Health Service Focus

29.07.15

Caesarean sections – are women being given a choice?

With nationwide caesarean rates higher than ever and well above the World Health Organisation’s recommendation, it’s safe to say nearly every trust in England has developed a section problem, reports NHE’s Luana Salles.

Caesarean section rates, which should theoretically be kept between 10-15%, now vary from 16% to nearly 40% in UK hospitals.

Yet although the World Health Organisation (WHO) recommended rates focus on a global scenario rather than individual hospitals (and thus do not account for demographic variations), caesarean figures have also been consistently increasing.

It is a relatively recent phenomenon. Obstetricians and midwives do not always agree on the causes, potentially due to a clash of interests. While some doctors say obesity and diabetes play an important role in rising caesarean rates, midwives and birth experts are more likely to claim that a loss of necessary maternity skills and consequential ‘lawsuit paranoia’ amongst staff are the real culprit, removing women’s rights to choose for themselves.

 ThinkstockPhotos-474147948

Deskilled maternity wards

Elizabeth Prochaska, head of UK organisation Birthrights, dedicated to improving women’s experience of pregnancy, said “de-skilled” NHS maternity wards are still feeling the impact of the persuasive ‘term breech trial’, 15 years on.

The trial, criticised by doctors and experts as flawed and erratic in its methodology, determined that caesarean sections were the safest option when babies are born feet first. As a result, mothers delivering breech babies were often forced to have a section, even though the trial’s conclusions were refuted and discredited by several sources.

Prochaska told us: “Subsequent research has shown that whilst breech births can have a higher instance of foetal death or harm, the risk is actually much smaller than had been suggested, and there are many benefits to vaginal births while caesarean sections carry lots of risks.

“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.”

One woman who contacted Birthrights after she was coerced by doctors to schedule a caesarean for her breech baby wrote about her experience. She said that, after days of research, she learned that a vaginal breech birth was “actually not rocket science” and that in the past “breech was treated as a different yet still normal position, delivered vaginally”.

She added: “Nowadays, however, the skill to help women deliver breech babies naturally is disappearing, and the lack of experience is followed by a lack of confidence.”

 

‘Undermining women’s confidence’

Pam Dorling, a now-retired Sheffield midwife, wrote about her experience with breech births after helping a woman deliver a breech baby at home nearly two decades ago, stating that many women “have been made very unsettled” by the suggestion of caesarean sections.

She said in a report for a 2014 issue of Midwifery Matters: “Undermining their confidence and making them fearful will not help them give birth to their babies spontaneously, and midwives and doctors should not unnecessarily reflect their own anxieties and fears onto women and their families. While acknowledging the need of mothers with a known breech presentation for a higher level of surveillance in labour, I also feel strongly that we should take individual circumstances into consideration.

“This would certainly enable midwives to gain experience and confidence both in their own abilities and in the normal processes of breech birth, and also give junior midwives and doctors the opportunity to appreciate that not all breech presentations are potential disaster areas.”

Dorling explained that just two years after her home birth experience, due to the term breech trial, the same mother she helped in 1999 would have come under ‘enormous pressure’ from doctors to have a caesarean instead.

 

Erring on the side of caution?

Despite some midwives still practising vaginal breech births even after the trial – including well-known figures like Mary Cronk MBE – they’re a dying breed.

Daghani RajasinghamDr Daghni Rajasingam, an obstetrician at Guy’s and St Thomas’ Hospital, argued that all obstetric staff are mandatorily trained to be able to deliver breech babies – but said there is a “general decrease in confidence” in doing it vaginally.

“Partially due to [the trial], the numbers of vaginal breech deliveries have dropped because these women have to be advised on the alternatives. It was pretty convincing at the time, and when we tell women about a potential risk, no matter how small, especially to do with an unborn baby, we will want them to err on the side of caution.”

However, rather than cautioned, women are instead frequently told they have no choice because something is ‘hospital policy’, as Dr Daghni said is the case with many units – including hers.

The official NICE guideline, CG132, says women in this situation should be offered the choice: “Pregnant women with a singleton breech presentation at term, for whom external cephalic version is contraindicated or has been unsuccessful, should be offered a caesarean section because it reduces perinatal mortality and neonatal morbidity. The guidance also suggests that when a woman requests a caesarean section, explore, discuss and record the specific reasons for the request.”

