I suspect that I could probably knit two life-sized babies out of the column inches devoted by the press to the C-section debate of the last 10 days. My babies would emerge (vaginally or abdominally) smeared with the blood of baying journalists, the tears of traumatised mothers and an additional price tag of £800 for the surgically extracted version.
The National Institute for Health and Clinical Excellence (NICE) is the origin of the furore. It recently commissioned an update of its 2004 guidance, resulting in a 275-page draft guideline, with the definitive version due later this month. These guidelines cover all aspects of caesarean sections, including planning, timing, the operation itself and care thereafter.
The media has focused almost exclusively on one element of the guidance only – can a woman simply ask for a caesarean section and get one? Cue polarised fuming by opinionated commentators bandying about “too posh to push” and women’s right to choose.
My personal story
All of this brought to mind my own slightly apathetic attempt to discuss a caesarean for no very good reason back in 1999, when I was pregnant with our daughter.
“What on earth for?” queried my consultant. “Do you really want to be lying about for weeks after major abdominal surgery, unable to get on with mothering?” I muttered something about wanting to preserve my pelvic floor, so that my future urinary continence and lovelife wouldn’t be compromised.
But I confess, that as a GP myself, I knew full well that many women who have vaginal births do not suffer these indignities. I also felt that taking any unnecessary surgical risks might be tempting fate to spike my vanity, whereas if I did suffer any lasting urogynaecological problems, evidence-based treatments would be available later down the years. So I demurred, and have satisfactorily pushed out two healthy children under heavy epidural anaesthesia.
The new NHS guidelines for caesarean section
So how will these proposed new guidelines change the options for women in a similar position in the future?
The NICE draft guidance sets out a specific pathway to be followed where a request is made for a non-medical, elective caesarean. The reasons for the request should be “explored, discussed and recorded” and that “the risks and benefits of a caesarean compared to a vaginal birth should be discussed” with the mother-to-be.
The risks of a caesarean compared to a vaginal delivery include a longer hospital stay, an increased chance of hysterectomy due to post-birth bleeding and an increased risk of cardiac arrest. A caesarean is conversely less likely than a vaginal birth to injure the vagina and cause pain during the birth and for the first three days thereafter. A caesarean is also less likely to result in early post-birth bleeding, and the baby is less likely to need admission to an intensive neonatal care unit.
Interestingly, the studies showed no difference between vaginal and planned caesarean births for pulmonary embolism, wound infections, intra-operative trauma, damage to the bladder, ureter or cervix, or the need for assisted ventilation.
So far, so good – women are to be offered timely and accurate information to help them guide their choice.
Heightened fear of childbirth
The guidance continues “When a woman requests a caesarean section because she has anxiety about childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her anxiety in a supportive manner”.
Furthermore “if after discussion … a vaginal birth is still not an acceptable option, offer a planned caesarean section.”
The question that this begs is clearly what kind of maternal anxieties about vaginal birth lead a woman to request a caesarean? And what could help them to work through these anxieties and perhaps choose a vaginal birth instead?
The draft guidance cites findings from 19 research studies, showing that six to ten per cent of women experience fear of childbirth. Reasons vary from previous childbirth experience, self doubt about the physical ability to deliver vaginally, fear of damage to the baby during vaginal delivery, fear of damage to the pelvic floor and unresolved issues relating to the genital area. The fear manifests itself as stress symptoms in everyday life, including nightmares and a wish to avoid the current pregnancy.
Further research needed
However there have been no studies to date comparing the effectiveness of any antenatal interventions aimed at supporting women who request a caesarean for non-medical reasons. Nor is there any evidence comparing the effects on women who wanted a caesarean and got one, versus those who wanted one and did not. It seems plausible that such anxious women might benefit from counselling, or cognitive behavioural therapy, or indeed just having one named midwife for the whole labour, however long it takes and even if her shift has ended. The reality is that we currently just don’t know.
Neither do we have any idea about the medium to long-term risks versus benefits of planned caesarean compared to vaginal birth. How do women fare at say 10 years post caesarean with regard to urinary incontinence, pain during sexual intercourse, bowel problems or psychological health? And how do the babies progress, from a respiratory, neurological or general medical wellbeing perspective, depending on whether mum chose a vaginal or surgical mode of delivery for them? Again, this research simply has not been done to date.
The economic case
What then of the economic case for maternal request caesarean section? The extra £800 price tag factors in hospital and surgical costs, but not subsequent costs resulting from treating any urinary incontinence caused by vaginal delivery. Nor does it consider the potential costs for post-natal psychological support for women denied a caesarean. Including these factors would almost inevitably reduce the overall cost difference between a vaginal delivery and a caesarean.
In the face of such uncertainties the guidance states that “on balance, this model does not provide strong evidence to refuse a woman’s request for caesarean on cost-effectiveness grounds”.
The draft guidance refers to the experience of the working group members in caring for such women. However their anecdotal experience that some women do opt for vaginal delivery after appropriate support, is simply not enough in our evidence-based (perhaps evidence-obsessed?) society.
And so?
NICE has to speak authoritatively, and on the basis of what research is currently available. Similarly journalists have to write a good story, be it of tragedy or new hope; and hence we are confronted with headlines that do not do the facts justice.
I am therefore not convinced that the women of tomorrow will be given caesareans more readily than the women of today. Good doctors will continue to gauge the distress of their patients and its impact on their well being and that of the baby. Obstetricians will now follow a standardised assessment process when a woman requests a caesarean, and some women will more easily access a second opinion if the first obstetrician declines to operate.
I suspect that half of the maternal requests will still be turned down, just as they are now.
And that the ‘me’ of 12 years ago will receive much the same response as she did then, only couched rather less colloquially.
image: flequi via flickr