New guidance to reduce epidurals and a target rate of 20% for C-Sections

[HmmThinkingAboutIt]

New guidance being issued by the RCOG, the NCT and the RCM is urging to decrease C-Sections to a target of 20%, to decrease epidurals and to make Midwife Led Care the default for low risk women. The document is here

This guidance is controversial and goes against the position of NICE, the NHSLA, and the DH.

I've already posted this in the Childbirth section, but I do think this needs a wider audience, and to get this seen by as many people as possible and it was suggested I posted this here rather than AIBU. Original thread is here

I do think this is definitely a Women's Rights issue for a couple of reasons:

Firstly its the language being used in the document. Its extremely paternalistic. It talks about getting the GP to influence patients to make 'good choices'. (I've expanded on how I feel about this on the other thread) and is extremely patronising and almost about trying to get women to behave in the correct manner rather than doing whats in their best interests.

Secondly theres the conflict of interest this causes - if a midwife/doctor is under pressure to achieve a target of 20% how are they going to do this as well as put the needs of the woman first?

Then theres the issue of restricting women's choices and options; especially with regard to pain relief.

The RCM, RCOG & NCT document has caused so much concern amongst a number of campaigners that its lead to them to issuing a <a class="break-all" href="https://docs.google.com/viewer?url=www.electivecesarean.com/images//12-aug-24%2520rcog%2520ccg%2520press%2520release%2520final.pdf" rel="nofollow" target="_blank">joint statement which sums up all the issues far better than I can.

I find the whole thing quite alarming and frightening. I don't appear to be alone if the other thread is anything to go by.

I know its all a bit of a read and apologies in advance, but this is important and doesn't seem to be being reported anywhere else, and I do think this needs to 'get out there' for discussion and debate.

Bigoldfanny I'm glad you raised those points. After I read Naomi Woolf's Misconceptions it left me horrified at the over medicalisation of birth in the States and the pressure on women to birth on the hospitals' schedules. You hear a lot about doctors overriding women's choices and midwives laughing at birth plans. From that perspective guidelines which encourage medical professionals to prioritise natural birth make a lot of sense.

I looked into engaging a private midwife to advocate for me - but I found that her birth philosophy was just as rigid but in the opposite direction, completely opposed to epidurals and really pushing home birth. I'm not opposed to having an epidural or a C section, I just want to be able make my own informed decisions and not have things taken out of my hands. I don't know how you legislate for that.

Thanks for the messages of support. If I'm going to get involved inthis thread I didn't want to drip-feed information.......

leftwing - I read that book too and felt dismayed by the disempowerment inherent in the US system. I put it down thinking that natural birth following the woman's own instincts would be better.

But who's to say what level of pain women should be able to put up with in delivering their babies. And who's to know that one woman isn't suffering a lot more than another in the same situation? Let women decide for themselves how to manage their own births without arbitrary targets.

Buggy said "I don't understand how it's got to the point of women having such little faith in their ability to give birth.
surely this needs addressing socially not through kpi's in hospital."

Buggy, I apologise in advance if I have misread your post.
But it sounds as if you are employing exactly the paternalistic and patronising attitude which this thread is challenging. Why are you angry that some women wish to have epidurals and c-sections? You seem to be assuming that "natural" (which includes forceps according to the RCM/NCT document) is best for everyone.

Treats "Let women decide for themselves how to manage their own births without arbitrary targets."

That is exactly how I feel. The medicalisation zealots are no better or worse than the natural birth zealots. Neither respect that women are different, have different needs, opinions and different ways of seeing risk.

It is appalling to subject women to interventions without consent.

It is equally bad to say that caesareans and epidurals would not be needed if women 'had confidence in their bodies.' So if you have a traumatic birth, it's your fault for is it?

Read treats comment - that's what equality is. Crediting women with the intelligence to make their own (and often different) decisions about how they give birth.

I took it to mean, she wants to know why women feel that birth is a big bad scary thing that isn't a personal attack on you. It is a social problem that we have gotten to the point that women are scared shitless to give birth, how is it a problem to want to redress that? Of course it should be discussed on a wider scale or it will snowball.