 

Individualised care

Sarah McMullen, head of research at parenting charity NCT, emphasised that 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.”

And as consultant midwife at Sheffield Teaching Hospitals, Alison Brodrick, said in a 2014 report for The Practising Midwife journal, discussing the risks of caesareans or vaginal births is important, but the woman’s ultimate and informed decision should be respected.

Most recently, the practice & standards professional advisor at the Royal College of Midwives, Mervi Jokinen, commented on new breech birth research published in BJOG: An International Journal of Obstetrics and Gynaecology. He said: “This is an interesting topic where some studies have had significant impact in changing practice, reducing women’s choice, and to some extent contributing to the rising numbers of caesarean sections globally.

“The authors conclude even combining all the studies does not necessarily give the right answers on an individual level. All births carry an element of risk, however small. The important issue here is that women are aware of the evidence around breech birth, including the risks and the benefits of either a vaginal delivery or caesarean, so that they can make a decision about how they want to give birth. It is important that they discuss this with their midwife or doctor who will offer advice and support.”

 783 Midwife c.David Jones - Press AssociationImage c. David Jones, Press Association

Wrong priorities

There are several ways to re-skill staff to empower women and their right to choose for themselves, from sending birth experts on training courses to having doctors learn from independent midwives who are still skilled in handling ‘complicated’ births. However an institutional effort to do that is not happening, and does not seem to be a priority.

Some claim that women can be coerced into having C-sections because doctors fear the risk of litigation with difficult labours like breech births if something happens to the baby.

NHE was told by multiple people interviewed for this article that some doctors resort to caesareans very quickly if there is any chance that the baby can get stuck or lose oxygen supply during a mismanaged birth, overlooking the risks traditionally associated with caesareans. Clinicians feel that they are at a much higher risk of being held accountable for damage if they do not perform a section and costs can soar up to millions of pounds, as recently evidenced by the mistakes in the Montgomery ruling.

Prochaska said it created a perverse incentive. “It’s not based on good clinical decision-making; it just skews [it]. Though in the UK we don’t take financial concerns into account directly in clinical decisions, they will be taking litigation risk into account, and also risk to their own clinical practice and professional registration.”

And yet despite maternity claims representing the highest value of clinical negligence claims reported to the NHS Litigation Authority, fewer than 0.1% of all births actually become the subject of a claim – showing that the ‘risk-averse culture’  observed in hospitals is, in fact, unsubstantiated. Critics say the culture is to minimise medical risks and overplay the risks of normal physiological processes, contributing to an increase in unnecessary caesareans.

Normalising caesarean rates is about providing women with the support they need regardless of what they choose – a basic human right and recent recommendation in the NICE guidance, which demands that every mother should be able to choose what is best for them, both mentally and physically, regardless of the situation. Yet with so many hospitals effectively denying them the right to choose and prioritising ‘policy’, it’s hard to know when women’s own voices will actually begin to have a place in the labour ward.

 131 160840566

Tell us what you think – have your say below or email opinion@nationalhealthexecutive.com

Top article image c. Todd Anderson, 'Zoe's delivery'

Comments

Denise Hynd   30/07/2015 at 23:35

Breech is a small reason for the escalating C/S all over the world including NZ! Here most women choose continuity of care by a midwife and birth in obstetric Units. Place of birth along with fear of women, their families and care givers who lack the experience and skills to encourage physiological out of hospital or undisturbed labour and birth are the major factors for increasing interventions culminating in C/S everywhere!

Fiona Mcowan   07/08/2015 at 21:45

I teach yoga for pregnancy and recently attended an update in Scotland where I learned of the rising CS rate. I would agree with the post above that breech presentation at term is only a small % of the overall increase. Although both of the presenters made the 'deskilling' point that it is a vicious circle....the increase in CS for breech presentations means that many younger midwives will never have been present through a vaginal breech delivery. The fact that CS is major surgery that can have all the potential complications thus involved seems to be rather overlooked.

