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Absolutely Jane – but the problem also is that the knee jerk reaction to this kind of coverage (not to the report itself, which is actually much more balanced than the coverage suggests, of course) is that the only solution is more monitoring, more hospitalisation, more technical solutions, and more fearful risk averse practices for all – which, as we know, is paradoxically more risky for women and babies, and which diverts funds that need to be spent elsewhere (on midwife-led care, for example) While certain campaigners are arguing that midwives and the whole midwifery project is at fault for not recognising intrapartum problems, and while the press is propounding this view with no good evidence beyond some very specific circumstances, and while there is an expanding belief that more measurement, scans, induction of labour and CS will solve the problem, what actually works to improve care for women and babies, and especially those who are more marginalised, cannot progress. The issue is how to get this political message to those who really can make a difference, and how to engage wider agencies in working on the problem. Indeed, I know that some of those in SANDS are very keen to advocate for this more joined-up long term multi-agency approach. It just doesn’t seem to getting over at the moment, though… All the best Soo From: Sandall, Jane [mailto:[log in to unmask]] Sent: 11 June 2015 08:36 To: [log in to unmask]; Soo Downe; [log in to unmask] AC. UK Subject: Re: UK press coverage MBBRACE report So, there is such strong evidence that inequality is directly related to morbidity and mortality overall. One of the major factors why Scandinavian countries have lower mortality is because they have less social inequality. The WHO commission on social determinants of health http://www.who.int/social_dete…/thecommission/finalreport/…/<http://www.who.int/social_determinants/thecommission/finalreport/en/> highlighted this, as did this brilliant work by Richard Wilkinson and Kate Pickett, the spirit level http://www.equalitytrust.org.uk/…/spirit-level-why-equality…<http://www.equalitytrust.org.uk/resources/spirit-level-why-equality-better-everyone>. These reports should be required reading for all those working in maternity and child health. So, we need an analysis that looks at morbidity and mortality after dperivation is taken into account, because we also know that the inverse care law shows that more deproved communities get poorer quality health care. Responses and solutions to this problem must acknolwdge that there are much wider influences. Of course we need to address avoidable harm and bullying non respectful services that do harm both to staff who work in them and to women, but lets think about what health services can do when we take this into account. We can think about why services are hard to access raher than why women are hard to reach, whether midwives ensure women know about all their rights and maternity entitlements, and where her social support is coming from. Isnt this what a social model of midwifery is all about??? Jane Jane Sandall Professor of Social Science and Women's Health NIHR Senior Investigator Division of Women’s Health | Faculty of Life Sciences & Medicine | King’s College London |Women’s Health Academic Centre | St. Thomas' Hospital London| SE1 7EH http://www.kcl.ac.uk/lsm/research/divisions/wh/index.aspx [log in to unmask] | 020 7188 8149 | Skype | jsandall PA Fiona George | [log in to unmask] | 020 7188 3639 https://kclpure.kcl.ac.uk/portal/jane.sandall Maternity and Women’s Health and Capacity Building theme lead NIHR CLAHRC South London | www.clahrc-southlondon.nihr.ac.uk<http://www.clahrc-southlondon.nihr.ac.uk/> King's Improvement Science | www.kingsimprovementscience.org<http://www.kingsimprovementscience.org/> ________________________________ From: A forum for discussion on midwifery and reproductive health research. <[log in to unmask]> on behalf of Soo Downe <[log in to unmask]> Sent: 11 June 2015 08:16 To: [log in to unmask] Subject: Re: UK press coverage MBBRACE report …but of course it is much easier for the press/government to focus on the quick fix of labour and birth, rather than to tackle the much wider issues of poverty and marginalisation… It would be extremely interesting to map the rates of stillbirth/neonatal death (above and below the country means) against the kind of units/rates of interventions and etc to see if this persistent impression that normalising birth as far as possible is associated with stillbirth/death in fact holds up. I notice that on the graphics (where colour coding is used to show the proportion of deaths above and below the mean and the size of the dots denotes the size of the unit) larger units do not necessarily have better outcomes, for instance, despite the increasing call to centralise in the name of better outcomes… All the best Soo From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Soo Downe Sent: 11 June 2015 08:12 To: [log in to unmask] Subject: Re: UK