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.

What Widow said.

I'm intrigued by the theory that this might pave the way to a reduction in EMCS as opposed to a reduction in VB. It's a very interesting way of looking at things and one I'd very much like to consider further.

"My opinion on maternal request ELCS is the same as on abortion - if you don't like them, then don't have one."

Boy I think I have seen it all on mumsnet. A debate on c section being compared to having an abortion. The quite rightly restricts abortion on demand in the third triesmeter however rich you are because it is murder.

The issue of c-sections on demand is not about morality. It is about cost and what the tax payer should pay for.

first reference =interesting background.
second reference=good case size, would have like to know the elective csection rate not just the significance of the reduction.
third reference= I would be of a questionaire sent out 1 year post partum (it takes someone very invested in the outcome to reply ie most likely had a bad experience, not really random if you see what I mean).

Be careful when you look at the reference I posted about:

In women who underwent counselling, fear of childbirth was associated with a three to six times higher rate of elective caesarean sections but not with higher rates of emergency caesarean section or negative childbirth experience. Very negative feelings without counselling were not associated with an increased caesarean section rate but were associated with a negative birth experience.

This is 3-6 X higher than the reference group (wish they published figures here, sorry, cannot be bothered on reading whole paper) and there is no data on how they felt about wanting an elective CS before counselling (if you look at the other papers they look more at preference for ELCS before and after). Also how were the groups divided into counselling/no counselling, did those that went for counselling feel they would need it for an elective and therefore choose to go for counselling? What I think is important is that the counselled had a similar "negative childbirth experience" rate to the rest of the refernce group-BUT I now need to check if people who suffer a fear of childbirth experience a similar rate of "negative child birth experience"....

How much is a home birth? More or less than VB in hospital?

I'll answer that. It's 68% of the cost of a hospital birth, shall we make everyone have a homebirth too?

Home birth is misleading as women who tend to have them are less representative of the population as they tend to be lower risk (and deemed less at risk of intervention) in the first place. Not the most fair comparison.

This includes all the hospital transfers.

I am very pro choice, for birth as well as pregnancy in general.

MrsJRT I can only speak for myself, but because of my issues, I would have much preferred an ELCS to an induction (which ended in my EMCS). I think there may be a gray area of women who have some issues that are not serious enough to get permission for an ELCS but that then cause problems in labour and end with an EMCS. This is probably the most likely pool that would choose ELCS if they could -- not women likely to have a straightforward VB.

For everyone going on about costs and the taxpayer: let's say that somehow, VB and ELCS cost exactly the same. Pretend, for the sake of argument, that there is no price difference. Would you still object to the new guidelines?

See, I think you would. I think despite all the talk about costs, it's fundamentally a moral judgment that ELCS are not necessary and therefore others should not be able to benefit from them.

I think fruity made some really perceptive points above.

reallytired - in my view both debates are about women's choices. NICE's advice seems to say that cost is not a reason to restrict women's choices and dictate how their pregnancy ends. I agree with that.

Those who insist that NICE is wrong and women should only be allowed ELCS under very few very specific circumstances usually use "moral" arguments, same as anti-choicers in the abortion debate. The whole natural vs unnatural debate is all about morals and nothing else.

I think as long as the woman knows about the risks and benefits of either birth method (and risks of vaginal attempt always includes EMCS) and has been informed about them by a neutral source, it should be up to her which route she wants to go.

(FWIW, I had a maternal request ELCS on the NHS and very grateful for a very understanding consultant, who, when he realised that I had looked carefully into risks of both ELCS and VBAC, did not twist my arm to do a trial of labour, but would have fully supported me if I had wanted that, too)

PosiesOfPoison makes a very interesting point. If homebirths are significantly cheaper than hospital births (68 percent of the cost of a hospital birth, if that's true) -

Then what is most cost effective for the tax payer and NHS is to force all women, REGARDLESS of their wishes, to have homebirths. And to to deny any woman a hospital birth unless they decide there is a 'clinical' need. And clinical need wouldn't include access to pain relief stronger than gas and air/epidural.

Presumably those posters claiming that women should be refused much wanted ELCS's purely on the grounds of cost to taxpayer and NHS resources would be happy with that.

