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 noindex" 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]

Who is saying they shouldn't be offered when they need one .

I'm stating that in a western country with access to decent health care 1 out of 5 women very likely don't need csec and that doctors and hcp should make an effort to inform women of this. This should be done during prenatal care not on the day of delivery.

Targets are just their to remind the doctors to not make their lives easier by pushing for not medically needy women to have csecs...which is now the norm in many countries.

[BigOldFanny]

that was addressed to ushy

[HmmThinkingAboutIt]

BOF, but thats what IS happening, and WILL happen even more because of targets.

I am too easy to be deemed not medically necessary.

Which means I will not be able to have children.... Cheers for understanding.

[Ushy]

BOF How do you know that 1 in 5 modern women don't need caesareans?
We are having bigger babies, a huge majority in our 30s, we lead more sedentary lives etc etc.

You can't pluck a figure out of the air and say this is what the caesaran rate should be.

There are clinical indications for caesarans very often starting with irregularities in the baby's heart rate.

You may be perfectly happy to hang on to avoid an 'unnecessary' caesarean but I would not be.

It should be each individual woman's choice of where she would like to set the risk not some arbitrary target based on no evidence whatsoever.

[BigOldFanny]

You can't pluck a figure out of the air and say this is what the caesaran rate should be.

You think that's what they have done?

[Ushy]

That IS what they have done.

[Treats]

BOF - that's fine when it's a black and white case. Is the mother or baby's life in danger if they don't have a c-section?

It's the borderline cases. Where a hospital is running at 19.5% and is having its funding threatened if it breaches 20%. A pregnant woman is brought in who is absolutely SHIT SCARED of giving birth because of a previous traumatic experience, but isn't otherwise showing any medical need. And she gets turned down for a c-section because they don't want to breach 20%. So she's forced into a long, painful natural birth that she doesn't want. Cue months of PND.......

It's drawing the line around who NEEDS a c-section. Who gets to decide? Do the women giving birth get to be part of that decision-making process? Or is it all decided for them by the blardy NCT?

[BigOldFanny]

I'm going to leave this thread because my view of labor as a feminist is that we shouldn't give in to what doctors the majority of them have been male are telling us to do when giving birth. I don't see this as restricting women, I see it as restricting doctors.

Telling us we can't have babies on our own, so we NEED them, is just another way the patriarchy has taken away our power.

If I told you my birth story with dc2 it would make you cry, not only did I get pushed down when I tried to walk but I had to slap a nurse away from me when she tried to physically force me to wear the monitor back on my stomach after I had taken it off after being forced to lie down or hours and in excruciating pain from not being able to walk. they were trying to pressure me in to pitossin which because I believed it would cause painful contraction they were insisting I have an epidural. I was threaened with being asked to leave in the middle of my labor.. And it just gets worse.

If I can face it I may start a thread about the night to let you know what you have to look forward to in your new shiny hospitalised births.

You see this as about choice, women's empowerment in their labor. Some pole dancers say the same thing about dancing, they don't see that they never had a free choice in the first place.

When the UK goes down that route and doctors are in charge not midwives and they don't know how women give birth naturally such as...My doctor told me my labor was progressing too slowly and that people shouldn't be in labor for 12 hours! When I argued with her she said... maybe that's how it works in "homebirths".

She genuinely had no idea how a woman labors without intervention. I fucking kid you not. this is what you have to look forward to if doctors get their way.

[Sioda]

"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've heard this argument so many times from the natural birth ideologues and it always baffles me. Humans are a different kind of animal in ways that actually matter. We're a social species with language so we can share complex experiences using words - so we can hear the stories of other women who've given birth and be influenced by them. We have a rational brain that allows us to anticipate the future and plan ahead to avoid risks - like the risk of pain or injury. And we have tool-wielding hands that allow us to create tools like caesareans and epidurals to achieve what we want. The combination of those abilities mean that comparisons to how animals give birth or what emotions we imagine they do or don't feel is, well, bizarre. Inherent in it is the notion that we can switch off our rational brain, re-educate our primate/social brain and just operate from our instincts. It's beyond nonsensical. Our brains just don't work that way.