press coverage MBBRACE report Well, of course, it misses the key point in the report which is that poverty, marginalisation and ethnicity are the key factors associated with stillbirth and neonatal mortality. Again. The report is very easy to read, and it makes this perfectly clear throughout…. All the best Soo From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of SHEENA BYROM Sent: 11 June 2015 07:34 To: [log in to unmask]<mailto:[log in to unmask]> Subject: UK press coverage MBBRACE report Morning all, Good morning, Not sure if you've seen the release of this report yesterday, https://www.npeu.ox.ac.uk/mbrrace-uk/reports Interested in thoughts on this press article http://www.thetimes.co.uk/tto/health/news/article4465692.ece?shareToken=f6bbec4a8e99cd2b7830aa7c1d567b20 Very best wishes Sheena www.sheenabyrom.com<http://www.sheenabyrom.com> On 11 Jun 2015, at 00:38, Celia Grigg <[log in to unmask]<mailto:[log in to unmask]>> wrote: Hi all, I too have been following this discussion with interest. I agree that it’s important to ask the questions you’ve raised Jenny. As one of the many 1980s’ childbirth activists who lobbied for childbearing women to be active and informed decision-makers and have ‘choices’, I have been dismayed at the way obstetrics has co-opted and corrupted the notion of choice in childbirth in the intervening years. (Of course this is classic behaviour of the powerful.) I wonder that by focusing the discussion on women and midwives and their respective roles and issues the proverbial elephant in the operating theatre is being missed! I believe that obstetrics bears responsibility for the current ‘problem’ of elective caesarean without clinical indication. It is obstetrics which defines and controls women’s ‘choices’, not women or midwives. Obstetrics has had no trouble adopting or promoting policies which decline/deny a long list of choices women request; for example, resuturing of FGM or planned tubal ligation at c/s, VBAC, vaginal breech birth, or even water birth, primary unit, local community or home birth in some contexts. It is obstetricians who consent to women’s ‘request’ for it, and they conduct this surgery. Indeed many condone it and some support it as acceptable, appropriate or even optimal. I think that those who argue that it is about women’s choices misrepresent the power held by obstetrics over women’s ‘choices’. Midwifery sometimes gets caught by the ‘choice’ terminology and doesn’t necessarily recognise or challenge the way it has been co-opted and corrupted. Of course women also get caught too. I think we should focus on the powerful and not the pawns in this. While issues of the context of women’s lives and fear of birth and the like are genuine issues, in a way they blame women, when obstetrics has constructed this whole issue, because it is a ‘choice’ which suits it. Midwives are often powerless in the middle, unsupported by the system and obstetrics and unable to introduce changes to guidelines or the organisation of the maternity system, which might change the power dynamic. Midwives in many contexts, including those here in NZ, are often frustrated by the lack of support from obstetric colleagues when referring women for consultation regarding this issue. They do their best to provide evidence based information, which includes details of the established risks of elective c/s (without clinical indication), only to find them minimized or even rejected by the obstetrician, who plays the ‘women’s choice’ trump card and it becomes a fait accompli. If obstetricians used the existing evidence to inform women, or better still, their institution’s policy and practice, then the whole game would change. While there are crocodile tears from obstetrics then its role and power is obscured. Best wishes with addressing the issue. Celia. Celia Grigg Midwife and PhD candidate Evaluating Maternity Units (EMU) Project Faculty of Nursing and Midwifery University of Sydney c/o PO Box 33 268 Christchurch 8244 New Zealand P: (03) 339 8796 m: 021 268 2128 e: [log in to unmask]<mailto:[log in to unmask]> e: [log in to unmask]<mailto:[log in to unmask]>. From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Jennifer Gamble Sent: Thursday, 11 June 2015 12:22 a.m. To: [log in to unmask]<mailto:[log in to unmask]> Subject: Re: electivecesarean.com<http://electivecesarean.com> commented on "Hard evidence: who carries out the most caesarean sections?" Hi Alison It has been an interesting discussion - thanks for getting it going. I would be happy to write - or cowrite - and article for The Conversation. I think there are a number of angles - here area my early thoughts 1) Who gets to choose and what choices are available/ accessible (i.e. how come choice of CS without clinical need is OK/ not OK and yet women have trouble 'choosing' normal birth without pharmacological pain relief or cannot choose / not accessible - COC by midwife/ homebirth/ VBAC etc - the privileging of some choices over others. Most women want to birth their babies naturally - what help/choice do they get?? 2) Choice is one thing - but who pays for CS that is not clinically indicated? 