Wow sweeping generalisations galore:

Those who insist that NICE is wrong and women should only be allowed ELCS under very few very specific circumstances usually use "moral" arguments, same as anti-choicers in the abortion debate. The whole natural vs unnatural debate is all about morals and nothing else.

And clinical need wouldn't include access to pain relief stronger than gas and air/epidural. ...actually they're pretty darn good.

Sorry, I wasn't clear. I meant to say that clinical need would not include access to epidurals - another debate where vague moral judgements dominate in a bullying way.

My point is that if women really want births to be the cheapest option for the taxpayer/nhs, then they would be happy for all women to be forced to attempt a homebirth, regardless of their preference. Maternal request for a hospiral birth would not be accepted. Epidural anaesthesia isn't available during HB (not available for some women in hospital either of course).

"My point is that if women really want births to be the cheapest option for the taxpayer/nhs"

Actually I think what people are concerned about is the fact that women and babies are dying in NHS hospitals during and shortly after labour because of a lack of midwifery care, and a lack of consultant input. And that's often down to insufficient staffing. That's why people are worried about an expensive treatment (one which will put great pressure on obstetric services, and one which is not linked to lower maternal or infant mortality) being made more widely available.

So - cards on the table those of you who are arguing for wider access to elective c/s: accepting the argument that that it may cost significantly more and make more demands on obstetric services (and I appreciate that not everyone accepts this to be the case), do you support money being directed away from other aspects of maternity care in order to fund these changes, and if so, what/where?

Or are you only prepared to defend c/s on demand if it can be proven to create no EXTRA costs, or if (A LOT) more money is forthcoming from the tax payer, and more obstetricians can be bought in. (remembering of course that many of these doctors will be bought in from countries where their services are needed far, far more than they're needed in the UK).

BTW - I agree that there is moralising going on on this thread, but most of it is by people supporting wider access to e/cs in response to people raising concerns about the financial implications of this move, and also in response to any comment questioning the necessity of having even more babies born by c/s than the currently high rate.

Fruitybread - I suppose the argument boils down to whether you think providing care which results in the lowest possible rate of maternal and infant mortality is more or less important than providing care where the priority is promoting maternal choice, and widening access to pain relief and surgical birth.

"I'm intrigued by the theory that this might pave the way to a reduction in EMCS"

I think the pathological fear of childbirth leading to failure to progress in labour isn't a particularly common scenario.

What IS a common scenario is c/s for failure to progress among first time mothers undergoing induction. Also failure to progress among first time mothers labouring in wards where there are severe shortages of midwives.

We don't know the true costs of a VB. The NICE guidelines acknowledge this by referring to longterm and delayed onset urinary incontinence, among other things.

Comparing 'on the day' costs is misleading. A brutal instrumental delivery will show up as 'cheap' if you refuse to add on the cost of physio/restitching/counselling etc.

When over 70 percent of admissions to
my local A&E at the weekend are alcohol related, and who get treated for free on the NHS, I won't buy a strangely woman-bashing argument about draining NHS services by expressing birth preferences. It would be as idiotic as blaming pro-homebirth support - a sudden rise in HBs needing one to one MW care at home, meaning that (melodramatic breath) mothers and babies in hospital would be even more badly attended as a result, and would DIE! etc etc. Melodramatic nonsense.

As others have said - surely most women will continue to prefer vbs. And it is plausible that allowing scheduled CS's to those 'gray area' women who have some clinical (mental or physical) reason for wanting a CS, but not one which is an overriding reason, may help reduce EMCS rates.

Those emcs's - the ones often deemed unnecessary or unwanted, that people seem to feel are avoidable - I think people who genuinely care about birth choice/experience should be concentrating on those. And trusting other women to be able to make informed intelligent choices.

"I won't buy a strangely woman-bashing argument about draining NHS services by expressing birth preferences"

Fruitybread: at present it's WIDELY acknowledged that consultant obstetric services are under strain in the UK. There is not enough consultant input in complicated vaginal deliveries, which is leading to an increase in the emergency c/s rate. If the planned c/s rate goes up, so that instead of having a 26% c/s rate, as at present, we have say, a 33% c/s rate (perfectly reasonable figure to suggest - similar to the US and Australia) there will undoubtedly be a higher need for more obstetric cover. I am absolutely ALL FOR more obstetricians working in the NHS, but someone has to pay for it. The government may refuse to allocate more money for maternity services. If this is the case would you still support an increase in the planned c/s rate? And more to the point, where are these consultant obstetricians going to come from? There aren't enough working in the UK at present. Should we be poaching staff from countries like India and the Philippines?

