There is much upset in the normal birth world today over the announcement that NICE is going to allow caesareans on request. However, the real statement goes a little deeper than the BBC and newspaper headlines suggest…
Firstly, it is not saying that a caesarean section is a safe alternative to vaginal birth, it is saying that improvements to surgical techniques and outcomes has reached a point where the risks of elective surgery are reduced to a point where they are in the realms of acceptable, under certain circumstances, and that a woman’s emotional health might be one of them.
My second comment would be that our over-stretched maternity service is going to find it hard to offer this service if many women take it up, because a caesarean is more expensive for the NHS to deliver, several times the cost, it also results in longer hospital stays, more SCBU admissions, more readmissions for mums and babies, more follow-up care and more midwifery time and input. The answer of course is to seek to make birth as low-intervention, safe and enjoyable as possible for as many women as possible, to free up valuable resources for those few who really need the high level input. That is more physiological births, more home births and fewer women deeply traumatised by their birth experiences, both as a benefit to themselves and so that there are fewer horror stories and more positive experiences to share with those yet to birth their babies!
With this new guidance, to be published at the end of November 2011 (NICE CS Guidance), Nice is trying to protect the rights and birth choices of women who are seeking to avoid birth for emotional reasons. The guidance says that women who arrive requesting a caesarean without medical reason need to have a full and frank discussion about what that entails and what the potential risks are (which is more than many women planning a caesarean get from their consultant now) and if it is appropriate, for example women who reveal previous episodes of abuse or birth trauma which is making them afraid of birth, women are to be offered counselling for those issues, regardless of any expectation over their birth choice. The guidance then goes on to state that if a woman still feels a caesarean is the emotionally safest option for her then her request should be accepted and supported. The guidance also says that if a surgeon has a moral objection to meeting the woman’s request for section, or if a surgeon feels unable to justify the increased risks to the woman, then they are obliged to pass the woman on to an NHS colleague who is better able to meet their request. Thus protecting the surgeon’s right to professional autonomy and personal integrity.
In reality this new guidance formalises and provides structure in accordance with what already happens in many areas. It also provides a clear framework for women to request a caesarean and know that they are going to get good support to do that and to address any emotional issues which might be contributing to their request for major abdominal surgery, which, let’s face it, is not a decision to be undertaken lightly.
It also provides a framework for giving women good quality information about the risks and benefits of surgical birth, and is expected to not only cover the increased risks to the mother and to the baby whose birth is being planned, but the risks to any future pregnancy she may have. This is not only the small increased risk of rupture during a VBAC , but the much bigger increased risks of issues like infertility, miscarriage, still birth or placental problems such as placenta previa or placenta accreta. It is very important that women understand that the risks carry over into the next pregnancy, and that those risks are not all eliminated by repeat surgery, and that also, the more caesareans a woman has, the more complicated and risky future surgical births become. I also hope that the NICE expectation that full information be given to allow women to make an informed decision about choosing a caesarean may even make maternity care teams think more critically about what a caesarean really means for a woman, both short and long-term, and may help reduce the sometimes blasé attitude to surgical birth seen in some maternity units!
Of course it is only guidance, it is not mandatory, which means that at the moment units, and individual practitioners, can pick and choose whether or not to follow them. However, once women are aware of the guidance and start requesting that their care teams follow the evidence based suggestions within them, it will be very difficult for a compassionate unit to refuse!
I am hoping that this does not become another mantra for blaming women for the rising caesarean rate, there is already enough blame-laying. Older women are blamed for the rise, women with a high BMI are blamed, those who are duped into believing that it will protect their bodies from the ravages of birth are blamed… We must be wary that it does not become a situation where women are blamed in large numbers for ‘wanting’ surgery. The number of women who are requesting a caesarean, either for emotional or social reasons, is comparatively tiny when compared with the 180,000 (1 in 4) babies who are currently born by caesarean surgery in the UK every year.
Personally, I think the NICE guidance on this is a good thing. It paves the way for active legislation on choice, real choice for women over what risks they see as important and what risks they are prepared to accept or not accept for them and their babies. It sets a precedent for women being allowed to request something which their care team feels increases their physical risk in order to protect their emotional health. It also allows for discussion on what actually constitutes ‘safe’ and how that evidence is gathered and presented. Women who are asking for support in their informed birth choices frequently know that what they are seeking is safe in a way their litigation-fearful care team don’t comprehend. Next stop a total rethink in the way women challenge the ‘home birth is too risky,’ ‘VBAC is dangerous,’ statements. If you allow me to increase the risks to myself and my baby by requesting a section, you need to allow me the same courtesy to book a well supported vaginal birth. There can be no argument against that now!