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.

Wants Yes there's not a whimper out of feminist organisations, or many feminists for that matter, about things like access to consultant-led care, epidurals and c sections. Where you'll find them, en masse, is in homebirth advocacy, the natural birth industry (selling independent midwifery, doula services, hypnobirthing courses etc.) and campaigns for more midwives and more midwife-led birth centres. Many of them pay lip service to choice for all women but you won't find them actually advocating for it. It's very messed up.

WantsToBeFree There are a number of people out there working very hard to challenge the 'normal birth' guidance proposed in this document (and many others like it), of which I am only one.

My website carries the slogan 'Your baby, Your body, Your choice' and I have protested the legitimacy of a prophylactic caesarean, on a voluntary basis, for the last eight years. In 2010, together with other organisations, I submitted evidence to NICE that would ultimately lead to its November 2011 maternal request caesarean recommendations. This was a huge step forward.

Similarly, in 2008, together with the Birth Trauma Association, csections.org and Birth Trauma Canada, we publicly called on the WHO to provide evidence for its 1985 15% caesarean threshold recommendation. One year later, the WHO admitted there is no empirical evidence for a 15% threshold and indeed an optimum rate is unknown. Most recently, earlier this year, the book I wrote with Dr. Magnus Murphy, a urogynecologist in Canada, was published.

The voices of larger organisations can financially afford to make themselves heard; it is more difficult for smaller organisations with little or no funding to have the same impact, and the fact that you needed to ask your question demonstrates this perfectly.

I just wanted to assure you that we are here, we do exist, and on an almost daily basis, we are working hard to ensure that women have access to a full spectrum of birth choices, and also that they receive more balanced and evidence-based information about the risks and benefits of different birth plans in order to help them make that choice (if they want to).

Where are the feminists? They are you. Where are you?

I hope there comes a time very soon where women get the information they need, in the manner they need it, to make the decisions that enable the best birth for them that the situation allows. And if it all goes against hopes, that they get the support necessary, both before the birth and after.

Yes I should have said that there are honourable exceptions to the lack of advocacy for birth choices - not least Pauline's website. The overwhelming influence of NCB ideology among women who would in most other circumstances value women's autonomy means that such groups and individuals have nowhere near the clout that groups like the NCT do unfortunately.

Foot I do my bit. Unfortunately there are many women who consider themselves feminists who effectively oppose choice under the guise of liberating other women from their patriarchy-induced choices of caesareans or epidurals (or formula - but that's a whole other story...). There are lots of them out there, I personally know quite a few. It's depressing.

PMHull,

I just wanted to say "thanks" for doing all your work. I really appreciate that there is somebody out there advocating on my behalf. Thank you.

The stores has been picked up my the Daily mail, the comments on there are awful. Why are we still our own worst enemy? Lost of comment along the line of 'I did it 3 times and if I can anyone can', 'all my friend who had epidurals tore really badly'. Only the individual woman can decide her pain threshold and as we are so often told every labour is different. It doesn't surprise me that the NCT support this.

It still bothers me that 7 months after my DC2 that the midwife tried to discourage me from having an epidural, it also bother me that when the epidural didn't work properly she refused to get the anesthetist back in. She still made me lie on the bed even though the epidural had failed just in case and when I said it was uncomfortable her reply was 'well you did choose an epidural'. It was patronizing and humiliating. As if wanting to not be in pain is unusual.

Sioda "Yes there's not a whimper out of feminist organisations, or many feminists for that matter, about things like access to consultant-led care, epidurals and c sections. Where you'll find them, en masse, is in homebirth advocacy, the natural birth industry (selling independent midwifery, doula services, hypnobirthing courses etc.) and campaigns for more midwives and more midwife-led birth centres. Many of them pay lip service to choice for all women but you won't find them actually advocating for it. It's very messed up"

Very true - and all under the guise that they don't have a product to sell, but just try to shield women from the knifewielders who only want to do it for profit.

FWIW - I chose ELCS and when I did my research it was hard to find unbiased figures and facts. In the same way that it's near impossible to find sober unbiased info on breastfeeding/formula.

NCB etc to me doesn't seem to me to be about empowering women but to put them in their place.

Yes there's not a whimper out of feminist organisations, or many feminists for that matter, about things like access to consultant-led care, epidurals and c sections. Where you'll find them, en masse, is in homebirth advocacy, the natural birth industry (selling independent midwifery, doula services, hypnobirthing courses etc.) and campaigns for more midwives and more midwife-led birth centres.

Yes, but I think that until very recently at least the CLU has been the default option for at least 90% of women. (Or at least an idealised version of the CLU where they are all well staffed and can immediately spot a problem and attend to it. Not the CLU where you never see the same person twice and go unattended for long stretches in labour, never mind get to actually see a Consultant.)