"And it is plausible that allowing scheduled CS's to those 'gray area' women who have some clinical (mental or physical) reason for wanting a CS, but not one which is an overriding reason, may help reduce EMCS rates. "

But there is no clear and consistent evidence that this would be the case is there? This is just hopeful speculation. On the other hand there IS clear evidence that reducing induction rates and improving both staffing levels and practice DO lead to clear falls in the emergency c/s rate. So, if there's any more money coming the way of maternity services, I'd prefer to see it used for this purpose, as it's women having emergency c/s AND THEIR BABIES who have the worst outcomes of all.

Like it or not - choices WILL be made as to how money will be allocated, because I'll eat my hat if the government is going to provide an increase in funding at this moment which will solve all the current problems besetting maternity services which are resulting in women having miserable births. There is no other area of the health service where there are no competing areas of need.

"Those emcs's - the ones often deemed unnecessary or unwanted, that people seem to feel are avoidable - I think people who genuinely care about birth choice/experience should be concentrating on those."

Actually I think rather than 'unnecessary' the appropriate word is 'avoidable'. Hospital care and interventions like induction often create pathologies in labour, which unfortunately a mother then NEEDS a c/s or instrumental birth to resolve. But yes - people are concentrating on these things. Unfortunately the an increase in midwifery staffing levels and more consultants on labour wards cost money. Money which will probably now be diverted into increasing resources for planned c/s and the additional postnatal care costs which come with it.

I wouldn't have wanted an elective C section if the birth looked likely to be straightforward and would have done well as a vaginal birth. C sections have their own disadvantages - one of which is a longer recovery period and risks of wound infection and DVT which vaginal births don't have. It isn't necessarily better than a vaginal delivery.There are also cases of women whose births (even the first one) were extremely quick to the point that they had to do very little pushing, and did not feel much pain - in those instances, a C section really has very little to offer that is better than a vaginal birth! It really needs to be decided on a case by case basis.

Shagmundfreud:"The government may refuse to allocate more money for maternity services."

The Department of Health allocates funds to the various NHS Trusts. Under the current NHS structure it CANNOT dictate how individual Trusts allocate those funds, as they are financially autonomous. The DofH can lay financial pressure politically by leaning on the various heads of the Trusts but no more than that. It can allocate separate individual national funds. But it can't tell each Trust what to do or how to do it.

"Like it or not - choices WILL be made as to how money will be allocated, because I'll eat my hat if the government is going to provide an increase in funding at this moment which will solve all the current problems besetting maternity services which are resulting in women having miserable births. There is no other area of the health service where there are no competing areas of need."

It'll be (under current structural rules) down to individual Trusts to allocate funds to implement NICE, and if they choose to do that, it doesn't NECESSARILY mean that other maternity services will be squeezed. That may be the case but it's not a given by any means because that's not how the funding is structured. You have to think of the NHS as hundreds of little branches of one brand, operating franchises - working within the same loose rules but being largely autonomous "small" businesses.

" There is no other area of the health service where there are no competing areas of need."
Sorry, not true. Even in therapeutic areas which on the face of it are well funded relatively speaking, there are massive inequalities. Look at the funding relating to breast cancer compared with funding for cancer in ANY other tumour site or patient group - it's massively disproportionate.

If you or I want to affect change in relation to maternity services, currently the ways to donthis are to attempt to be a voice that is heard by NICE, and then monitor locally how well/badly NICE is implemented. Involvement on a local level will affect local change because that's where the funds are eventually sliced up - by local healthcare managers.

due to a pretty horrific birth with dd (SD- for anyone who cares) I THINK I would be granted an ELCS for any subsequent births (Pretty much confirmed by my tear clinic consultant after the event) BUT it would save a HUGE amout of worry and anxiety if I could request a CS if medical opinion changed and they thought another VB would be a good idea. I cannot afford full private hospital care but I would pay the extra £800 if I could guarantee my wishes. (Although I am darn sure my VB cost the NHS more than a ELCS would have!)

why should I have that anxiety of wondering if I will get allocated a sympathetic consultant (I would have to seriously consider my options if a cs was refused, I swore I would never put me, DH, DC or my family through all that again, and I meant it!)