3) The difference between choosing not to have an intervention and choosing to have one that is not clinically indicated - how do you "make" a practitioner perform a CS in the absence of clinical indication? Where does this stop? What if someone wanted a CS at 37 weeks gestation? What about 34 weeks?? earlier??? - is this "choice"?? 4) CS and undisturbed normal birth are not in the same league - you can have a "good" CS - control etc etc - but it is nowhere near the same as well supported, undisturbed normal birth - that is spiritual/ other worldly - hard to articulate - almost taboo to talk about. One of our student midwives wrote "Birth is a normal yet profound life event for women, their families and the collective community and a time in life in which the dichotomy of vulnerability and strength are represented simultaneously". another student wrote "Midwifery is such a spiritual idea to me, that trying to articulate it seems almost taboo and as if I were breaking a spell. A spell that only women and I are privy to." Regards Jenny Professor Jenny Gamble Professor of Midwifery, Discipline Head for Midwifery@Griffith Maternity and Family Unit | Centre for Health Practice Innovation | Menzies Health Institute School of Nursing and Midwifery | Griffith University Ph: +61 7 338 21083 | M: 0404080518 Email: [log in to unmask]<mailto:[log in to unmask]> Midwifery@Griffith: Leading the way•Transforming lives [Image removed by sender. Image removed by sender.] Address: Office 3.29 - Academic 1 (LO5), University Drive, Meadowbrook. QLD. Australia. 4131 Griffith University Midwifery Facebook - Midwifery@Griffith<https://www.facebook.com/MidwiferyGriffithUniversity> On 10 June 2015 at 17:59, Macfarlane, Alison <[log in to unmask]<mailto:[log in to unmask]>> wrote: My questions prompted by the original reply to my article on 'The Conversation' have led to really interesting discussions on both the midwifery-research and the normalbirth-research lists, but not to a response to 'electivecaesarean' on The Conversation. This is read quite widely and it seems to me that a new article would be a good idea. Although it is international, the team which runs 'The Conversation' is based at City. If there are people ready and willing to write one or more articles, I can approach them. Any offers /proposals? Alison Macfarlane ________________________________ From: Cluett E. <[log in to unmask]<mailto:[log in to unmask]>> Sent: 08 June 2015 08:00 To: [log in to unmask]<mailto:[log in to unmask]> Subject: Re: electivecesarean.com<http://electivecesarean.com> commented on "Hard evidence: who carries out the most caesarean sections?" I agree interesting conversation, I wonder if its also about the changing profile of women having first babies in particular. While completely anecdotal, my client case experience is that its the older women, who are requesting CS even for 1st child to have ‘control’ over the whole event. I feel we should be widening this debate to more midwives, and get women’s views as well, and exploring the possible of following this debate up with some evidence ? Best wishes LIZ I aim to read my emails once each working day and respond to enquiries as soon as possible, but if you require an urgent answer please phone me (07768401234) or contact the Faculty reception 02380597979 who can redirect your enquiry. ************************************************************************* Dr Elizabeth R Cluett PhD MSc RM RGN PGCEA Director of Programs for Family, Child and Psychosocial Health. Lead Midwife for Education. Academic Unit 1-Professional Practice in Health Sciences- Stepping up to excellence Faculty of Health Sciences, Nightingale Building (67) University of Southampton, SO17 1BJ tel; 023 8059 7850 Mobile; 07768401234 Web: www.southampton.ac.uk/healthsciences<http://www.southampton.ac.uk/healthsciences> Assessment & Learning in Practice website: http://www.southampton.ac.uk/alps/ [Image removed by sender. Image removed by sender. Description: Facebook]<http://www.facebook.com/healthsciences> [Image removed by sender. 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The information contained in this e-mail and any reply you make may be disclosed unless it is legally exempt from disclosure. Any material supplied to iSolutions by way of their email servers may be stored in the electronic records management system of the University as appropriate. From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]<mailto:[log in to unmask]>] On Behalf Of Stewart Mary Sent: 08 June 2015 08:34 To: [log in to unmask]<mailto:[log in to unmask]> Subject: Re: electivecesarean.com<http://electivecesarean.com> commented on "Hard evidence: who carries out the most caesarean sections?" This is, as Sheena pointed out, a great discussion! I have been struck by some of the comments about the need to address what seems to be some women’s deep-rooted fear of childbirth. I wonder whether the issue begins even earlier (i.e. pre-pregnancy). I’m