PLANS BY THE British NHS watchdog to allow women to choose to have a Caesarean section, even where it is not medically necessary, have been described as “reasonable” by representatives of both obstetricians and mothers here.
The National Institute for Clinical Excellence (NICE) in Britain is due to publish new guidelines on C-sections for British obstetricians next month.
In the final draft of the guidelines, which have been circulated for a “pre-publication check” for factual errors, the institute says in general, “CS is a safe operation, especially when performed as a planned procedure”.
Currently in Ireland and Britain, women do not have an automatic right to ask for a C-section. There are no Irish guidelines on when C-sections should and should not be performed here.
Prof Fionnuala McAuliffe of the Institute of Obstetricians and Gynaecologists says that Irish hospitals follow the British guidelines, which state: “Maternal request is not on its own an indication for Caesarean section” and “An individual clinician has the right to decline a request for Caesarean section in the absence of an identifiable reason.” They recommend that women should be offered counselling if they are afraid of childbirth.
However, the new guidelines will state: “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.”
McAuliffe says the draft guidelines sound “a very reasonable approach and representative of how we would do things here anyway”. She stressed the vast majority of women would choose a vaginal birth where possible, and the numbers asking for a C-section represented about four per cent of expectant mothers per year. The most common reason given is fear or a bad experience of childbirth.
Niamh Healy, ante-natal educator with Cuidiú and co-author of Bump2Babe, a consumer guide to maternity services in Ireland, agrees the new NICE guidelines seem "reasonable".
“If a mother has had a traumatic and horrendous experience of childbirth, where there was intervention and concern for the baby’s welfare, and says ‘There is no way I am going through that again’, you can’t argue with that. If she is terrified of going through a vaginal birth, you can’t argue with that,” she says.
“But what I would say is that Caesarean rates here are too high. In some hospitals, the rates are as high as 40 per cent, and if there was more time spent with the mother during her pregnancy, more midwife-led births, where the mother gets to know her midwife in the months before the birth, there would be less fear and women would be more confident about themselves going into giving birth.”
C-sections here are continuing to rise, with figures in the Perinatal Statistics Report 2008, published last December, indicating the rate to be at 26 per cent. Rates are lower in Britain at about 24 per cent, but concern about rising numbers there last month led a primary care trust in North Yorkshire and York to state that C-sections would not be available to mothers unless medically necessary. It is a position they will likely have to row back on from next month.
NICE says an increasing proportion of planned C-sections are being performed at the request of the mother. These requests should not be ignored, and, in terms of the mother’s mental-wellbeing, they may be deemed “medically necessary.
“There are many reasons for such requests, but these are not always revealed by the women or adequately explored and clearly documented by their carers.”
It says between six and eight per cent of mothers expressed a preference for a C-section. The most common reasons given for wanting the procedure were “previous negative birth experience, a complication in the current pregnancy or a fear of giving birth”.
McAuliffe says that when a woman asks for a C-section in Ireland, the implications of the procedure are discussed, including increased pain, longer recovery period and some evidence of greater difficulty establishing breastfeeding.
“The doctor or midwife will tease out the issues for the mother, and often the underlying reason for wanting a section is anxiety and sometimes depression, which needs to be addressed. There may have been complications in a previous birth, or a fear of blood,” she says.
“They may need to have counselling and, in most instances, women will decide to go for a vaginal birth. But in cases where they are just so distressed at the thought of giving birth that it is impacting on their mental health, then one could say it is medically necessary for her to have a C-section.”
Neither McAuliffe nor Healy believes the new guidelines will result in any increase in C-sections being performed here.
“Women have a variety of reasons to request a C-section birth,” says Healy. “Social trends may have more of an impact than the publishing of clinical guidelines.”
In McAuliffe’s view, the vast majority of women will continue to prefer a vaginal birth. “It is only where a woman has a deep-rooted fear of a vaginal birth that they would be determined to request a C-section, I believe.”
