Insight: Special delivery - caesarian sections

'Too posh to push' has become a familiar term coined by the media to describe the growing number of women in the UK who want to circumvent the unpredictability of vaginal childbirth and opt for surgery instead.

In the past two decades the rate of women having caesarean deliveries has doubled. It currently stands at around one in five deliveries. According to NHS statistics, there was no significant change in the caesarean rate from 2007 to 2008 and 2008 to 2009, at 24.6 per cent for both years (154,814 caesareans in 2008-09 and 153,406 in 2007 - 08).

Last year the World Health Organisation updated its recommendations on caesarean rates, stating that 'no empirical evidence for an optimum percentage exists' and that 'world regions may set their own standards'. This is despite previously recommending that the rate should not exceed 10 to 15 per cent.

The increase over the past 20 years has been due in part to increased safety in the procedure and technical advances which have enabled clinicians to identify case complications earlier. Half of all caesareans performed in UK hospitals are emergency procedures.

Caesarean on demand is not technically possible, but the rate varies between NHS hospitals, with the highest at around 30 per cent. In some private hospitals the rate is as high as one in three deliveries.

According to guidelines from the National Institute for Clinical Excellence (NICE), a woman's fears must be listened to, and if a caesarean is refused she is entitled to a second opinion.

One obstetrician says, 'Women may have a variety of fears about a vaginal delivery, and there is support available. They can be referred to a professional such as a midwife or obstetrician for advice, and many hospitals now have counsellors. Of those women who voice fears, around 50 per cent go through with a vaginal birth after being counselled.'

He adds, 'One of the reasons that caesareans have increased is because they are safer than they used to be. Thirty years ago they posed a significant risk to the mother. However, there is still a desire to keep rates low for a range of reasons, including the fact that caesareans tend to result in women having fewer babies and they can have a range of complications, including scar tissue to the uterus.'

IN FAVOUR

Pauline McDonagh Hull is a writer and mother of two who campaigns for elective caesarean as a legitimate birth choice. She challenges the assumption that vaginal birth is the best and safest first choice for all women. She says that she wants to dispel the myths around maternal requests and elective caesarean.

She says, 'I believe women have the right to make an informed decision as to what kind of birth they want to have. Whether a woman is granted a planned caesarean section delivery is a postcode lottery, and there is a lot of pressure to drive down rates.'

Ms McDonagh Hull's website is a hub for petitions, blogs, news and research which all support elective caesarean, and she is keen to counter the negative press she thinks it receives. 'Negative stories on elective caesarean tend to get blanket press. At the same time, a lot of international research which highlights the safety of caesareans never seems to reach the public domain,' she says.

COST IMPLICATIONS

A vital issue in relation to elective caesareans is that of cost. NICE has created a cost model in an effort to explore the financial implications of maternal requests for caesarean section to the NHS. Using its estimates, the cost savings from refusing maternal requests for planned caesesarean sections are estimated at over £10m.

However, NICE underlines that any such estimates of health service savings are bound to be crude, as they do not take into account the additional ante-natal care or counselling involved in planning a vaginal birth. They also do not take into account additional non-health service costs to having a request for a planned c-section delivery refused, or of the additional burden of increased emergency procedures.

With current economic pressures on the NHS, new evidence is emerging that promoting normal birth can help to save the NHS millions of pounds every year. Midwives and nurses at a range of hospitals, including Blackpool, Flyde anad Wyre Hospitals NHS Trust and Western Sussex Hospitals, have recently submitted examples to the NHS Institute of Innovation of how they have saved money by improving birthing practice and environment, to cut caesarean rates.

However, Ms McDonagh Hull contests the idea that planned caesarean sections are a cost burden to the NHS.

She says, 'The NHS masks the costs of litigation for vaginal deliveries that go wrong and the cost of counselling for births which result in children with medical problems and disabilities, or indeed pelvic floor damage to women. These costs are simply not factored in.'

CHANGING MINDSETS

Meawnhile, the Campaign for Normal Birth, supported by the Royal College of Midwives, is working hard to change the idea that caesarean section is another routine mode of delivery.

Mervi Jokinen, who heads the campaign, says, 'It recognises that there has been a loss of skill among both midwives and mothers to discuss what is normal in childbirth. We are trying to take everything back to basics and stress the fact that women are naturally designed to give birth, and that it is a normal procedure.

'That is not to deny that caesarean delivery has its place and is important where there are physiological reasons for a woman not to give birth normally. But we want to counter the idea that it is the norm. Twenty years ago it was regarded as an operation after which you had to recover.'

Ms Jokinen says that the campaign has achieved success by simplifying its message and providing top-ten tips for labour that give women confidence, the ability to listen to their own bodies and accept that childbirth can be a long process. She also reports that the campaign is achieving success globally, where some countries' c-section rates are as high as 80 per cent.

'This has been the case in Brazil, for example, where caesarean birth rates are very high and where midwives have only a small voice. Care is dominated by obstetricians and driven by medical insurance, where surgical intervention is accepted by the insurance companies. The system is similar in the US, where very often an obstetrician steps in at the last moment to "catch the baby" and then disappears.'

Essentially, the campaign aims to be a reminder that good birth experiences can happen despite the challenges. As Ms Jokinen says, 'Intervention and caesarean section shouldn't be the first choice - they should be the last.'

NICE GUIDELINES

In current guidelines issued by NICE, it is stated that pregnant women should be offered evidence-based information and support to enable them to make informed decisions about childbirth. Addressing women's views and concerns should be recognised as being integral to the decision-making process.

NICE says that bearing in mind the fact that one in five women will have a c-section, they must be given evidence based information, such as:

• indications for c-section (such as fetal compromise, 'failure to progress' in labour, breech presentation)

• what the procedure involves

• associated risks and benefits

• implications for future pregnancies and birth afterwards.

Communication and information should be provided in a form that is accessible to pregnant women taking into account the information and cultural needs of minority communities and women whose first language is not English or who cannot read, together with the needs of women with disabilities or learning difficulties.

Further information

• Pauline McDonagh-Hull, www.electivecesarean.com

• Royal College of Midwives Campaign for Normal Birth, www.rcm.org.uk

• www.nice.org.uk

• Hospital Episode Statistics, www.hesonline.nhs.uk