NICE recommend all women should be able to have a cs

[LoveBeingAWitch]

Just seen tomorrow's front page of the Sunday times saying that NICE are saying cd has become such a safe op that every woman should be able to have one if that's what they want. Im quite surprised by this.

"No, but that's because it's about the NICE guidelines for ELCS, not the impact of the implementation on current maternity services. That's an entirely separate subject"

No - it's absolutely not. Demand for elective c/s will go up as long as substandard care for women having vaginal births is common.

There is no other area of the NHS where people can opt for an expensive treatment where the clinical outcomes are poorer than those associated with a cheaper treatment. Elective c/s are only comparatively safe to planned v/b because so many women having planned v/b are having substandard care leading to high rates of emergency c/s and instrumental birth. If women having planned v/bs in the UK had better care and lower rates of intervention the argument for parity of elective c/s and vb would no longer be valid - v/b would quite clearly be safer for low risk mothers and babies, and fewer women would want an operative birth if they had confidence they would get good care in labour.

cereal, I'm certainly not against pain relief, just trying to find a non-birth-related equivalent situation and failing!

I think the NHS and NCT both have a lot to learn and need to homogenise their offerings - the NCT where I used to live was excellent, and although it was clear that they had a party line, I never felt pressurised, unlike your experience. OTOH one of the posters here said they thought the NHS was brilliant, whereas I thought they were awful. It shouldn't matter where you live, the provision should be the same, otherwise it seems discriminatory.

A model to compare the cost-effectiveness of maternal request CS versus planned vaginal birth in primiparous women without any medical or obstetric indication for CS was developed. Full details of 38 this model are presented in chapter 13 but a summary is provided below.
Risks for the two modes of birth were taken from a clinical review undertaken for this guideline update comparing outcomes by planned mode of birth, rather than actual mode, of birth (see section 4.2). The analysis considered both the costs of birth and ?downstream? costs associated with the outcomes reported in the clinical review and found that a planned vaginal birth was approximately £800 cheaper than a maternal request caesarean section. This implies that the NHS could save £5.6 million for every percentage point reduction in caesarean section if the characteristics of the population were similar to those of women included within the guideline model. A cost utility analysis found that planned vaginal birth dominated maternal request caesarean section.
However, there may be other outcomes, such as urinary incontinence, which were not reported in the studies that were included in the clinical review which make the findings reported above more uncertain. Sensitivity analysis suggested that this could, under certain assumptions, produce a different cost-effectiveness result.

Let me translate into English.
£800 difference is bollocks as stated in chapter 13.

yes, NotnOtter, my understanding from what I have heard is that epidurals are really hard to get, you have to ask at the right time, women being told, its too early to ask, you are too late in asking, or no anaesthetist available. And that on occasion women are made to feel ashamed in wanting one and midwives are involved in creating this sense of shame.

i know childbirth is not like an illness anymore than pregnancy is, but surely we can do better than for women than what we are doing now?
I really ought to be in bed now, I need my rest!!

Sorry - meant to add, increasing planned c/s rates without a corresponding increase in the maternity budget would impact on the care of women trying for a vaginal birth. In my view this is unsupportable.

"my understanding from what I have heard is that epidurals are really hard to get"

Have a look at the quality care commission survey on this one at birthchoice.co.uk

Most women get the pain relief they request, when they request it, though some hospitals score much better on this than others.

Bags I agree with what you're saying about sunk cost, but at the same time, when resources are finite, you have to make recommendations within those constraints. It just pisses me off that women are having to wait hours for an epidural, and have been told "the NHS doesn't have unlimited resources you know", but it's suddenly not a problem anymore because some guys in whitehall have decided it would be far easier just to conveyor belt everyone through....and maybe they're right. Scrap the labour ward. Have everyone booked in at 38 wks, mask up the docs, and off we go. If they got that efficient, it would be cheaper than the current system.

I just worry that we're looking in the wrong direction to the solution of poor mat care in the UK, and going for the easiest path.

re not looking at the whole picture, an example I was thinking of was when they declared a drug to be non-cost effective because it only prevented blindness in 33% of cases, but they didn't take into account the cost to other departmental budgets (eg social services) of having to support a blind person vs someone with impaired, but functioning vision, which were huge. If they took that into account, it was cost effective. However, they only look at the impact of their own budgets.

""No, but that's because it's about the NICE guidelines for ELCS, not the impact of the implementation on current maternity services. That's an entirely separate subject"

No - it's absolutely not. Demand for elective c/s will go up as long as substandard care for women having vaginal births is common.

