NICE or not?

In case you’ve been living in a home with no electricity, phone, internet and TV for a hilarious Channel 4 reality experiment, NICE (that’s the National Institute for Health and Clinical Excellence) just issued a new set of guidelines on caesarean birth.

It covers all aspects of caesareans from a medical perspective and has lots of good stuff in it, like this recommendation about early skin-to-skin contact:

“Early skin-to-skin contact between the woman and her baby should be encouraged and facilitated because it improves maternal perceptions of the infant, mothering skills, maternal behaviour,  and breastfeeding  outcomes, and reduces infant crying.”

and (big up for us doulas):

“Women should be informed that continuous support during labour from women with or without prior training reduces the likelihood of CS.”

Neither of these elements have been much picked up in the public domain. Why? Because of the these two recommendations that have sent the media in to a hysterical, hand-flapping frenzy:

“For all  women requesting a CS, if after discussion and offer of support (including perinatal mental health support for women with anxiety  about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS. An obstetrician has the right to decline a woman‟s request for a CS. If this happens, they should refer the woman to an NHS obstetrician in the same unit who will carry out the CS.”

The essence of the recommendations is that a woman has the right to choose her baby’s mode of birth outside of medical or mental health concerns. She can obtain a caesarean because she wants one – for whatever reason – and if her doctor isn’t comfortable with that, another who is must be found.

The media has been awash with comment. Some  celebrating the presumed demise of the vaginal birth (like this angry piece by Cristina Odone) and others, like Louise Foxcroft, anxious at the impact of what could be seen as cosmetic surgery in the arena of childbirth. As ever with coverage of birth, emotions run high, a giant divide springs up between the two ‘sides’ and often the real point gets missed

What do I think? Well, I believe in choice and if you vehemently don’t want a vaginal birth I don’t think you should be made to have one. Most midwives on my twitter stream seem to agree that the guidelines are just setting out what has been practice for some time: if a woman is adamant about her wishes and clear about the risks and benefits of all her options she is normally able to obtain what she needs. Excellent and entirely reasonable.

My concern is what impact of the guidelines will have on the wider culture of birth.

Firstly what will they mean within the network of health care professionals? What many (including me) see as the over-medicalisation of normal birth is already embedded within the maternity services, though there are plenty of initiatives, individuals and movements trying to change this. While caesareans may be a safe and appropriate choice for some, many women are keen to avoid medical intervention and the additional risks it can carry. This can be tricky within some hospital settings (especially with the rise of induction of labour) and consequently emergency caesarean section rates (largely made up of women who didn’t want and didn’t set out to have a surgical birth) are on the rise.

Despite this there is still an acknowledgement amongst the obstetricians I have worked with that a vaginal birth is something they want to help women achieve. While the couple may not always be happy with the medicalised approach to this there still appears to be a desire to help women have a vaginal birth. Could these guidelines begin to erode this approach amongst some health care professionals? Will the perception be that there now two equally safe, appropriate and well-tested ways to give birth and vaginal birth isn’t worth fighting for? What does this do to an already loaded deck of cards for women entering a hospital environment and hoping to give birth without surgical assistance?

I can’t help but feel that this will impact on the perception of birth amongst women – especially those who’ve not yet given birth. I’ve written before about a culture of fear around childbirth. While these guidelines may really be about ensuring a small minority of women have a choice they make respected, the reporting around them, lack of education about birth and lack of real change in the medical model of care can only have an increasing detrimental effect on our society’s perception of birth. More frightened and uninformed women is not a good thing and if we offer them elective caesareans instead of tackling the root of our society’s birth-phobia, I worry we could get to a frightening place.

So my deepest concern is what happens if vaginal birth really does begin to die out as some reports will gleefully have us believe? I’ve read and listened to too much of Michel Odent’s work to be unaware of the impact the physiology of birth has on the forming of attachments, development of love and much more. Birth is more to a woman and baby than the hours it actually takes – it impacts on them both physically and mentally. Of course individual couples who have a baby by caesarean can and do develop wonderful, deep and lasting bonds as a family. But what happens to society as a whole if we loose the hormonal process of birth in the majority of cases? It’s something untested over a long-enough period of time to know the answers. This is a vital factor not yet considered by the majority of those making decisions about birth.

So of course I want women to make informed and empowered choices about their bodies, babies and births. If that choice is a caesarean then we’re lucky to live somewhere where that is a real option. Matching this though there urgently needs to be an equally forceful and well-reported drive to make vaginal, intervention-free birth possible for the majority who want it and a real acknowledgement that the emergency caesarean rate is too high.

Education about birth needs to happen, it needs to happen in a positive way and at a young age so that women opt for caesareans because of their own knowledge and power and not because of  lack of information about their own bodies and the fear that creates.

Comments
2 Responses to “NICE or not?”
  1. CoffeeMummy says:

    Well written, even-handed and thought-provoking post. Good stuff.

  2. Shiom says:

    Such a vloltiae subject and yet so very important! And no matter how many women you talk to you’ll probably get that many different answers!Knowledge is power make the right decision for yourself and your personal situation!

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