Add your comment

 

national health executive tv

more videos >

latest healthcare news

Two Cumbrian NHS Trusts approved for merger

20/09/2019Two Cumbrian NHS Trusts approved for merger

Cumbria Partnership NHS Foundation Trust (CPFT) and North Cumbria University Hospitals NHS Trust (NCUH) have had their plans to merge into one tr... more >
British Dental Association to protect children who miss dental appointments

20/09/2019British Dental Association to protect children who miss dental appointments

Community and special care dentistry experts at Sheffield Teaching Hospitals NHS Foundation Trust have helped to develop a toolkit as a way to sa... more >
NHS calls on remaining social media companies to clamp down on ‘potentially harmful material’

19/09/2019NHS calls on remaining social media companies to clamp down on ‘potentially harmful material’

The chief executive of the NHS in England has urged remaining social media firms to get tougher on potentially harmful material being posted onli... more >

editor's comment

25/09/2017A hotbed of innovation

This edition of NHE comes hot on the heels of this year’s NHS Expo which, once again, proved to be a huge success at Manchester Central. A number of announcements were made during the event, with the health secretary naming the second wave of NHS digital pioneers, or ‘fast followers’, which follow the initial global digital e... read more >

last word

The NHS needs more senior women in leadership

The NHS needs more senior women in leadership

The gender pay gap in the NHS remains a hotly debated topic, especially as the final report from the Gender Pay Gap in Medicine Review approaches. Andrea Hester, deputy director of employment rel... more > more last word articles >

681 149x260 NHE Subscribe button

the scalpel's daily blog

An ageing population means hand care and injury prevention is more important than ever

23/08/2019An ageing population means hand care and injury prevention is more important than ever

Grey Giddins, member of the British Society for Surgery of the Hand, discusses how hand care and injury prevention have become increasingly important given the UK’s ageing population   It’s no secret that the UK’s ageing population presents challenges for the NHS. The fact that we are living longer means greater demand for medical care across a number of healthcare specialisms, one of which is hand surgery. ... more >
read more blog posts from 'the scalpel' >

comment

Peter Kyle MP: It’s time to say thank you this Public Service Day

21/06/2019Peter Kyle MP: It’s time to say thank you this Public Service Day

Taking time to say thank you is one of the hidden pillars of a society. Being on the receiving end of some “thanks” can make communit... more >
Nurses named as least-appreciated public sector workers

13/06/2019Nurses named as least-appreciated public sector workers

Nurses have been named as the most under-appreciated public sector professionals as new research reveals how shockingly under-vauled our NHS, edu... more >
Helpforce to launch training programmes for NHS volunteers

10/06/2019Helpforce to launch training programmes for NHS volunteers

Kay Fawcett OBE, clinical advisor and education lead at Helpforce, and Lynn Twinn, talent development consultant, outline the new national traini... more >
Creating the Cardigan integrated care centre

10/06/2019Creating the Cardigan integrated care centre

Peter Skitt, county director and commissioner for Ceredigion Hywel Dda University Health Board, looks ahead to the new integrated care centre bei... more >
Pay and reward in the NHS needs to be taken seriously

10/06/2019Pay and reward in the NHS needs to be taken seriously

Ben Gershlick, senior economics analyst at the Health Foundation, examines the new pay deal for NHS staff.  More than £50bn is sp... more >

interviews

NHS dreams come true for Teesside domestic

17/09/2019NHS dreams come true for Teesside domestic

Over 20 years ago, a Teesside hospital cleaner put down her mop and took steps towards her midwifery dreams. Lisa Payne has been delivering ... more >
How can winter pressures be dealt with? Introduce a National Social Care Service, RCP president suggests

24/10/2018How can winter pressures be dealt with? Introduce a National Social Care Service, RCP president suggests

A dedicated national social care service could be a potential solution to surging demand burdening acute health providers over the winter months,... more >
RCP president on new Liverpool college building: ‘This will be a hub for clinicians in the north’

24/10/2018RCP president on new Liverpool college building: ‘This will be a hub for clinicians in the north’

The president of the Royal College of Physicians (RCP) has told NHE that the college’s new headquarters based in Liverpool will become a hu... more >
Duncan Selbie: A step on the journey to population health

24/01/2018Duncan Selbie: A step on the journey to population health

The NHS plays a part in the country’s wellness – but it’s far from being all that matters. Duncan Selbie, chief executive of Pu... more >
Cutting through the fake news

22/11/2017Cutting through the fake news

In an era of so-called ‘fake news’ growing alongside a renewed focus on reducing stigma around mental health, Paul Farmer, chief exec... more >