'Caesareans should not be chosen for social convenience'
One-to-one midwifery care is needed so women are able to make informed decisions about birth rather than ones based on fear and hearsay, says Cathy Warwick
A frenzy of media activity was generated around the National Institute for Health and Clinical Excellence guidelines on Caesarean section in the past few weeks, even before the guidelines were published. Well, they have now arrived and the media activity is no less frenzied.
The guidelines rightly generate a great deal of debate about women’s right to a Caesarean section. I will say right away that the Royal College of Midwives is not anti-Caesarean section. What we are is pro-informed choice by women. The issue here, to be clear, is 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.
The debate around Caesarean sections is not a new one. The same discussion has been raging for decades, 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 it should not be underestimated.
“The NHS is not here for our social convenience and hard-pressed NHS resources have to be used appropriately”
Some women want a Caesarean section for purely social convenience. I am prepared to put my head above the parapet and say that I do not think making a choice on this basis is appropriate. The NHS is not here for our social convenience and hard-pressed NHS resources have to be used appropriately. Also, a Caesarean section costs more than a normal birth.
The guidelines essentially reflect what is already happening. The guidelines are not saying that a woman should walk into a meeting with her obstetrician and say “I want a Caesarean” and the obstetrician says, “OK, no problem”. What should be happening now and continues to be recommended in the updated guidelines is that there is an ongoing discussion between the obstetrician, midwives and the woman about the pros and cons of 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 deny her that choice. 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 be possible.
Many of the women asking for an automatic elective Caesarean have perhaps previously had a difficult birth. This is why I am pleased to see the recommendation that women who have anxieties about birth are referred to a health professional for perinatal mental health support. When individualised support like this 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.
Important as this is, it is perhaps a diversion from what really needs attention - 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 fully support and advise women towards this. One-to-one care in labour from a midwife a woman ideally knows and trusts is particularly important.
I really believe that if midwives are able to 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 armed with the necessary knowledge and from a position of trust in maternity services, not one based on a fear of birth and hearsay.
The NICE guidelines and the debate they have, are and will be generating is not about denying women choice. Ultimately, they are doing something very important, they are promoting informed choice.
Cathy Warwick is chief executive of the Royal College of Midwives