conscious of the fact that there is increasing cultural and social pressure on young women to sanitise, control and, in some ways, infantilise their bodies i.e. the seemingly intractable ‘demand’ that women remove most/all of their pubic hair, presenting themselves as pre-pubertal while overtly sexualised in other ways; the continuing taboo around ‘leaky’ bodies and the reality of bodily functions, including menstruation etc. A couple of years ago I was very struck by a conversation with a young friend in her early 20s – the daughter of a good friend. I know that this young woman has been taught to feel comfortable with, and proud of her body without feeling the need to bow to social pressure. However, we had both read an article in the paper about labiaplasty and my young friend was wondering aloud whether this was something she ‘needed’ to have done. She knew, in her rational mind, that labiaplasty is madness and yet she felt there was something quite wrong with her own labia and that maybe she needed to get it fixed. If young women are absorbing such relentless messages about the unsatisfactory nature of their own bodies, then perhaps it isn’t surprising that they cannot face the prospect of subjecting that body to vaginal birth – knowing that their body will be inspected by others and may be found wanting, and that the body they have spent so many years cultivating will be out of their control. Maybe as midwives/doulas/interested parties we need to start thinking about addressing some of these issues way before young women and men start thinking about pregnant and birth. Very best wishes Mary Consultant midwife - antenatal care Guy's and St Thomas' Hospital NHS Trust 10th floor - North Wing St Thomas' Hospital London SE1 7EH Phone (internal): ext 55471 External: 0207 188 7188 ext. 55471 ________________________________ From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Maggie Banks Sent: 07 June 2015 21:18 To: [log in to unmask]<mailto:[log in to unmask]> Subject: Re: electivecesarean.com<http://electivecesarean.com> commented on "Hard evidence: who carries out the most caesarean sections?" It is interesting to see how low the maternal request for Caesarean section is in Sheena’s link http://ow.ly/2btkjf . Like Soo, I don’t believe women have a deep-seated fear of childbirth and it hasn’t been my experience that women want CS – and I am talking about the many I have contact with beyond the homebirthers of my own practice. kind regards Maggie Banks PhD, RM, RGON 15 Te Awa Road, RD 3, Hamilton 3283, New Zealand Phone 64 7 8564612; Email [log in to unmask]<mailto:[log in to unmask]>; Website www.birthspirit.co.nz<http://www.birthspirit.co.nz> Post-dates Pregnancy Workshop (Online)<http://www.birthspirit.co.nz/postdates-pregnancy-workshop-online/> 10 - 17 July 2015 The Spirit of Birth: Nature, Nurture and the Evidence Workshop (Online)<http://www.birthspirit.co.nz/the-spirit-of-birth-nature-nurture-and-the-evidence-workshop-online/> 7 - 14 August 2015 Water Birth Workshop (Online)<http://www.birthspirit.co.nz/water-birth-workshop-online/> 4-11 September 2015 next available Breech Birth Online Workshop<http://www.birthspirit.co.nz/breech-birth-online-workshop/> 2-22 November 2015 From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of SHEENA BYROM Sent: Monday, 8 June 2015 2:17 a.m. To: [log in to unmask]<mailto:[log in to unmask]> Subject: Re: electivecesarean.com<http://electivecesarean.com> commented on "Hard evidence: who carries out the most caesarean sections?" Hi everyone, great debate - thank you! Not sure if you’ve seen this? It’s causing a flurry of panic on Twitter, by some obs in US! http://ow.ly/2btkjf With very best wishes Sheena sheenabyrom.com<http://sheenabyrom.com> Twitter: @SagefemmeSB<https://twitter.com/SagefemmeSB> On 6 Jun 2015, at 15:55, Nicky McGuinness <[log in to unmask]<mailto:[log in to unmask]>> wrote: Hi all, Your comments about the impact of cultural conceptions of time and birth timings really struck a chord with me. I' ve just written a literature review on expected dates of delivery and its impact on women’s experiences. The review was interested in looking at the psychological impact of the EDD on women’s experience, and the wider implications for the usage of the EDD in antenatal care. I was only able to locate a couple of bits on the psychological impact of the EDD and the significance women attach to it. Van de Kooy (1994) reporting on her survey of midwives, describes how women felt upset and disappointed when their EDD was changed. Authors have also discussed how women can find it hard to tolerate waiting past their EDD and may expect IOL in order to end being in a ‘time limbo’, or even ‘elect’ caesarean sections as they become anxious about the possible harm of ‘too much pregnancy time’. I reached the conclusion that normality of gestation length should be assessed in relation to the individual context, to the ‘normal for her’, rather than exclusively to the population average. The importance of individual factors, or ‘biologic