OTHER ISSUES
I think one of the first things people say about woman centred care being put ahead of budgets and statistics is the cost of it. I personally think this shows the lack of joined up thinking in maternity as a whole. I mentioned above the report that looked into the cost to society of neglecting maternal mental health. The problem is that budgets begin and end at the labour ward doors and don't extend to longer term health problems - both mental and physical - and the knock on effects they may have for that woman on a wider level to society which include everything from benefits to negligence pay outs. Decisions are being made based on the fact on how much things cost initially which may not reflect the real cost of something. I passionately believe that if you invest more in women centred care then the financial benefits that would reap would be enormous and would benefit women immeasurably regardless of their choices.
The way in which data is being collected is supporting certain ideological and political beliefs rather than looking to improve care and provide evidence based medicine is not helping the matter. Its an epidemic problem.
Studies routinely draw conclusions separating VBs from EMCS which are a possible outcome of a VB and instead group ELCS with EMCS. This is not sound methodology. It makes VBs look safer than they are and ELCS worse than they are, with profound implications for our understanding of risks involved. An ELCS has very different risks to an EMCS. You need to have an exceptional understanding of statistics to be able to understand the data currently available and be able to question its worth to get a true reflection of risk. The trouble is, that even a lot of HCPs are excepting figures at face value, because the figures do support their ideological and political beliefs and the pressures placed on them.
Why is it, that the number of ELCS, EMCS and instrumental births are data that is easily and freely available to the public but there is a massive lack of transparency over 3rd and 4th degree tears? How can women make informed decisions when this crucial information is being with held. Its information that a sizeable proportion of women are concerned about and would like to know. It means that hospitals are much less accountable; there may be some that can boast about high unassisted birth rates but may have a dirty little secret for that.
In addition to this we have great gaps in our knowledge over why women are even having ELCS in the first place. The whole thing needs a major overall.
The Select Committee Fourth Report on health from 2003 stated the following:
80. Around 63% of caesarean sections carried out were identified as emergency procedures, while 37% were identified as elective. The Department noted that, in the Audit, 7% of caesareans were attributed to maternal request. However, the Audit Report itself indicated that such classifications might be misleading:
Caesarean section has traditionally been divided into two groups, either elective or emergency procedures. The emergency category is broad, as it may include procedures done within minutes to save the life of a mother or baby as well as those in which mother and baby are well but where early delivery is desirable … In some centres this has led to an ad hoc local adaptation … This has resulted in data inconsistencies between hospitals
81. With regard to the 'maternal request' category identified by the Department, the Centre for Family Research at the University of Cambridge found that individual obstetricians used different definitions of a maternal request, with some recording this as a reason for undertaking caesarean section even if it had been recommended by clinical staff as the best course of action.
84. Perhaps the most contentious and least understood of these factors is women's choice. The British Association of Perinatal Medicine (BAPM) told us that "greater consumer choice in choosing when and how to deliver", is a factor which contributed to rising caesarean section rates. However, several others detected a perception, fuelled by media coverage of private practice, that the rise in caesarean rates is largely a consequence of maternal request for the procedure. Dr Soo Downe of the Midwifery Studies Research Unit, University of Central Lancashire, told us that:
There appears to be little evidence that the sharp rise in the rates of caesarean section can be fully explained by a rise in maternal requests for the operation. Maternal request subsequent on a traumatic first birth experience may, however, play a small part in the rise.
85. Caesarean section rates in private hospitals are often higher than in the NHS (the Portland Hospital in London has a caesarean section rate of some 44%). As we have noted, while these rates have little impact on national statistics, the levels of public awareness of celebrities who deliver their babies by caesarean section in private hospital may have a disproportionate influence on culture and perceptions.
86. According to the Centre for Family Research at the University of Cambridge, the RCOG and many others who provided written evidence for our inquiry, pregnant women want more information on the risks and benefits of caesarean section and wish to be involved in the decision-making process. A survey carried out between 1999 and 2002 by the Centre for Family Research at the University found that that maternal requests for caesareans were made mainly because of fears about the health of mother or baby. In their most extreme form, these fears constituted a phobia of giving birth (tokophobia), and a small number of seriously traumatised women may need surgery in order to avoid severe psychological problems.
I repeat this is from 2003. Yet here we are in 2015 with very little progress and some of the same problems. My 'clinically indicated need' for an ELCS was recorded as maternal request. There was no recording in the statistics that it had anything to do with my mental health. So despite there being a question raised about a lack of understanding and poor recording of reasons for ELCS BY A PARLIMENTARY GROUP, fuck all has really been done in TWELVE YEARS to address that.
This does highlight my fear that the review may not change anything, unless there is real political will at government and trust level to change things. My worry is, that the can of worms that would be opened by admitting that poor care has lead to women receiving care that is substandard and has damaged their physical and/or mental health is just too big.
The issue is that contrary to the above comment about traumatic first births playing a small part in the rise of maternal requests, www.theguardian.com/lifeandstyle/2010/nov/14/scared-birth-trauma-midwives in 2010 the Guardian reported the following.
The NHS is responding to a surge in cases of birth trauma by setting up specialist support services to reduce the rising demand for a caesarean delivery from those who, after a bad experience, are scared to undergo labour again.
Midwives say increasing numbers of women are so badly affected by their first experience of birth that they are postponing for years, or abandoning, plans to have any more children.
There are no NHS-wide statistics on the problem. But maternity staff at many hospitals report a rise in such cases over the past two or three years.
At Liverpool Women's hospital, for example, the number of mothers who have asked for an elective caesarean with their forthcoming child, because they suffered trauma the last time, has risen 40%.
Other hospitals, including St Mary's in Manchester and Stepping Hill in Stockport, have seen the same trend and are also introducing counselling services.
At the moment ELCS do seem to be looked at as the solution to traumatic births, which I personally feel even as someone who choose to have an ELCS this really is the wrong approach and is a way of trying to deal with the effects problems rather than dealing with problems themselves.
It is also quite apparent that there is ignorance as to what birth trauma is. I've seen a lot of threads on MN where women have been distressed enough to go for a debrief only to face dismissive comments that they can't be traumatised because they had a 'text book' birth. Which actually is even more damaging. Such comments display an appalling lack of respect to women and a real ignorance of the subject. Especially when you consider that one of the things that makes women feel like this in the first place is a dismissal of them and their feelings.
The Birth Trauma Association knock this out of the water by making the comment that its in the eye of the beholder; basically anyone who feels traumatised is and should be listened to and treated accordingly.
Essentially I think the problems stem from ring fenced budgets, an obsession with targets over humanity, a short sighted health care model, a lack of regard for mental health, a lack of respect and dignity for women, poor communication, political pressures from above meaning that doctors and midwives have a conflict of interest between the needs of the patient and their own jobs, poor understanding of statistics, ideology influencing outcomes, lack of transparency, poor planning and provision of services, massive ignorance of mental health, poor interpretation of guidance, policy over personal care, poor staffing, lack of political interest and will with regard to maternity, a cultural attitude to put up and shut up, women being less empowered, able and willing to complain about poor care, inconsistency and wide disparity in care throughout the country which is confusing to women (and indeed HCPs - one Trust did not understand the format of notes from another in my case), women not even being aware of their rights and when they have good cause to complain and institutionalised backside covering.
I have written an essay and beat the character limit for a single post as it is. I could say a shed tonne more. I hope I haven't killed MNHQ with boredom from my ranting! I'm sorry its not a little more coherent. I hope there is something in there that is of use and makes sense.