Caesarean rates don’t indicate quality of care and targets are dangerous
Pauline Hull from electivecesarean.com looks at whether the aim of reducing caesarean rates is improving outcomes.
Caesareans save lives, but for several decades, NHS maternity policy has focused on reducing caesarean rates and increasing rates of ‘normal’ birth, without communicating evidence of improved outcomes for babies with intervention, fewer stillbirths and less pelvic floor injury for mothers.
Warnings from charities, maternity care organisations and doctors, that imposing arbitrary caesarean rates is dangerous and costly, have been ignored, with NHS hospitals assessed, criticised and celebrated according to their annual number of surgeries; the flawed assumption being that a low percentage is commensurate with high-quality care and low cost.
It took the Report of the Morecambe Bay Investigation and Montgomery v Lanarkshire Health Board Supreme Court judgment in 2015 to finally challenge this status quo; criticising the “inappropriate pursuit of normal childbirth” and awarding £5.25m for the 1999 birth of a baby who ”would have been born uninjured” with a caesarean.
The Royal College of Obstetricians and Gynaecologists (RCOG) press office has said Montgomery “will have a significant influence on obstetrics and gynaecology practice in the UK, with potential impacts on doctor-patient communications, information sharing and informed consent.”
But nevertheless, and despite strong opposition, the latest NICE intrapartum care guidance still recommends: “Advise low risk nulliparous women that planning to give birth in a midwifery led unit…is particularly suitable for them… and the outcome for the baby is no different compared with an obstetric unit.” And RCOG still recommends: “One strategy for reducing the overall CS rate is the promotion of VBAC, where appropriate.”
One other step in the right direction, given the obfuscation and under-reporting of many adverse outcomes, is RCOG’s decision to begin counting (some) babies’ deaths, but without retracting its 2012 recommendation for 20% caesarean rates, it’s failing to prevent more babies’ deaths too.
Perhaps nowhere is this failing more evident than in the investigative reports published by the Care Quality Commission (CQC), an independent body charged with monitoring maternity providers, “to make sure they meet fundamental standards of quality and safety”.
Specific data on hospitals’ rates of stillbirth, perinatal and neonatal mortality, intrapartum death and injury, maternal mortality and morbidity (including pelvic floor) are not reported, but caesarean versus ‘normal’ or vaginal birth rates are always cited, and presented as key performance indicators.
A 2016 report of the Royal Berkshire Hospital, for example, found the trust “performed above or near their target of 60% for vaginal birth after caesarean”, yet six years earlier, £7.85m was awarded to a child injured during a VBAC (a £3.66m lump sum with index linked annual payments of £140,000, rising to £225,000 from 2019, for life).
There is absolutely no consideration of the impact such targets might have on families’ lives or NHS litigation costs.
Similarly, at North Middlesex University Hospital, baby Kristian died in 2015 after his mother’s caesarean request was denied, another baby died in 2009 after a planned caesarean for suspected macrosomia was cancelled, and another baby died in 2004 when a caesarean was not performed for breech presentation. These are cases that made it into the media.
Yet under the heading ‘Patient outcomes’, a 2014 CQC Quality Report praised the trust because its “normal birth delivery rate was 65%, higher than the England average of 60.7%.”
The CQC said, “This was positive given the high-risk population.” One year later, baby Kristian died during a forced normal birth.
Unsurprisingly, the trust’s website still boasts of a caesarean rate that’s “relatively low compared to other London maternity units”, and is still “Promoting normality”.
Sherwood Forest Hospitals NHSFT website offers another example, boasting that “at King’s Mill Hospital, we are proud to have one of the highest percentages of normal births in the country, one of the lowest caesarean rates at just 18% and a home birth rate way above the national average.”
A recent CQC report rated the hospital as “requiring improvement” on safety, effectiveness and responsiveness, with patients “not always protected from the risk of avoidable harm”, but on this key point, the CQC remained positive: “Caesarean section rates and natural birth rates were better than the national averages.”
And these examples are just the tip of the iceberg…
It is worth clarifying the definition of ‘normal’ birth here, given the pressure on hospitals to increase their rates – it is one without induction or epidural, and can include “antenatal, delivery or postnatal complications (including for example postpartum haemorrhage, perineal tear, repair of perineal trauma, admission to SCBU or NICU).”
This is the pinnacle of care that hospitals are told to achieve.
Worse still, recommendations published by the RCOG, RCM and NCT in 2012 impressed that it “is important to try to increase this rate as well as that of vaginal birth, which includes delivery by forceps and ventouse” – regardless of the damage forceps can do to babies and to women.
Why? Because “Every potential caesarean section that is enabled to be a normal birth saves £1200 in tariff price alone.” Except the cost of subsequent attempts to repair pelvic floor damage or to counsel women for birth trauma are not factored into this statement.
As long as maternity care continues to focus more on the birth process than the birth outcome, all these anomalies will continue to occur, and the NHS litigation bill will continue to grow.
Stillbirth rates remain high; and more parents are asking why. Forceps rates are increasing, silence of the pelvic floor taboo is breaking, and more women are asking why no one told them of the risks.
Bad outcomes, not high caesarean rates, are what’s fuelling the ever-increasing NHS litigation bill, and the highest payouts of all are a direct result of failures to carry out timely caesareans.
The NHS can’t afford the mistakes it’s already made, so why is it being told to make more of the same?
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