The reality is the levels of CS/VB are unlikely to be significantly different if maternal choice is taken into account. Very few people would choose major surgery as opposed to a straightforward VB. BUT women could feel more in control of their own care and own choices. In my case, if I were refused a CS I would feel that both me and my baby would be being put at a high risk and if anything happened during the VB I would have grounds to sue the arse off the hospital (Thus free choice saving the NHS money!)

Sorry for the ranty post but it is nearly 5 am and I have to get up in 2 hrs

"In my case, if I were refused a CS I would feel that both me and my baby would be being put at a high risk and if anything happened during the VB I would have grounds to sue the arse off the hospital"

Sadly this IS something that hospitals are going to have to take into account if they are going to deny electives... I don't like this as an force for driving it, but it is a reality. I believe one of the women who tragically lost her baby in cumbria at that hospital under investigation was told she was expecting a large baby and requested a c-section. She wasn't allowed one and the baby died.

Maternity litigation is 60% of all the NHS payouts (and it only accounts for 20% of claims - so they are either more successful or have bigger payouts - either way shows a MAJOR problem). For trusts this is an issue that they HAVE to consider when allocating funding to various departments. A bit of legal action soon focuses the mind of suits... The bill last year was £85million and it will continue to rise unless they put much more investment in. Compare that to the figure of £5million for each 1% rise (which I don't accept anyway and I think our worst case rate will be more like Germany at 29%-30% than Aus or US).

The really big issue I see is if not all Trusts adopt this, then other Trusts will be put under strain as they will have more people outside their area coming there purely as they can get an elective there. Its not so much of an issue where there are postcode problems with NICE guidelines as you are stuck in the PCT you live. But maternity rules allow you to go outside that a lot more easily. You'll end up with strain in that way, with other hospitals simply passing the buck elsewhere and laughing their heads off about it at the expense of women.

I agree with your points, Shagmundfreud.

I am by no means anti c-section (I had a planned one due to abnormally high BP and have been told I have to this time round too - do not live in the UK and yes feel a little cheated that I won't ever have a VB but have decided not to go against my obstetrician's advice..). I do, however disagree that the elective c-section rate will not increase IF every mother had the option to choose elcs. I strongly believe that those who are traumatized mentally and physically by previous births should be counselled on this and ultimately given the choice how they subsequently give birth. To be honest not so sure about first time mothers - I really think that if the rates of improper care/negligence in the NHS are decreased then way less mothers will have these horrendous experiences. The vast majority of people posting on this thread/this website in general are intelligent, independent women but unfortunately you/we are not representative of this country. The whole wag culture/appearance/celeb-obsessed society is in full swing and I strongly believe this will assist in, in particular the younger mothers choosing the elcs route. Maybe I'm wrong but I would be interested to see the results in 5 years should elcs be opened to all (I realize this isn't what NICE are necessarily recommending but it will get to this point).

For me the cost is an issue but it is primarily the lack of resources as CS mothers require much more post-birth assistance and that has to happen immediately post-birth - there is no open timeframe e.g. That there might be for incontinence issues etc..I am, in now way belittling people with these problems caused by VB (though interestingly my obstetrician told me that incontinence is/will be a problem for almost all women who have given birth - obviously there are those who suffer a great deal more than others) however more the fact that their needs are for the most part not immediate.

And that is a problem throughout the NHS. From who gets certain cancer drugs to ivf policies and maternity care. For me it is a massive indication that the pct system does not work.

I am pretty sure, although I can never prove, that the reason dd's birth didn't end up in a cs was that that night there simply wasn't the theatre capacity. When I went into surgery after all the way down everyone we came across was saying "oh god not another cs tonight" they were relieved that it was "just" a repair job. They were turning women in labour away and negotiating rooms for the women who were there.

The pct in their wisdom followed this 6 months later by closing the next closest maternity unit.

Maternity care is horribly under funded and is getting worse. In these situations women and children are put at unacceptable risk. Litigation is just going to rise and rise if grass roots funding is not significantly improved.