variability’, needs to be considered in order to better calculate the EDD. In addition, the argument for moving to an expected due range rather than EDD, may well have positive outcomes for women in how they conceptualise and approach their gestation time. Anyway just thought I'd share.... Best wishes, Nicky McGuinness (Student Midwife, former social researcher, including Birthrights Dignity in Childbirth survey) ________________________________ From: "Hall, Priscilla Joy" <[log in to unmask]<mailto:[log in to unmask]>> To: [log in to unmask]<mailto:[log in to unmask]> Sent: Friday, 5 June 2015, 16:37 Subject: Re: FW: electivecesarean.com<http://electivecesarean.com> commented on "Hard evidence: who carries out the most caesarean sections?" I would like to chime in. It seems that we are having a conversation about whether women should have the right to choose and elective cesarean, when the real issues are further upstream, as some of you have pointed out. I wonder what would happen to requests for elective cesareans if we addressed women's fears about labor, if they felt more confident about their body's capacity for birth, and if they were able to experience greater agency during birth, so that they can shape the birth experience according to their own needs and wishes. I like your comment, Soo, about childbirth practices that make birth so frightening for women. We need to address that issue first, and then see what happens to elective cesarean requests. Then perhaps the elective cesarean problem will go away or nearly go away. I wonder if we need to study women's perceptions of the meaning of time in birth. The timing of birth is uncertain-the due date, the beginning, how long labor lasts but women are accustomed to having their life scheduled in discrete time slots. Physiologic labor doesn't fit in very well, and a scheduled cesarean is over in 45 minutes. There is no uncertainty. Priscilla Hall RN CNM PhD Emory University Nell Hodgson Woodruff School of Nursing 1520 Clifton Road NE Atlanta, Georgia 30322 224 805 8673 ________________________________ From: Soo Downe [[log in to unmask]<mailto:[log in to unmask]>] Sent: Wednesday, June 03, 2015 4:24 AM Subject: Re: FW: electivecesarean.com<http://electivecesarean.com> commented on "Hard evidence: who carries out the most caesarean sections?" Nicky, I think this is a good reflection on the issues. And I think where there is genuine fear of childbirth, there are probably going to be more benefits than risks in a CS for a woman – but maybe not for her baby. I also think (and I suspect you might agree?) that there is misinformation in the text you cite below, as, whatever prevailing medical/midwifery opinion is (and we have been wrong about so many things in the past – twilight sleep, routine use of CTG, putting babies on their bellies to sleep…) the evidence is clear – elective CS for physically and psychological healthy women carries more risk for the baby with no associated benefits, and more risk of serious life-threatening events for the mother. This is even without putting into the mix the growing evidence on the microbiotic and epigenetic benefits of physiological labour and birth for the baby into its adulthood. If we have made childbirth so extremely frightening for women that they are willing to take these risks (and if they understand them fully) then yes, we as midwives do need to support individual women who choose CS in this situation. BUT - it then also becomes our absolute responsibility to resist/reverse childbirth practices/models/values and attitudes that render it so scary for such women. However, in my earlier email, I was really reacting to situations where women don’t really have a deep seated fear of childbirth, they just don’t fancy going through it, and they see it (due to media representation?) as just another option – like a woman in the Trust I was working in some years ago who had a CS as she had pedigree dogs and wanted to show them at a particular show, so she wanted the baby out in time for her to be able to do this. Fascinating discussion! All the best Soo From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Nicky Grace Sent: 03 June 2015 08:44 To: [log in to unmask]<mailto:[log in to unmask]> Subject: Re: FW: electivecesarean.com<http://electivecesarean.com> commented on "Hard evidence: who carries out the most caesarean sections?" Please excuse me writing on my phone. This subject is close to my heart. I'm currently looking after a nulliparous woman who is planning a private el lscs through fear of birth basically. Thank you Alison for drawing our attention to this organisation. It seems to be the brainchild of one woman who has also written a book. Her philosophy is: 'The risks involved with any surgery are very real and should not be underestimated, but neither should the risks inherent with pregnancy and childbirth in general. We want to highlight the growing medical opinion that elective cesarean risks are favourably comparable with vaginal delivery risks in healthy women. We do not suggest that every