaginal birth.

I wish now I had gone for a c section - I ended up with two tears, an episiotomy, haemorrhage and PND with a vaginal delivery.

[WeShouldBeFriends]

I think we should be doing more to address why there are so many traumatic vaginal deliveries these days rather than just granting elcs on demand tbh. I know people will say there have always been traumatic vaginal deliveries, and I don't dispute this, and we want to do all we can to avoid it and keep our bodies and our babies safe but I really think we are going down the wrong path. Telling pregnant women they risk 4th degree tears and faecal incontinince for life, painful sex, scarring, prolapse etc...if they have their babies 'normally' WILL scare them and perpetuate the problem of birth being considered a medical complaint that require doctors to relieve them of. The medicalisation of childbirth has a lot to answer for imo.

[BlairWaldorfsHeadband]

I think we should be doing more to address why there are so many traumatic vaginal deliveries these days rather than just granting elcs on demand tbh.

What if you just don’t want a vaginal delivery?

Telling pregnant women they risk 4th degree tears and faecal incontinince for life, painful sex, scarring, prolapse etc...if they have their babies 'normally' WILL scare them and perpetuate the problem of birth being considered a medical complaint that require doctors to relieve them of. The medicalisation of childbirth has a lot to answer for imo.

It’s the truth though. Should we lie to people to not scare them?

[DuggeeHugs]

I think we should be doing more to address why there are so many traumatic vaginal deliveries these days

Telling pregnant women they risk 4th degree tears and faecal incontinince for life, painful sex, scarring, prolapse etc...if they have their babies 'normally' WILL scare them

Perhaps the second sentence could help with the first though? Perhaps if pregnant women were told the risks they could have some agency, choose the risks which are acceptable to them and perhaps reduce trauma by having more control of their deliveries. Some women will still be happy if their delivery requires induction and forceps, others will prefer a CS, others may want to try a home delivery. But that should be their choice .

My feeling, one that is shared by many others, is that if I'd felt informed and in control much of the trauma of my first delivery would probably not have been there. That could well have changed my need for the control of an ELCS with my second. As it stands, you couldn't pay me enough to attempt a vaginal delivery again.

[WeShouldBeFriends]

Personally, and I don't know why you wouldn't, I read up as much as I could about birth when I was pregnant for the first time. I was well aware of all the risks but also that they were an unlikely complication for most births. I never for a second considered an elcs just in case. If however the midwife at booking had said 'right, this is everything that could possibly go wrong with a vaginal birth, you could have an elcs if you like' I would probably have doubted that I could achieve a straightforward birth. And as we know that fear and adrenaline affect the birthing process it would likely have been a self-fulfilling prophecy. Obviously if I had suffered a complication, my thoughts for subsequent births would undoubtedly be different. My point is that I think it's important that vaginal delivery is considered the default.

[Aw12345]

I fully support women's choices and especially the right to have elcs if that's their wish.... The only thing I would say is that the complication rate is higher with caesarean compared to vaginal delivery... And I say that as someone who had sepsis after a caesarean. (Obviously there are risks associated with however baby is born though!)

[BlairWaldorfsHeadband]

My point is that I think it's important that vaginal delivery is considered the default.

Why?

[WeShouldBeFriends]

That was surmising the rest of my post.

[BlairWaldorfsHeadband]

You’ve not stated why you think vag should be the default for everyone, though. Why do you think it’s superior?

[DuggeeHugs]

I don't know why you wouldn't

Because you expect your HCPs to provide you with relevant and accurate information, the same as with any other healthcare situation?

Because you don't expect the level of bias which actually exists?

Because you aren't equipped to do that level of research, evaluate sources, cross reference figures that are quoted?

Because there's a huge amount of information thrown at you during pregnancy and the vast majority of it promotes the image of a straightforward vaginal delivery being the norm so, as a first timer, you trust it?

Women should not have to research these risks - it is basic information which should be routinely presented without bias

[BlairWaldorfsHeadband]

To be honest even if someone had got a crystal ball and said “Blair you’re going to have a normal vaginal birth. You and the baby will be okay, it will be a normal non instrumental birth with a 1st degree tear and over in eight hours” I would still have chosen a cesarean.

[WeShouldBeFriends]

Because it's the biological norm ie, an immensely clever mechanism that has seen the human race survive for thousands of years. I acknowledge that right now there is a culture of unnecessary intervention (pretty much every horror story can be traced back to something along the lines of 'I went 10 days over so had to be induced' or 'I'm over 40 so had to be induced' or 'they said my baby would be big so I had to be induced') that has caused vaginal delivery to be less safe for more women, and therefore they should be able to make an informed choice and choose an elcs. BUT, the long term solution is not, I believe, the normalisation of elcs on a massive scale but instead to address the issues that are causing more and more interventions and injuries during vaginal births.

[BlairWaldorfsHeadband]

Because it's the biological norm ie, an immensely clever mechanism that has seen the human race survive for thousands of years.

So is dying at 30 with no teeth from an infection. Something being natural doesn’t mean it’s partiulatly good.

BUT, the long term solution is not, I believe, the normalisation of elcs on a massive scale but instead to address the issues that are causing more and more interventions and injuries during vaginal births.

But you’re not understanding that for some of us, a “normal” vaginal birth isn’t what we want or are hoping for.

I do not want to give birth vaginally. No matter how easy, natural or straightforward it is. I, and every other woman, should have the right to choose.

[blorgzorb]

Thank you for this. After a great deal of research I believe an ELCS is the right choice for me but feeling quite nervous about how I'm going to get what I want. Currently 21 weeks and getting more anxious as the time goes on.