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Doctors still failing to support women in individual childbirth preferences

Women still have to “struggle” to establish autonomous decision-making during childbirth despite this aspect being central to new guidelines by the Royal College of Obstetricians and Gynaecologists, childbirth charity Birthrights said.

While the charity welcomed the guideline, published today (1 October), its co-chair, Rebecca Schiller, said: “Sadly women let us know that they often have to fight to secure support for their decisions after a previous caesarean – whether that is to request an elective caesarean, plan a vaginal birth after more than one caesarean or use water for pain relief during a VBAC [vaginal birth after a previous caesarean section].

“Despite evidence and guidance, women still struggle to have their autonomy respected during pregnancy and birth.

“It is clear from this guidance that women’s individual circumstances and preferences should be central to decision-making and that they should have access to the evidence so that they can make these decisions with the support of their clinicians.

“Services need to be designed to ensure women’s decisions can be supported and compassionate, respectful care provided at all times.”

Schiller said the guidance – which states vaginal birth after a previous caesarean is just as likely to be successful – “makes it clear” that women have a range of choices available when giving birth after a caesarean, but this is not always respected.

The guidance confirmed that, even after two or more caesareans, the success rate remains as high as after just one – and the same as for first time mothers.

It provides evidence-based information to ensure doctors advise women of their choices and manage their care, including details on how to adopt a personalised approach to labour.

Janesh Gupta, a professor of obstetrics and gynaecology and lead author of the revised guideline, said: “Women can be assured that in most cases it is possible and safe to have a vaginal birth after a previous caesarean section.

“The guideline can be used to aid doctors in their assessment of individual women and, unless there are clinical reasons why a vaginal birth should not be attempted, help inform the woman and her partner of her choices and the risks involved with either vaginal birth or a repeat caesarean section.”

Vice president of the royal college, Professor Alan Cameron, stressed the importance of women being aware of their ability to choose between a vaginal or caesarean section. He emphasised that individual preferences should be taken into account by doctors.

“This updated guideline includes a new recommendation on the use of a checklist or clinical care pathway to make sure best practice is maintained, that women are counselled regarding their options and the risks with either a repeat caesarean or vaginal birth are fully explained to them,” he said.

Nationwide failures

In July, NHE spoke to Elizabeth Prochaska, head of Birthrights, about whether women had a choice over their own labour and the impacts of the controversial ‘term breech trial’ on ‘de-skilled’ maternity staff in the NHS.

She said staff often refer to caesareans immediately when there is a breech-presenting baby, but insisted that this removed the right of a woman to choose.

“Women come to us at Birthrights with breech babies and say they’ve been told they have no choice – doctors are refusing to allow the woman to give birth normally because they believe it’s either too risky or that they don’t have the skills to support her in a normal breech birth.

“They don’t know how to support a woman, they don’t know the manoeuvres required if the baby gets stuck. I’ve even seen letters from hospitals saying they do not have the skills to support vaginal breech.”

And Sarah McMullen, head of research at parenting charity NCT, emphasised the need for personalised and continuous care in NHS staff.

She said: “Individualised care is so, so important – and that’s what women tell us, that they want the information, they want to be listened to and recognised that their preferences need to be taken into account as well, and their choices respected.”

NHE’s investigation also revealed that nationwide caesarean rates are higher than ever and well above the World Health Organisation’s recommended rate, meaning nearly every trust in England has developed a C-section problem.

(Top image c. David Jones)


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