woman should consider elective surgery and fully support a woman's choice to give birth vaginally. We just ask that both choices are equally respected. Most of all, we want to help you make a more informed choice about elective cesarean birth, by providing you with data, research, interviews and opinion that you may not be aware of. You will still need to discuss your individual risks and benefits with your own physician, and we also suggest that you research other websites and books too. We welcome visitors from around the world, and wish you all the very best with the birth of your baby and look forward to hearing about your experiences in the near future.' Every instinct of mine rebels against el lscs but it isn't straightforward is it? As midwives we are duty-bound to support women's choices. If we believe they have the capacity to choose, for instance, VBAC or home birth when not entirely low risk, then it seems logical to accept their choices when they veer towards the more medicalised options such as elective induction or caesarean. If course it's not as simple as that because from a feminist perspective we could say that it is a matter for consciousness raising or in the case of fear, psychological and emotional support... Regarding Soo's point comparing the right to smoke - good point! I think you're right though it seems an extreme analogy. The difference must be in the acceptability of the issue culturally. Plus I guess there are are few positives to women smoking from a health perspective (though you could argue stress relief?) whereas there are arguably some health benefits to elective caesarean eg fewer vaginal lacerations? (albeit a very large abdominal laceration!) Just a few thoughts... -- Sent from myMail app for Android Tuesday, 02 June 2015, 04:00pm +01:00 from "Macfarlane, Alison" <[log in to unmask]<mailto:[log in to unmask]>>: In October 2013, I wrote an article on variations in caesarean section rates, based on data which had been published in May 2103 in the Euro-Peristat European Perinatal Health Report for The Conversation. http://theconversation.com/hard-evidence-who-carries-out-the-most-caesarean-sections-19674 The Euro-Peristat Report, plus a more recent much more detailed article in BJOG on variations in mode of delivery can be found on our web sitewww.europeristat.com<http://www.europeristat.com/> Recently, the response below was posted on The Conversation by an organisation I hadn’t heard of previously, electivecesarean.com<http://electivecesarean.com>. The author says I should have been more positive about access to elective caesareans. I haven’t replied yet and if anyone else would like to do so, please go ahead. Is this a new organisation? Alison Macfarlane From: The Conversation [mailto:[log in to unmask]] Sent: 23 May 2015 05:40 To: Macfarlane, Alison Subject: electivecesarean.com<http://electivecesarean.com> commented on "Hard evidence: who carries out the most caesarean sections?" electivecesarean.com<http://electivecesarean.com> commented: Re: "NHS maternity units in England should all follow a common set of guidelines published by the National Institute for Clinical Excellence (Nice), which stipulates among many other things, that women should not be automatically offered caesarean sections which are not clinically necessary." This statement appears to misrepresent the NICE Clinical Guideline CG132 and subsequent June 2013 NICE QS32 publication. While NICE does not say 'automatically offer' a caesarean, it does say that one should ultimately be offered if that is what the woman wants. The CG132 recommendations read: "Maternal request for CSWhen a woman requests a CS because she has anxiety about childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her anxiety in a supportive manner. For 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. An obstetrician unwilling to perform a CS should refer the woman to an obstetrician who will carry out the CS. NICE QS32 recommends offering a “promptly arranged [discussion] following a request”, “consultant involvement in decision-making” and “dedicated” lists that provide “protected surgical and anaesthetic time and appropriate staffing” for planned caesareans. The author could and should have been much clearer on this point given some of the other information that is presented as part of the article. NICE is an evidence-based organisation and a significant number of organisation stakeholders were involved in writing the CG132 guidance. To add your say go to http://theconversation.com/hard-evidence-who-carries-out-the-most-caesarean-sections-19674 If you don't want to receive notifications for this article, you can unsubscribe from notifications on this article . You can also unsubscribe from all comment notifications if you'd rather not receive them for any articles. ________________________________ This e-mail message (including any attachments) is for the sole use of the intended recipient(s) and may contain confidential and privileged information. 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