In most places you have had to be very determined to organise a homebirth, and MLUs aren't an option because they have been closed down. If the pendulum really swings towards either of these, as it was in the 1950s when it was difficult to get a hospital birth, then I think feminist organisations would swing into action.

I think it depends on how you read and interpret the document. I may be wrong but if antenatal care was improved and labour was well supported then intervention and emcs would probably fall to the targets suggested. So if the care and support was provided as the document intends the targets would be achieved. The problem is if the targets become the focus rather than the methods to achieve them then it would not help individual women IYSWIM? Most women would probably like a straight-forward birth with little or no pain in surroundings providing the most support so that they recover well - as well as the birth that gives the best outcome for their baby. For some that may mean an elcs, others a home birth?

The emcs rate is considered higher than necessary because women are not supported and cared for - because of a lack of one to one care, because of the threat of negligence, because of the over medicalisation. It is this that affects whether women get to choose an elcs - if the emcs rate was reduced then there probably wouldn't be as many elcs requested, but then women who did request an elcs would find less resistance to obtaining one.

Maybe the document should be reworded do that the targets are more like outcomes expected rather than used as targets to be achieved?

Bit late to this and maybe off topic a bit tho related...

Why is there such a heirarchy of what women can / can't and choose to do / not do with their bodies? I don't get it.

100% natural labour, no drugs, squeeze baby out ... 'Well done YOU!'
EMCS after epidural - 'Oh. Well... At least you tried :('
ELCS - 'But you're not really a Mother until you've Given Birth'

All things I've heard recently, in relation to my super medical EMCS and a friend's attempted hypnobirth VBSC which didn't work as planned.

Ditto BF - I read a mate's comment recently that it's 'incredibly selfish' to 'not even try to BF'...

As though you're 'more' of a mother if you have a natural birth, BF etc etc.

Does what I'm trying to say make sense?

I would like to know if there is any other medical procedure for which patients are routinely denied adequate pain relief, or brainwashed into thinking that using pain relief is 'failing'.

Seriously, are there any? is it just a coincidence that this only happens in a circumstance that only affects women? pfft.

Interesting discussion about the role of feminism in this. I think there are historical reasons why feminism = NCB. It wasn't so long ago that midwives refused to take responsibility for a woman in labour because she wanted to position herself on all fours rather than lie on her back with her legs in stirrups in the 'accepted' manner*. It was the NCT that effectively campaigned for women to be able to have more choice in labour. Previously you did what the doctor told you and that was that. So - back in the day - feminists were on the side of the NCT because they were the ones who wanted to empower women.

The NCT has ALWAYS been about NCB, so it's not really fair to criticise it for being a major advocate of this approach. What's changed is that the orthodoxy has now swung right round - mostly because the NCT has been so successful, and that's not a wholly bad thing - and the drive to give everyone a natural birth is now over-riding the needs of individual women. It is, to say the least, ironic.

*This happened in the Royal Free in London in the early 80s. I can't remember if I read this in the Naomi Woolf book or 'Birth - A history' by Tina Cassidy.

Sorry I can't wade through 16 phs. On my iPod.

However, I think women should be made to consider the short and long term effects of interventions during labour.

Weighing up the evidence I wanted neither a epidural or a CS, unless absolutely necessary.

They are far from easy options.

I remember a WHO stat that the c section rate for a developed country should be 10%. With the implication that the excess is due to poor management eg unnecessary inductions, 'once a section, always a c section' mentality of some OBs, hospitals' opposition to home birth, lack of one to one midwife care throughout pg& birth etc.

If more resources were put into good midwifery then the c section rate would come down naturally.

I weighed up the evidence too - as a diabetic with x8 previous abdominal surgeries - and opted for an induction at 38 weeks. Which after 39 hours was declared failed, so I had an epidural and an EMCS. I knew the likelihood of a c-sec was high, and the risks of induction - they far outweighed the risks of leaving DS until he was ready to come out and risking shoulder dycotia, major pelvic injury and / or serious complications from the unstable BM's for us.

I agree that all women should be informed in an unbiased manner about the benefits and risks of possible interventions.

I had a FAB consultant who gave me reams of studies - from both sides - to read, and told me her view, and let me choose. I was VeRY lucky to have this. ALL women should have the option of such info and choice.

But the NCT class and the one 2 hour NHS class we had didn't discuss induction, c-sec, epidurals, types of intervention etc at all. All I had from those classes was a rosy (and unrealistic for me) view of active, natural labour, which left me feeling shit and like I was somehow failing by not even TRYING the natural option. Which was as equally unbalanced and biased as if my consultant had said 'We're inducing, you are too high risk, end of'.

But I've had much grief since then from NB advocTe friends who say, sad faced, that I'll 'just never know the joy of pushing the Baby out' ... I got a healthy baby, I was healthy and recovered - all that mattered to me :)

I guess for me it's as simple as 'my body, my choice' - I can't make ab informed decision without information - if that information is biased (either way) then my choice is biased, rather than right for me.

