Just come to this thread and have found it frustrating to read certain comments from both sides. Its not a competition and the mud slinging and ignorance displayed by some posters does no one any good.
Let me explain a few things which the NICE guidance on maternal request were based on and why the guidance was updated in the first place as the background is highly relevant to the whole debate and highlights a number of issues in how medical data is being presented to the public and profession itself. It highlights just how much biased information is being propagated for various agendas. And it highlights how the guidelines are being misinterpreted by some.
The NICE guideline are primarily focused on this aspect of anxiety/trauma. The reason for this was the group who wrote the guidelines identify the fact that there was a wide disparity and lack of clear definition of what 'need' was. This was leading to a wide variation of care and treatment across the country. Some consultations were more proactive than others in identifying that 'need' wasn't purely physical but also included mental health aspects. This was meaning some women who had a genuine 'need' were being ignored or dismissed and this was causing an enormous amount of unnecessary distress to them by denying them this choice. This included women going to the extreme of aborting a much wanted pregnancy in a small number of cases, but in the less extreme cases, denying a woman her choice seemed to be damaging to her health (higher rates of PND and PTSD appear to be associated with this in several studies).
It was noted that there tended to be a pattern in women who asked for ELCS - these included a much higher incidence of them having had a previously traumatic birth, had a history of anxiety or other mental health issues, had been raped or sexually abused, had delayed pregnancy until they were older, were more likely to have had fertility issues. All reasons that effectively made them higher risk or more vulnerable than the 'average' woman.
The actual guidelines are as follows:
Maternal request for CS
When a woman requests a CS explore, discuss and record the specific reasons for the request.
If a woman requests a CS when there is no other indication, discuss the overall risks and benefits of CS compared with vaginal birth and record that this discussion has taken place. Include a discussion with other members of the obstetric team (including the obstetrician, midwife and anaesthetist) if necessary to explore the reasons for the request, and ensure the woman has accurate information.
When a woman requests a CS because she has anxiety about childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her anxiety in a supportive manner.
Ensure the healthcare professional providing perinatal mental health support has access to the planned place of birth during the antenatal period in order to provide care.
For women requesting a CS, if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS.
An obstetrician unwilling to perform a CS should refer the woman to an obstetrician who will carry out the CS.
Note a couple of things about the above
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Although the emphasis in the document is on anxiety - the guidelines are worded to state 'because of anxiety' as just one reason why a woman might request an ELCS. This means there is no definition of what a 'valid' reason for an ELCS is. And the panel acknowledged this and stated that whatever the reasoning they could not offer a medical argument why a woman shouldn't have an ELCS if, after knowing the pros and cons, she felt it was the best option for her. In short - ALL reasons for wanting an ELCS were effectively deemed valid based on the evidence they had.
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The word 'offer' rather than insist on a woman having mental health support. Unfortunately this particular paragraph is the one that has been more widely be misinterpreted and misused with women feeling like / and being told they MUST have some sort of counselling in order to get an ELCS. Its simply not the intent of the document.
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That an ELCS should always be available no matter what. It should not be refused if a woman does understand the risks. This paragraph came from the fear that, even in women who wanted an ELCS for a 'lifestyle' choice, that denying them one might have an impact on the women's mental health. It also recognised the pattern of women who asked for an ELCS being more likely to have trust issues (perhaps from a trauma birth or from having people in a position of power abuse that trust with them) and this paragraph ensured that those women - who might otherwise completely avoid seeking medical assistance - would engage with healthcare providers and give them the chance to build up trust again. FOR THEIR OWN SAFETY AND SAFETY OF THEIR CHILD. Its key to understand this is a safety net and comfort blanket to the whole concept.
NICE also pointed out the fundamentally flawed way that methods of birth are compared in studies terms of finance and health. There is some merit to comparing an unassisted VB, an instrumental VB, an ELCS and a EMCS directly but only in certain situations. In reality there is only two methods of birth - a planned VB; which includes the risks of an instrumental VB and an EMCS - and a planned ELCS. If you just compare an unassisted VB to an ELCS you tend to understate the risks and costs of a VB and overstate the risks and costs of an ELCS making it poor methodology to do so.
