The media storm that has blown up around NICE guidelines on caesarean section over the last couple of days has generated a great deal of debate and rightly so. I will say right away that the Royal College of Midwives is not anti-caesarean section, it is pro-informed choice by women. Let me also clarify that we are talking here about elective caesarean sections, not emergency caesareans driven by an urgent clinical need. It is also important to note that I am talking about a complex decision-making process based on the physical or psychological needs of women.
This debate is one that that needs to be had, though it is not a new one. The same discussion has been raging since I first entered midwifery over three decades ago, and I am sure it will continue for many more. What is important is that the complexity of this discussion and the decision making around this should not be underestimated.
Lets start with the easiest issue. Some women want a caesarean section for purely social convenience. I am prepared to put my head on the block and say that I do not think making a choice on this basis is appropriate. The NHS was not set up for our social convenience and hard-pressed NHS resources have to be used appropriately. The fact is a caesarean section is more costly than a normal birth. It is also a fact that unless a woman has unlimited resources with which to pay for round-the-clock help there is a very high chance that her life from the moment of birth will be very unpredictable. A bit of flexibility around the time of delivery may be good preparation!
The guidelines essentially reflect what is already happening in maternity services. It is not a case that they are recommending that a woman should walk into a meeting with an obstetrician and say 'I want a caesarean' and the obstetrician should say, 'ok no problem'. What should follow now and is recommended for the future is that there is an on-going discussion between the obstetrician, midwives and the woman about the pros and cons of the different types of birth.
If a woman, for whatever reason, feels she is psychologically unable to face the prospect of a normal delivery then I have yet to meet a clinician who would currently deny her that choice and I agree with the NICE suggestion that 'if after proper counselling' a 'vaginal birth is still not acceptable' then the option of caesarean section should still be possible.
However, many of the women who may be asking for an automatic elective caesarean have perhaps previously had a traumatic or difficult birth. This is why I am pleased to see the recommendation for women who have such anxiety about birth 'be referred to a health professional with expertise in providing perinatal mental health support'. We know that when such individualised support is offered in consultant midwives' clinics, these anxieties can be allayed for many women, and they can go on to have a normal vaginal birth.
The focus on caesarean sections is perhaps a diversion from what really needs attention. Perhaps, the real issue at the heart of this debate is the underfunding of maternity services and the lack of midwives. Midwives need to be able to give time to women to really discuss what they want, and then be able to fully support and advise women towards this. One-to-one care in labour from a midwife a woman ideally knows and certainly trusts is particularly important. I really believe that if midwives are able to really make sure that women understand what their choices mean for them and their baby - the risks and benefits - then far fewer women will choose elective caesareans. They will be making decisions from a fully informed position and from a position of trust in maternity services, not one based on simply fear of birth and hearsay.
The NICE guidelines and the debate they are generating is not about denying women choice. Ultimately they are doing something very important, they are promoting informed choice.
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