I'm on the fence in terms of the medicalisation of childbirth and find I get very stuck - it's life saving, and potentially totally disempowering.

100% natural labour, no drugs, squeeze baby out ... 'Well done YOU!'
EMCS after epidural - 'Oh. Well... At least you tried sad'
ELCS - 'But you're not really a Mother until you've Given Birth'

Women can't win though,can they? Someone who has a home birth will be criticised for being selfish, woo, lentil-weaving, more concerned about her own experience than the baby etc., etc.. Even though these statements don't stand up to examination and all women care about their baby, far more than anyone else, and want what's best for both of them.

Frilly* That's awful and unfortunately not such an uncommon experience. One of the problems is that women are understandably so busy with their newborns, and sometimes so traumatized, that they don't complain to the hospital afterwards. Would you consider it? It shouldn't be the responsibility of individual patients to try to address these kinds of systemic problems but it can have an effect if enough women do it.

LaVolcan It's just that binary that's the problem. The focus should always have been on respecting women's autonomy, not on swinging the pendulum this way and that between hospitals vs. home/MLU. That that wasn't and isn't the case is an indictment of feminism.

White Renaming things as targets, guidelines or expected outcomes doesn't change their effect. It might if the context of this wasn't both cost-cutting and ideological. But in that context any guideline like this can and will influence care negatively.

Basically There's some good sociological and feminist research out there on it - on the ideology of Total Motherhood and things like that. Seems to me it boils down to the warm glow of superiority one gets for being on top of a hierarchy.

StarBall Your reading laziness shows. No one is suggesting that women should not be provided with accurate information about the risks and benefits of any intervention (or lack of intervention). That's not quite the same thing as their being 'made to consider' them. This is a feminist forum you know?
BTW, many women find that epidurals and CS were an easier option for them. Do their experiences not count?

Margery Is this the same WHO that PMHull mentioned above? Did you read that post? And you still think their nonsense about rates of CS is trustworthy?

Can I say something in defense of NCT? The contents of their classes must really vary between branches. One thing I remember from my NCT classes was actually what I would call a rather "normalised" attitude to pain management, including epidurals, and c-sections. I went into the classes having a vague notions that interventions such as epidurals were scary negative things. However, the NCT classes made me feel much more confident about these options, definitely de-mystified them for me and made them appear more "normal." I remember the general mantra in my branch being "what matters most is a healthy baby."

I am still pissed off at them for not telling us how excruciatingly difficult breastfeeding could be though!

WhitegoldWeilder has it spot on.

Thanks CH!

I take your point Sioda - however the 'targets' are more likely there as the juicy carrot to encourage better antenatal care and support - resulting in potential savings further down the line. The NHS has always been a little short-sighted over spending money up front to make savings long term.

Everyone has expectations of labour and birth. We now are information rich yet actual experience knowledge poor for first time labour and birth. We have more choice than ever - surely? Yet we also have been given a certain amount of responsibility too for what happens in labour and birth - it can be difficult for a women to consider what is the best option when she's been in labour for a number of hours, in pain and unsure what to do next? It can be difficult for a MW to suggest what options are available? Pain is subjective. It may be that good care and support before this point and an open mind by all will provide the best outcome, physically and emotionally.

Maybe the targets should be about achieving continuation of care, one to one support? Even providing information about options for birth, pain relief, other interventions can be difficult because of people's own prior knowledge, beliefs and expectations - which all have to be acknowledged.

sioda - I don't think feminism has been all that strong on motherhood though, has it? It was all about empowerment which seemed to mean education (good), better jobs ( also good) but in the process the importance of childbirth and child rearing was downplayed - or at least it's was seen as being synonymous with being a housewife. Not surprisingly IMO the issues around childbirth weren't fully addressed. They were to some extent back in the 60s with campaigns to admit fathers into the labour suites and not taking babies off to nursery, and the 70s with campaigns against routine enemas, shaving and episiotomies. Now while they are important things they perhaps weren't where the major emphasis should have been? Or perhaps they were right for the time but we have sat back and thought that now it's all OK?

(It sounds as though I am not a feminist but I definitely am, but we need to pick our battles, I think. The dire state of maternity care now is one battle worth fighting about.)

Maybe the targets should be about achieving continuation of care, one to one support?

Yes, yes, yes to this. But people have been saying this for about 20 odd years now e.g. Changing childbirth called for continuity of care and woman centred care. Both lead to lower rates of intervention and satisfaction for the woman concerned, but it hasn't happened. Why not? How can it be made to happen?

no I didn'r read the earlier post.

But I still dont think it's very feminist to endorse what could be argued is mass mulitation of women which is done for men's benefit often on ill informed women.