[FairPhyllis]

BOF, I'm sorry you had such a horrible birth experience. I currently live in the US and one of the reasons I would like to leave is that I don't like the idea of having children here. But my view of labour as a feminist is that it's demeaning, cruel and medically unethical to coerce women into having any form of birth management that they are unhappy with, even "natural" labour as the proposal describes it. People who want an epidural or a caesarian are not trying to take away the opportunity to labour without intervention from anyone: they just don't want it for themselves. Instead of saying that all births will inevitably become medicalised if some people are allowed to choose epidurals, why don't we focus on promoting a culture in which all women's childbirth choices are respected?

I haven't given birth, but I hope to some day. If that day comes then all I really want is to have a vaginal birth with the knowledge that a spinal or epidural is available; and not to have anyone patronise me, or try to coerce me by telling me about the risks of complications from epidurals (I know them), or take advantage of me being vulnerable to deny me pain relief. That is what I fear. And I don't even have tokophobia so god knows what it must be like for someone who does.

[Jules125]

Some of us do need experienced obstetricians BOF.

In my first pregnancy I developed life threatening complications from pre-eclampsia at 26 weeks. My blood pressure was 240/120 (normal 120/80), my kidneys and liver failed, I had no blood clotting function (not great with childbirth!) and I developed heart failure. I would certainly have died without the mostly male obstetricians and senior doctors intent on saving my life. My DD1 could not be saved and was stillborn.

Yes, my case was very severe but not unique. 5% of first time mothers develop pre-eclampsia. I had no medical conditions or obvious risk factors so was under "low risk" midwifery care. The midwives failed to act on my phone calls or complaints of headaches; I do not really trust them to be able to recognise when a pregnancy becomes very high risk and needs urgent attention. Its possible that DD1 would be alive if they had acted when I first asked for help.

My second pregnancy was much better but DD2 was lying transverse at term. Again, midwives kept telling me she was head down and engaged. It was only very senior doctors (with their machines!) that worked out this was not the case and saved me from a traumatic induction at best (or a cord prolapse and dead or damaged baby at worst). My ELCS was not ideal perhaps but safely delivered me my wonderful DD2.

I do not want to sound like i am criticising midwives; I've also been looked after my some wonderful midwives; they just are not skilled to deal with experiences like mine. And problems in pregnancy are not that rare. I worry that there will not be sufficient senior doctors on the ward, should I urgently need them (I am 28 weeks with DD3).

I am sorry you;ve had traumatic expereiences too BOF. But I am very pro medical intervention (it saved my life twice and possibly my DD2) and very aware of the risks of pregnancy. i would like to be cared for by the most skilled and experienced doctors available. I welcome continuous monitoring (don't want to go through another stillbirth like DD1 and I recognise the pregnancy can get complicated very fast).

I hope you can see that my choice is rational and provides and entirely different perspective. Apologies for long post

[Jules125]

PS I've requested an ELCS due to anxiety. I still don't have that signed off at 28 weeks. The midwives are trying to encourage me to have a VBAC I don't want. The obstetricians are stalling me a bit ("we'll look at the situation later).

So yes, I think these targets do make it more difficult for women like me to get the births that make them feel less worried.

[HmmThinkingAboutIt]

BigOldFanny Tue 28-Aug-12 22:34:39
You can't pluck a figure out of the air and say this is what the caesaran rate should be.

You think that's what they have done?

WHO dropped targets. They state that all women who need one should get one. They also state there is no empirical evidence for an optimum rate of c-sections.

So yeah a 20% target is a number plucked out of nothing what so ever.

[Treats]

BOF I'm so sorry about your experiences. And I've read many, many threads on Mumsnet of other testimonies from women who are traumatised by what happened to them during birth, so I know that you are not alone.

There was a particularly interesting thread about 18 months ago which was discussing women's experiences of pain in labour and it was striking how - for many people - it was the pain, and being refused pain relief, that was the most traumatising aspect of the experience.

So, while I don't want to tell you what you experienced, I wonder if it was actually the disempowerment and not being listened to that was distressing, rather than the actual medical procedures? Obviously, I would think that, because it backs up my own view.......

And I agree with Sioda because I think that all too often, women's experiences are dismissed or scoffed at and we're expected to put up with pain that would be managed under other circumstances.

Jules125 - I lost my baby after a prolapsed cord. I'm very glad that your delivery had a good outcome.

[ArthurandGeorge]

Women who are informed are being denied the C sections that they want/need.

Women who are informed are being denied the opportunity to have the natural births that they want/need.

Both, imo, are due to at best paternalistic and at worst misogynistic attitudes in society at large and the medical and midwifery professions specifically. It shows a lack of understanding of the diversity of women's desires and experiences that is belittling to us as a gender group.

