In case you’re not following the recent round of articles about the National Health Service’s new guidelines about cesareans, here’s a quick round-up.
A tried and true tactic used in the British media (especially in The Daily Fail Daily Mail) is to attempt to provoke shock and awe about women who actually—gasp!—want a cesarean. It is apparent that the discussion has less to do about method of delivery than it does about trying to lure readers into debating one of the pervasive anti-feminist narratives of the modern Western woman, i.e., she is selfish/lazy/unwilling to mother properly/unwilling to EVEN USE HER VAGINA TO GIVE BIRTH! And can you believe she might even go back to work in six weeks? WHO WILL FIX MY SUPPER? For the U.S. equivalent, turn on Fox News.
The balanced coverage:
Women can choose Caesarean birth [BBC, November 22, 2011]
NHS caesarean guidelines aim to push down demand for procedure: Guidance from Nice says while no woman should be refused a caesarean, proper information will drive surgery rate down [The Guardian, November 22, 2011]
A few of the many that apparently didn’t pay attention to the press release:
Caesareans will be offered to women in fear of labour amid concerns some are so afraid they seek abortion [Daily Mail, November 23, 2011]
Women to gain right to have planned Caesareans on NHS: Changes could lead to large and costly rise in numbers of women demanding the procedure [The Independent, November 27, 2011]
Caesareans to be offered to all amid fears over midwife shortages: Caesareans are to be offered to all pregnant women who ask for them, new guidelines state, amid concerns that some are too scared to give birth naturally on Britain’s overstretched labour wards. [The Telegraph, November 27, 2011]
The interview with National Institute for Health and Clinical Excellence (Nice) appeared in The Guardian article listed above clarified the NHS’s actual guidelines and rationale. They state that the goal is to ensure that no woman who wants a cesarean should be turned down, yet should receive proper counseling as to the risks of the surgery.
No woman who wants a caesarean should be refused one, but if women have the risks of surgery explained to them, the numbers should fall, according to fresh NHS guidance on childbirth.
The National Institute for Health and Clinical Excellence (Nice) has tried to deny speculation in the media that the new guidelines meant women would be entitled to a caesarean on demand, but the implication remains that nobody should be turned down.
Nice said most women would choose a vaginal delivery if they received proper information, and its guidelines committee said they did not recognise the concept of women choosing a caesarean because they were “too posh to push”.
Most women who asked for a caesarean had either physical or mental health issues that made them unable or unwilling to try ordinary delivery, they said.
The phrase “too posh to push” was “something the media created”, said committee member Nina Khazaezadeh, a consultant midwife at St Thomas’ hospital.
Once women had a full discussion of the risks and benefits with health professionals, “they want to opt for the safest option. A lot of the anxiety is related to lack of information and lack of knowledge,” she said.
The concept that informed choice will actually have an effect of lowering the rate of procedure utilization isn’t unique to Nice and can be found elsewhere, such as on the Dartmouth Atlas of Health Care site.
A recent study reported that almost three-quarters of Americans say they have declined interventions that were recommended by their physicians, because they thought that it was unnecessary or the benefits did not outweigh the risks or side effects. Other studies have confirmed that informed patients want much less surgery, on average, than surgeons are inclined to perform. Making patients aware of the risks and trade-offs associated with treatment choices is one good way of reducing demand for such things as hospital admissions, redundant or unnecessary testing, and surgery when there are other options. Because physicians are reimbursed for activities, the system encourages them to do more. Paying physicians to spend more time advising patients about treatment alternatives (for example, lifestyle changes and medications, rather than bypass surgery), without penalizing them economically for doing less, is another important strategy for reducing utilization. [Emphases mine]
It will be interesting to watch rates in the UK over the next few years and hopefully the NHS has a means to track data on whether cesareans are requested so that causation can be verified (or not). How these guidelines actually play out in the provider-patient relationship is always a different story, but my hope is that the new guidelines represent a step toward making preference-sensitive care and adequate risks-benefits counseling the norm for pregnant patients.