There is no other area of the NHS where people can opt for an expensive treatment where the clinical outcomes are poorer than those associated with a cheaper treatment. Elective c/s are only comparatively safe to planned v/b because so many women having planned v/b are having substandard care leading to high rates of emergency c/s and instrumental birth. If women having planned v/bs in the UK had better care and lower rates of intervention the argument for parity of elective c/s and vb would no longer be valid - v/b would quite clearly be safer for low risk mothers and babies, and fewer women would want an operative birth if they had confidence they would get good care in labour."

Sorry for scruffy quoting!

I agree with you, that women have VBs should have far better care than they currently get. And I agree that there would probably be less demand for CS for subsequent births. But the point I was making still stands - what NICE recommend should not (and currently are not) related to the current budgetary pressures of the local NHS. That goes across all therapeutic areas.

As for the clinical outcomes being poorer in the more expensive treatment, well that's kinda what the background research to NICE addresses, and they think differently.

My first baby was undiagnosed back-to-back and 9lb 10oz. After 35 hours of labour including 2 hours of pushing I had an emergency section - except they couldn't get her out, she was wedged into my pelvis after having been pushed for so long. T-incision followed and thankfully she was fine, but it was enormously traumatic, bloody painful and recovery took a long time.

Next two were planned sections, the first was with a wonderful midwife who made it a magical experience with skin to skin contact immediately and who de-medicalised the whole experience for us. We returned three years on to deliver our third child at the same hospital to be told we couldn't repeat that experience, it was very functional, highly medicalised and my pain relief wore off during the section being performed. I don't think the midwife even told us her name. The only thing that got me through it was an amazing anaesthatist (not his fault btw that the anaesthetic wore off, i now know have a high tolerance to it, they had to top up many times during the surgery).

So from my experience a CS CAN be a positive experience, but you need a bloody good midwife to make that happen. I think everyone has the right to choose, but to assume that a CS is somehow an easier option - NOT THE CASE.

"No-one should decide for another woman what her birth choices should be iggly"

While the NHS funds are finite, treatments will always be rationed on the basis of cost effectiveness balanced with the clinical outcomes.

The NICE recommendation to offer elective c/s on demand arises from our exceptionally high rates of emergency c/s and instrumental birth (which IMO are often linked to substandard care). In health terms elective c/s now looks like quite a good option at a population level in terms of clinical outcomes, where large numbers of women are having botched vaginal births.

Bagofholly I do not see my post as patronising.

"Bags I agree with what you're saying about sunk cost, but at the same time, when resources are finite, you have to make recommendations within those constraints."

No, and it's a really fundamental point about NICE. If you look at other therapeutic areas, say, cancer services - it's quite right that NICE should be free to fully appraise and recommend new treatments even if the local NHS is skint. How the local NHS manages its budgets is not their concern. Otherwise new therapies would never be available on the NHS! NICE would be told "nope, we can't afford that, so go back and recommend something different." It makes a travesty of independent clinical appraisal.

I did not get four when i requested them Leningrad

nor stitched afterwards which will now lead to further 'procedures' despite my asking at the time

"Leaving women to labour and birth in agony is unsupportable"

Most women are able to cope with their pain in labour. Most aren't traumatised by it. Including the majority of those women who have quite long and painful labours.

And those who aren't able to cope should (and usually are) offered pain relief, which is often very effective.

Iggly, it's patronising to assume that women need to be taught to look at facts, and that the only reason that they're chosing ELCS is because they're too scared or ignorant to decide otherwise.

21 epidural top ups required for Ds labour.........

21!!! god, poor you.

I find it enpowering when I feel I can make an informed choice, if that does not help them feel more comfortable other approaches. This would be with well qualified therapists they would know the best ways to help their patient, so in some cases they would not advocate teaching methods of information research.

Taking the arbitrary £800 out of it, as it appears NICE actually have no frikkin clue what the cost differential is, a better way may be to look at it purely by economies of scale at point of delivery (i.e. maternity dept budget)

Generally, if you do more of something it should be more cost efficient. Therefore the most cost effective way to do "births" is either to do all c-sections or all VBs. We know that they can't do all VB's as some c-sections are medically necessary, but they could do all c-sections.

Let's assume that budgets are static- so no more money is available to mat wards, which I think is realistic

To start with, if choice is freely available, you'll probably have about 50/50. That will squeeze the resources available to VB because at point of delivery the c-sections will be more expensive (dont think anyone's disputing that). Care for VB gets worse. More people opt for c-sections. See where this is going?

It's so, so misguided. VB will become the preserve of the rich with their private midwives.

"I didn't get an epidural when I requested it"

I didn't get a homebirth when I requested it - had to pay for an independent midwife.

Resources are limited for all of us. I can see just as much of a rationale for arguing for waterbirth on demand, homebirth on demand, caseloading on demand.

Have to say, can't remember seeing posts on mumsnet arguing that the lack of birthpools in the UK is evidence of a cruel conspiracy by tight-fisted and hard-hearted NHS managers, trying to force labouring women back into the stone age......