Women have ALWAYS been scared shitless to give birth though... its nothing new.

I did a hypnotbirthing class with my first dc and it discussed the beginnings of fear in child birth, I dont think it really is something that has always been a problem. You don't see animals shitting themselves about giving birth.. even though they have a healthy fear of other animals, threats, etc.

I should say "in labor animals don't seem stressed" I obviously haven't discussed my theory with many cats.

The way births happen in hospitals (being forced to lay on your back etc) can cause pain in women, it's a horrible cycle.

BOF But isn't the issue we all see this differently?

You see it as a social problem. I don't. I see it as a practical problem. Babies are getting larger, women are giving birth later, there are lots of reasons.

Birth has always been problematical and always killed women in droves.

I don't see my atttitude to birth as being a social problem.

I have no problem, however, on you holding your views and I am not trying to persuade you round to my way of thinking. I don't think there's anything wrong with you believing what you do.

I just don't agree with you.

We're all entitled to our own views to be respected for our own birth and a duty to respect others views when they are giving birth.

I always find this a fascinating thing to reflect on when saying fear of birth is a modern invention.

A french doctor in 1858 wrote the following his book about pregnant women:

?If they are giving birth for the first time, waiting for unknown pain worries them beyond all measure and they are plunged into an indescribable state of anxiety. If they are already mothers, they are terrified by the memory of the past and the prospect of the future; they are privately convinced that they are going to die from the ordeal which awaits them?.

He added

?this idea becomes absolutely fixed in their heads and triggers a melancholy frame of mind which takes over all their thoughts?

Perfect description of what would now be diagnosed as modern day primary and secondary tocophobia.

Actually I would prefer not to have an epidural - i am a running marathons, climbing everest type person and i would rather have pain with control than lack of pain and feel out of control of my own body, just my personal preference. But i don't see the nhs rushing to help pay for my hypnobirthing classes to give me the tools to attempt birth without an epidural... and i am not entirely confident the nhs has the resources to help me attempt a fully active birth either. You can't just set targets and convince women to do things the way you want without providing resources and support.

[and before anybody says anything, i am fully aware that i might need/want an epidural and a cs when the time comes, but that doesn't change how i feel now or the strategy i want to start out with].

I agree that more should be done to help pregnant women feel more confident about the process of giving birth and there are lots of measures that can be taken to help reduce the fear of what's involved - not to mention changes in attitude among HCPs and alterations to hospital policies and environment to make the whole thing more pleasant for the families involved.

But ultimately, a pregnant woman needs to feel empowered to take ownership of her body and birthing process - and if that includes the certainty that she can have an epidural or section if she so requests, then so be it. Setting targets will simply erode choices and disempower women further.

HmmThinkingAboutIt Christ, I'm not surprised considering what women put up with now in hospitals I'd hate to think what it was like in 1858. My point was "modern times" since women have given over their births to the medical community. Which would include your French doctor.

Women didn't give birth in hospitals in 1858. It was a 20th century development.

I thought birth at hospitals started during the industrial revoloution

Wikipedia

At the onset of the Industrial Revolution in the 19th century, giving birth at home became more difficult due to congested living spaces and dirty living conditions. This drove urban and lower class women to newly available hospitals, while wealthy and middle-class women continued to labor at home.[2] In the early 1900s there was an increasing availability of hospitals, and more women began going into the hospital for labor and delivery. In the United States, the middle classes were especially receptive to the medicalization of childbirth, which seemed to promise a safer and less painful labor.[3] In fact, the ability to labor without pain was part of the early feminist movement[1]. With this change from primarily homebirth to primarily hospital birth came changes in the care women received during labor: although no longer the case, in the 1940s it was common for women to be routinely sedated and for babies to be delivered from their unconscious mothers with forceps (termed by Dr. Robert A. Bradley as "knock-em-out, drag-em-out obstetrics"). Other routine obstetric interventions have similarly come and gone: shaving of the mother's pubic region; mandatory intravenous drips; enemas; hand strapping of the laboring women; and the 12 hour monitoring of newborns in a nursery away from the mother.

