"Middle class mothers should be talked out of caesareans"
Middle-class mothers 'should be talked out of caesareans'
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Middle-class women should be talked out of demanding caesarean births because reducing the rate would bring "significant" savings to the NHS, proposed clinical guidance suggests.
By Stephen Adams, Medical Correspondent 10:00PM BST 23 May 2011
One in four births in Britain today is now carried out by caesarean, a major operation which costs the NHS thousands of pounds a time.
The rate has more than doubled since 1980, and some research suggests their growing popularity has been driven partly by more affluent mothers demanding them - those who critics say are "too posh to push".
Many obstetricians consider the rate to be too high.
Now the National Institute for Health and Clinical Excellence (Nice) has issued draft guidance saying women who want caesareans simply because they fear giving birth naturally, rather than for a clinical reason, should be made to have a full discussion about their options.
It says the doctor should offer to set up a separate appointment so that the woman's concerns about childbirth can be addressed.
The guidance, which is out for consultation, recommends: "When a woman requests a CS [caesarean section] because she has a fear of childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her fears in a supportive manner."
Doctors should "discuss the overall risks and benefits" of caesarean section compared with a natural birth and explore the reason for the caesarean request "to ensure the woman has accurate information".
Women should still be able to have caesareans if they do not want to give birth normally, the guidance makes clear: "If after providing support, a vaginal birth is still not an acceptable option to the woman, offer a planned CS."
Recovery from birth after a normal delivery tends to be quicker than after caesarean.
However, the balance of risks to mother and child between caesarean and natural delivery is "controversial", according to the medical information site Patient UK.
That is now recognised in the new guidance, which says the evidence on risks is conflicting.
Since 1980 the number of caesareans has risen from 54,000 a year to almost 162,000 - or from 9.0 to 24.8 per cent of total births.
This has come at an additional expense to the NHS. Caesareans cost thousands due to the costs of the operating theatre, staff, and longer stays in hospital. A vaginal birth with no complications typically costs £400.
The Nice guidance notes that finding out why some women choose caesareans "should be given high priority because the benefit to the NHS would be significant".
However, exactly what has driven the rise in caesareans remains contentious.
Last week a study was published indicating it has partly been driven by the demands of the middle class mother.
Ruth Dundas, of the Medical Research Council, said that while 30 years ago mothers having caesareans "were more likely to come from deprived social backgrounds", by 2000 they were more likely to be from "higher social classes".
But NHS statistics show the proportion of planned caesareans has actually dropped slightly since 1980, from 44 to 40 per cent.
Other research indicates that women rarely actively choose them, and that more than nine in 10 are performed on medical advice.
Some obstetricians believe the increase is largely due to greater numbers of older first-time mothers - who also tend to be middle-class mothers - who actually need them.
Jane Munro, from the Royal College of Midwives, welcomed the guidelines.
She said: "We are particularly pleased to see the focus on an appropriate discussion of the risks and benefits of caesarean section and the importance of the psychological needs of women and their possible fears about birth."
The National Childbirth Trust also thought the suggestion of counselling those who feared childbirth was a positive step.
Elizabeth Duff, a senior policy advisor at the charity, said when there were no medical complications, "a normal birth is safer for both mother and child".
She added: "Referral to a healthcare professional to help address a woman’s fear of childbirth is a good way of providing support and enabling the mother to have a positive experience of birth."
A spokesman for the Birth Trauma Association said the organisation was "delighted" that Nice had produced guidance with "more accurate assessments of the risks and benefits of caesarean section". The previous guidance was "deeply flawed" on this point and overestimated the risks of caesarean, she added.
I totally agree with a point Carolyn Hastie made about this: "Talking 'through' the fears may be helpful to these women; talking them 'out' of caesareans wouldn't work because if the fear (and it is often dread they feel) is still present, their bodies are not going to work well."
