‘I was denied a caesarean’
Mother ignored despite her ‘horrific’ first birth
When Lucie Tidman drew up her birth plan, she knew exactly how she wanted to deliver her second child. By an elective caesarean section. But Tidman, a 34-year-old specialist bladder and bowel nurse from Falmouth, Cornwall, was far from being “too posh to push”. After a traumatic first experience of childbirth in February 2012, which saw her haemorrhage 4.5 litres of blood and left her with acute anxiety and post-traumatic stress disorder (PTSD), Tidman was recommended by her midwife to discuss caesareans with her obstetrician on medical grounds.
Moreover, she knew her rights. Guidelines from the National Institute for Health and Care Excellence (Nice) state that women who ask for a caesarean should be offered one if, after support and discussion with a doctor, they feel it is best for them.
So Tidman was stunned to be turned down by a locum doctor in an appointment that lasted barely 10 minutes. “I was told I was low-risk,” she says. “I could go in a birthing pool, have an ‘active’ labour, but to have a C-section would be highly unnecessary.” She left feeling “silly that I asked and that I had wasted his time; silly that I was dramatising my PTSD and wasting valuable NHS time”.
And, like many women, she felt accused of having an agenda, “as if a C-section would be more convenient to fit in with my lifestyle and not for my individual reasons.”
Frustratingly, her experience is far from unusual. Research from the childbirth charity Birthrights has revealed that only 26 per cent of trusts are abiding by Nice guidelines, with 47 per cent of trusts having inconsistent or confusing policies on offering caesareans on request.
Worse still, despite 28 per cent of women requesting a caesarean because they had an underlying health problem, such as pelvic pain, that did not meet the medical threshold for requiring a caesarean, trusts were telling women to go elsewhere if they didn’t want a vaginal birth.
Rebecca Schiller, chief executive of Birthrights and author of Your No Guilt Pregnancy Plan, says the charity conducted the research because the issue was the most common reason women contacted its advice service. “We’ve been shocked and saddened,” says Schiller, “by the barriers women face, the disrespectful treatment of those requesting caesareans and, in some cases, complete withdrawal of care in late pregnancy leaving women abandoned.” The reasons behind trusts denying women caesareans are varied, ranging from cost to targets on lowering caesarean rates, to a lack of guidance at some trusts that leaves it up to the approach of individual midwives and doctors. There is undoubtedly a cost factor. Nice says caesareans are £700 more expensive on average in the short term, though Schiller points out that this drops to £84 if long-term costs including caring for women after damage from vaginal birth are included.
In general, women having uncomplicated pregnancies have fewer physical health risks associated with vaginal birth, but, says Schiller, the data are mixed and some low-quality. “Many studies consider emergency caesarean and planned caesarean together when we know planned caesarean has far better outcomes than emergency.”
Some critics claim that mothers find it more difficult to bond with a baby after a caesarean. But Schiller disagrees. “Many women bond easily after caesarean, just as some women find it hard to bond after a vaginal birth. There’s some evidence that caesarean can impact on bonding
‘We shouldn’t have to shout to get attention – but I feel I should have bugged more’
and also evidence that traumatic births can make it harder for women to bond with their babies. But women take this into account and work out what’s best for them.”
Schiller adds: “Paternalism is still rife in maternity care and the attitude that women aren’t equipped to make these decisions plays a part in this.”
And yet what this rationale ignores is that most women are not spuriously asking for C-sections. Like Tidman, they may have previously experienced a traumatic birth.
Or they may suffer tokophobia, a pathological fear of childbirth, which affects one in every five women, said the National Childbirth Trust.
Moreover, women are aware of an increasing lack of continuity of care and the effects of underfunding in hospitals. Knowing that you might rarely see the same midwife twice is not confidence-inspiring.
No wonder, then, that women are becoming more interested in caesareans, not less. According to Liz Halliday, deputy head of midwifery at Private Midwives, there has been a 162 per cent rise in women asking the company about them this year.
“Women want continuity of care in all aspects,” says Halliday. “They want their own midwife and obstetrician. They want to meet the anaesthetist in advance.”
Despite prices for a private caesarean package starting at £9,950, demand is high enough for the service to have just expanded from London to the North West. “Our philosophy is based around a woman being the centre of care,” says Halliday, “making decisions to suit her and her family.”
Which is exactly what Tidman wanted. Instead, when she went into labour in January this year, she had a close repeat of her first labour, with another terrifying haemorrhage, watching as her baby was born struggling for air. “She had to have rescue breaths and my other half saw her come out purple,” says Tidman. “She got taken one way and I got taken to theatre. It was horrific.”
There will be no third child. “We are incredibly lucky to have two healthy, happy beautiful girls,” she says, “but I cannot go through that again, mentally or physically.”
Of course, as Tidman would be the first to say, every woman’s experience is different. Lara Hooker, 33, from Dartford, Kent, is due to give birth in November and has been persuaded not to have the caesarean she initially wanted.
“I had read that one in four births end up in caesarean,” Hooker says, “and felt that I had a good case as my anxiety could lead to a potentially dangerous situation.” She even asked for a general anaesthetic, so she would be asleep throughout. But she was turned down. “The midwife suggested that I see a specialist mental health midwife instead.”
At two appointments, Hooker was able to talk about her anxiety and fear. “Much of it came from not knowing about labour,” she says now, “and also not understanding the choices available to me. In the sessions, the midwives explained all about my painrelief options and I could then develop a much more informed birth plan.”
She won’t rule out an emergency caesarean if the baby is in distress and would still have a planned caesarean if the baby was breech. But, for now, she feels in control of her choices. Which is what Birthrights wants for all women, although Schiller believes institutional change is needed first.
“All NHS trust and clinical commissioning groups that we have rated red or amber need to review their policies and process to ensure they are truly in line with Nice guidance,” she says. “Women, midwives and doctors should be involved in redesigning the process.”
In the meantime, what can mothersto-be do to get the birth they want?
“Be aware of the Nice guidance and take a copy with you to an appointment,” says Schiller. “Try to book with a case-loading midwifery team so you can get to know a named midwife.
“Use the tools in Your No Guilt
Pregnancy Plan to remember all the questions you need to ask to get a balance picture of risk and benefit for you. And if you are having trouble getting your request granted, contact the Birthrights advice service.”
Last month, Tidman and her family had a debrief with the Royal Cornwall Hospitals Trust (RCHT), where she gave birth. The trust has since said it practised evidence-based care with respect to caesarean sections.
Tidman says: “The debrief acknowledged that the consultant in question was an excellent clinician and colleague, and in acute situations he was outstanding, but they were aware that he is ‘too fast-paced’ at appointments. It’s ironic, every multi-disciplinarian I met on my journey at RCHT was amazing, including the community midwives, and especially the maternity ward sister on the day of my daughter’s birth and the registrar on call.
“The ward sister never left my side, the consultant was understanding and compassionate. I was happy with the rest of my care at RCHT and the midwifery was amazing. It’s just incredibly unfortunate that there was a missing piece of the jigsaw halfway through my journey.”
But she has these words for other women: “We shouldn’t have to jump through hoops and be known as the patient that shouts to get attention – but I feel like I should have been that patient. I should have asked to see my assigned consultant, I should have bugged more. Women who are suffering from going through a previous traumatic birth or who are worried should speak to their maternity team or GP. We need to talk more.” And, of course, to be heard.