Women should be given free choices with regards to birth, this might mean paying for my sister's hypnobirthing classes or my C section with no "medical" indications. Neither is wrong, neither is right except for the individual who wants them.

[PatronSaintOfDucks]

BoF, as others, I find your birth experiences horrific. BUT, I do feel that you are seriously contradicting yourself and is doing to other women what was done to you, only from a different ideological position. Yes, we can speak about self-delusion, self-discipline and lap dancers who think that they are liberated feminists but really are not. Only you seem to think that the right way to enlighten the lap dancers is to preach to them. I, however, would argue we should listen to them instead, understand their stories, positions and fears and rather look at the social systems and ideologies as a whole as opposed to blaming the individual women for being silly little uneducated scared sell-outs to patriarchy.

Same with birthing women. Yes, I agree with you that birth is overly medicalised and that much could be done to improve the experience of women, babies and to reduce the rates of drastic medical intervention. However, is imposing tariffs on C-sections really a good starting point? It seems the proposal is putting the cart before the horse, and if, instead, we started implementing changes in the ideology of birth, looking at hospital processes, women's choices, education, etc., a reduction in C-sections would simply follow.

Using the cut in C-section tariffs as a starting point seems to put the blame for the present situation right back onto the individual women. We are not talking about broad changes, we are talking about somebody (who??? doctors and bureaucrats, obviously) assessing whether individual women "need" C-sections. This does not sound very feminist to me. It looks like just another expression of patriarchy, telling silly little women what they should be doing.

As for being scared shittless of birth - Historically, the chances of women and babies dying in childbirth have always been high until the rather recent times. They are still very high in many parts of the world. We are scared of birth for a very good reason.

[PatronSaintOfDucks]

"If I can face it I may start a thread about the night to let you know what you have to look forward to in your new shiny hospitalised births. " - BoF, can't you see how patronising and downright rude you are being? I do not want people to preach at me. I want a conversation.

[Treats]

"It seems the proposal is putting the cart before the horse, and if, instead, we started implementing changes in the ideology of birth, looking at hospital processes, women's choices, education, etc., a reduction in C-sections would simply follow. "

I agree with this PatronSaintofDucks

And also that it's rational to be scared of birth. Telling women that they shouldn't be scared of birth is not the right way to go. Giving them what they need to feel confident would be more effective. And - for some - nothing less than a c-section will do that.

[Leftwingharpie]

BOF as I understood it from Woolf's account, part of the problem in the US is that the whole process is profit driven because birth services are funded by health insurance, so a highly medicalised birth is more profitable, giving HCPs a conflict of interest. With the NHS you have the opposite problem, with targets fixed for cost saving.

If you do legislate to advocate patient choice, you then need to address the problem of those with particular vested interests seeking to influence choice. One of the big frustrations is that, as the patient, you don't feel that you can trust anybody.

[seoladair]

BOF, it's a strange, inverted sort of feminism which says "doctors are mostly men, therefore I don't want doctors to get involved in birth". Wouldn't feminism be better directed in helping all women to get access to the sort of birth they would like, whether they crave a water birth, a home birth, an epidural, or an elective c-sec?

[Leftwingharpie]

I don't think BOF meant that she didn't want doctors involved with birth because they're mostly men - I think the 'mostly men' observation was an aside.

[PMHull]

Update for everyone:

RCOG removes controversial guidance from website
cesareandebate.blogspot.co.uk/2012/08/rcog-removes-controversial-guidance.html

Last night I wrote (not for the first time) to my MP, and I'd just like to thank everyone who has done/is doing the same.

[WantsToBeFree]

Here's my question- where are the feminists? Where are the pro choice organisations and WHY aren't they protesting this nonsense?

They're quick to come up with slogans such as "My body, my choice" and "Stay out of my uterus", but is that limited to abortion and birth control? Why can't we extend it to childbirth options?

Feminists have sadly bought into the NCT bullshit and seem to be blissfully unaware of the misogyny at the heart of NCB movement.

[buggyRunner]

sorry i should clarify- I am angry about the fact that giving birth has to be one of the most important physical things one can do. it is also something only women can do yet the inteserests of women are ignored. also the fear of birth seems to be working very conveniently for the medical profession in enabling them to bully a lot of women into proceedures they are not comfortable with.

[Sioda]

Pauline That's good news!

Buggy Yes but this guidance is about the medical profession bullying women out of procedures that they need or want.