Supporting Women

AIMS Journal, 2010, Vol 22 No 2

Debbie Chippington Derrick explains more about supporting women requesting a caesarean

Gina Lowdon and I have been supporting women on caesarean and VBAC issues for over 20 years. In the early years most enquiries were by phone and came through NCT, AIMS or the Caesarean Support Network. The majority of enquiries at that time were from women who were struggling to come to terms with their caesarean, wanting to know how to avoid having another one, or trying to plan a good caesarean when they had a medical reason for their baby to be delivered this way.

In the early days we had the occasional enquiry from a woman who felt that she should have a caesarean and was trying to find support for this; however, usually these women had a medical reason that was just not being taken seriously, such as a problem with their back or an illness that caused them excessive fatigue.

As time went on we began to receive more enquiries from women who were wanting a caesarean in order to avoid a vaginal birth, and in 2002 when we set up the website www.caesarean.org.uk the number of these enquiries was increasing. We found we were receiving enquiries via the site from both extremes of the birth spectrum; women with a list of supposed indications fighting for support to avoid surgery and women without any clearly accepted medical indications for a caesarean wanting one in order to avoid labour.

Why do they want a caesarean?

Some women have a simple clear reason for preferring caesarean birth, such as a bad previous birth experience or having been sexually assaulted or raped. Others with a strong fear of the birth process are able to pinpoint events that have led to their fear, such as being admitted to a maternity ward for a gynaecological reason, having a friend lose a baby, being with a sister or friend for their birth and watching them suffer. However, others have deep emotional fear of birth that they can't explain.

Women wanting a caesarean talk about things like the unacceptability and unpredictability of a vaginal birth, a fear of birth, terrible frightening emotions, being terrified, it 'scaring the hell out of them', having a deep-rooted fear, a phobic terror, or being filled with dread. Many tell us these feelings have been with them a long time, or that they have felt like this for as long as they can remember.

Some women have particular concerns such as worrying that they may be too petite to birth a baby, or that they will have a large baby and are often able to quote others in their families who have had problems because of these factors. These are also typical reasons given by the medical profession to explain why labours stall, or forceps or caesareans are needed, and these women have taken on board such explanations despite lack of given evidence supporting these theories. Other women may have had someone close to them lose a baby and consequently view birth as dangerous.

I think it is critically important to understand the way these women view birth. Women who have grown up with a terror of birth will see a caesarean as a solution to their problem. Some women will have been brought up to see a caesarean as their right, such as women brought up Brazil, South Africa, Singapore, and other areas where caesareans are seen as the privileged way to have a baby, and may have never considered that they would do anything else but have a caesarean. Sometimes practical issues can be solved by a caesarean too, such as a partner who is in the armed forces who may only be able to be present at a birth that is scheduled to take place on a specific date. Some women will come from families where they and their siblings were all born by caesarean and they will have grown up with the assumption that their own children would need to be born this way too, for them caesarean birth is accepted normality.

In some cases women take great care to avoid getting pregnant unless they can be reassured that they will be able to have a caesarean; and we are aware of a few women who have terminated a pregnancy because of a fear of birth and because agreement for a caesarean seemed unlikely.

What do we offer them?

For women enquiring about requesting a caesarean our usual starting point is an explanation of their rights, in that they can't demand a caesarean, but can insist on a second opinion allowing them to make their request to someone else if they don't find their initial consultant supportive. If they are not yet pregnant we encourage them to start discussions before they are pregnant, explaining that they may need to be insistent in order to get an appointment. We believe addressing these issues is necessary to put them back in control before we can explore any other aspects with them.

We provide a listening ear (usually on email), giving them a chance to explore their fears and helping them to be able to consider other options, whilst avoiding being judgmental or pushy. We also try to explain some of the childbirth and maternity services issues that may have led to their perception of birth. This will often include discussing home birth and independent midwifery as issues such as privacy, dignity and control are better addressed by these care options; and these factors are often crucial for these women.

We encourage them to contact a senior midwife as well as to speak to their consultant and we provide them with a range of other sources of information as well as contacts for discussion groups.

We make it clear that this is their decision and that they can be in control of getting what they need for their birth. Finally we make it clear that they can come back to us at any time for further support.

How are they treated by the NHS?

In a few places staff are providing really good support to these women, listening to their needs, helping them access better continuity of midwifery care and psychological support, and making sure throughout their pregnancy and birth that they are supported. Usually women will get the agreement that they want from their consultant, and the suggestion of seeking a second opinion has usually been sufficient when they have met resistance.

The majority of women will find some staff who are under standing, but because care is so fragmented it is usual for them to have to repeatedly explain their situation and their needs. Even when an agreement about a caesarean has been made and documented in their notes, those caring for them will want to start the discussions from scratch with the result that women can become defensive because it can seem the agreement that has been reached may be over turned. Women also often talk about people being nasty to them and say that they feel that this is because they feel accused of making a 'wrong' choice.

It is also not uncommon for crucial information not to be included in women's notes. For example, when women have been referred to a psychologist, information provided by the psychologist supporting the basis of psychological need as a clinical indication for caesarean may be missing from the woman's notes, and even if it is there those caring for her will not have had time to read it.

What do they eventually do?

Most of these women will get a caesarean, but many still do not feel well supported, and they come through birth (as the majority of women do) with a feeling that they have suffered what they have to suffer in order to have a baby, they have survived it and must now move on to parenting their child.

In a few cases women have been so poorly supported that they have terminated a pregnancy, paid for a private caesarean or gone to another country to get one. Others have been forced to labour against their will, only to get an unplanned caesarean due to failure to progress.

At times though, women will be well supported and come through their experience with a new air of confidence; they will have had control returned to them and they come through the birth with that air of being able to cope with anything life throws at them. They, like the mother who has had a really good home birth, feel like screaming their achievement from the top of a mountain.

Occasionally women will be able to find a way to address their fears of vaginal birth. They may get good psychological therapy, and/or excellent midwifery support which enables them to give a vaginal birth a go. Often these women will also have in place an agreement that they can opt out and have a planned caesarean should they feel that they can cope no longer.

However, the woman who stands out in my mind had negotiated her caesarean and had every intention of going through with it, but went into labour before the booked date. She arrived at the hospital and was reassured that they would get her to theatre soon, by people whom she had met before and trusted to respect and support her. She was relaxed and surprised at how well she was coping with labour, and I am sure that the staff who had dealt with her previously must have been surprised too. She then asked to be allowed to labour a little longer, and before long got an urge to push. There was concern about getting her to theatre rapidly, but she then asked to carry on and quickly gave birth to her daughter herself. She was so proud of what she had done, but remained adamant that if the caesarean had not been agreed there is no way she could have had the wonderful birth that she did.

How could these women be supported better?

If all women were getting one-to-one midwifery care then I feel a lot of the problems would immediately be addressed. However, until that is a reality these women need to be supported within our fragmented services.

These women need to be able to get support from a consultant in order to be reassured that a caesarean can be provided, but they really should be referred to psychological services to see if their issues can be sufficiently addressed to make a vaginal birth an acceptable option for them or to provide a medical diagnosis for the need for a caesarean on psychological grounds. They should also have good midwifery care, preferably from as few midwives as is possible, so that they can be confident that they will be well supported however they birth their baby.