They also stated that healthcare does not start and end at the maternity wards doors. So neither do the costs, financial and medical. So if you are properly comparing the two you MUST look at complications to be fair. Their conclusion was when they looked at the complications of incontinence alone then an ELCS came out favourable. They said that cost should NOT be used as justification to deny an ELCS as this was unfair and that an ELCS was a cost effective way to give birth. Remember NICE do NOT make recommendations and draw up guidelines without assessing cost. The irony was also that they found that in their models, once the level of ELCS reached a certain point, it was actually cheaper for an ELCS (think factory production line). So anyone using the cost argument to say thats why we should all be having VBs ought to be very careful.
NICE are a group who have been vilified at times for making decisions about drugs and treatments on the basis of cost. So its very ironic when they say something is cost effective, that they get ignored and the argument that keeps getting repeated is the old one with poor scientific data behind it.
Theres also another poor methodology at play here which a lot of people like to ignore. Risks are not universal. There are certain groups where the chances of being able to achieve an unassisted birth is statistically lower than an instrumental birth or an EMCS. Its still possible, but it is currently impossible to work out which women these might be. However this means that the woman does not have a physical 'need' for an ELCS and her reasons for wanting a ELCS deemed 'invalid'. Is it right that in this situation, she should be denied an ELCS if thats what she wants? Should she be automatically be forced to roll the dice and see what happens rather than deciding whether she would prefer the risks associated with an ELCS? Women in this country are not stupid nor ill-educated and are capable of deciding which is better if they are given unbiased information.
Equally the converse is also true - There are groups where the statistical chances of an unassisted VB is extremely high. And in answer to the argument on how you give birth affecting others and how an ELCS might prevent someone who needs an EMCS having one - should these women be denied a homebirth because there wouldn't be enough midwives on the ward if they attended a homebirth? Especially since place of birth study noted that women were more likely to have medical intervention if they give birth in hospital. Not to mention if more women are having ELCS, this would potential reduce the number of EMCS in the process too. (Consider the very genuine case for the argument that a sizeable percentage women requesting an ELCS might be in a higher risk group for an EMCS in the first place). The solution is not to deny others, but to make sure the proper facilities are available for all for the appropriate care for all. Which may well include this element of choice.
I also want to comment on the number of people who say "if you want a ELCS you should use a private hospital". The trouble is, that simply isn't an option, even if you can afford it for the majority of the UK. Virtually all private hospitals do not have the facility and experience to perform an ELCS; there is only one private maternity hospital in the UK and all the private maternity wards in NHS hospitals are in the SE. So effectively you are denied this option. And as I have already stated, in terms of cost, the stick to beat women with, has been deemed totally invalid anyway.
All in all, this debate is totally dominated by emotion and ideological belief. It shouldn't be. It should be dominated by evidence based medicine rather than ideology and politics - you know like what NICE did when they wrote the damn guidelines. And the panel fwiw was made up of both midwives and consultants working together, before that old chestnut pops up.
When the guidelines were about to be published in their final format something very interesting happened. A number of hospitals preempted it by saying they had a policy of refusing ALL maternal requests. Which is a very interesting move don't you think? Why preempt the publication of a paper which did lengthy research into the subject and deliberately state you are going to ignore it, if it supports maternal requests? Why do that unless its a political move? Why ignore the idea that women are capable and making a decision based on evidence? Answer: Its very easy to paint the picture of the selfish mother who is too much of a princess to give birth naturally because their is so much ignorance and prejudice on the subject. Some of which is displayed on this thread.
Every woman is different. They have different needs and different ways of assessing risk and coping with things if the worst should happen. We need to put this into the debate, especially if the equation is saying that on balance there is a very valid and justifiable argument financially and for her health to state that women should be given the choice.
Instead, despite the intention of the new guidelines, nothing has been achieved in terms of ending the disparity in care between hospitals. If anything its made it far worse. However, it has achieved raising awareness and a growing acceptance that birth trauma and fear of childbirth does exist and needs to be taken seriously and treated. And it has raised the debate about women's autonomy over their own bodies in childbirth and what this means in terms of rights. Which is actually good for everyone regardless of whether you'd prefer a homebirth, a midwife led vb a consultant led vb or an ELCS.
This needs to stop being one group pitted against another group and it needs to become about identifying the needs, rights and differences between women for the benefit of all.