Is it really a revolutionary idea to ask for a more balanced show of women's labors? I wasn't scared of child birth I knew it was what just happens. It makes a difference, I was only scared when I gave birth to my second child here in the states because I knew the medacalised version was going to be pushed on me.

Fear of child birth causes longer labors and more pain for women. Giving a woman an epidural means she has to give birth on her back, and if the epidural doesn't work effectively (which happens) she's in pain but can't move to alleviate it, or give birth in a better position squatting/hands and knees/water

[http://thechart.blogs.cnn.com/2012/06/27/fearing-childbirth-may-prolong-labor/]]

BOF It isn't true you have to be inactive or on your back for an epidural. I gave birth vertically with a low infusion epidural and for me it was a better, calmer and more positive experience than a previous natural birth. I appreciate it's not everyone's choice but it was mine and I was happy with it.

We are all different and I entirely agree that women should get better support and not have a medicalised birth forced on them but neither should they feel they have to conform to the natural birth model.

I agree it is good to reduce anxiety but I think you do have to be very careful about saying fear causes longer labours because it implies a failing on the part of women. Women who suffer 'delay' are not to blame for their problem.

Immacs point is spot on. Improve the birth environment and care but ultimately respect women's choices.

If the NCT and other woo merchants want me to "have confidence in my own body", they can fucking well start by campaigning to ensure that I will be able to have access to pain relief and surgical intervention in childbirth if I feel those things are necessary.

I reserve the right to be scared shitless of something that kills hundreds of thousands of women a year and leaves many more severely injured. This is not the result of a "social problem." This is what birth is "naturally" like.

If there is a social problem, it is with the woo being peddled that it's "natural" for women to suffer intolerable pain and that we should just suck it up because we wanted to have a baby after all.

Sorry I can't be more constructive, too angry right now.

Sorry BOF - re missed your bit of research, yes, read it and it does say fear increases length of labour for 47 minutes after adjustment but there are other studies saying that fear does not have any impact on caesareans.

So again, I think saying that fear causes many problems is not too good an idea.

Added to which, if health carers start saying they are going to restrict epidurals or leave women in long labours to avoid caesareans, you will turn anxiety into terror.

So this guidance that started this thread off is bad news.

I'm certainly not blaming women, I'm blaming a society (and doctors) who give the women the feeling straight away that child birth is something she can't do.

I'm not one of these people who thinks anyone has "failed" if they have any kind of birth in particular. I think telling doctors that should make an effort to see that their patients have a feeling of empowerment and don't necessarily need intervention keeps the doctors in check. Honestly ti would be easier for them if we all epidurals and scheduled inductions. It would be, so there needs to be an incentive.

I don't think 20% is such a low number that it will restrict women do you? I think it will encourage doctors to not automatically start telling women they need a csec for this that and the other. I know women who wanted vbac, but were told not to by doctors.. this will stop that sort of thing..hopefully

BOF Incentive to do what? Refuse pain relief? Read Fairs post. That is how many people feel.

We're just different. Some women want interventions like pain relief. They won't feel empowered if their doctor has an incentive to persuade them they don't need it. Others feel like you. That's fine.

We're not going to agree on this are we?

Shall we give up an agree to differ?

BOF just have to come back on this:

"I don't think 20% is such a low number that it will restrict women do you?"

Yes, yes, yes, yes.

I know one child who is brain damaged as a result of doctors delaying c/s, I have a friend with incontinence who, had she been to a private doctor would have been told never to attempt a vaginal birth.

Women need to be offered caesareans when they are needed clinically. That is not a black and white point but a grey one so women need to be engaged in the decision. You do not want doctors checking their caesarean statistics before they decide to save someone's life or health.

Sorry really do not agree with targets. They lead to unintended consequences.

What FairPhyllis said.

I hear what some of you are saying about reducing fear of labour. But I don't think that's the whole answer. Some of us have very rational reasons for being fearful of labour. What I need to know about my forthcoming labour is that I'll have a choice about how I can give birth and help and support at every step of the way. There's not much I can do to address the reasons why I'm already fearful, but - with help - I can manage my anxiety enough to deliver this baby safely.

Again, it's about acknowledging that women have different needs and responding to the individual rather than diagnosing something wrong with the way that a whole population of women give birth.