Clinical Director NHS England says – stop focusing on CS rates!

For too long, healthcare providers have been concentrating on optimum caesarean rates, this despite the fact that nearly 10 years ago the World Health Organisation retracted their recommendations as there was “no empirical evidence for an optimum percentage”.

Now the Clinical Director for NHS England – Matthew Jolly – joined the fight by stating that caesarean rates should not have targets set as these can lead to “all sorts of unfortunate consequences.”

Attempting to artificially driving down the caesarean rate is dangerous. Over half the litigation costs in the NHS are still in obstetrics many of which relate to birth outcomes which could have been avoided if a woman’s concerns or wishes had been respected.

  • 47% of maternity units set target rates
  • 50%+ are graded on whether they encourage natural births

Cost is the major factor driving these targets and where cost is considered above a mother and/or baby’s safety, bad decision are going to be made and bad advice is going to be given to mothers.

NICE guidelines clearly state women should be able to make an informed choice about how they give birth. But targets like these are reducing options and we are regularly contacted by women at their wits end, wanting to know how they can challenge the advice given by their carers which they believe to be compromised.

But, is the tide turning? We are working with the Care Quality Commission to understand more about women’s caesarean experience, feeding into the development of this year’s Care survey. Watch this space to see whether such statements are actually reflecting a change in the behaviour of our Trusts.

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Vaginal seeding – a safe fad?

Some women seem to be taking matters into their own hands when attempting to address the issue of whether or not a caesarean birth places babies at a disadvantage in the development of their microbiome (the colonisation of their gut with health bacteria).

In recent years there has been a lot of talk in the press linking caesarean born children with a higher incidence of obesity or asthma. Such media scaremongering is not helpful for those mothers whose medical situation has meant a caesarean has been a necessity and whose recovery has already been hampered by emotional trauma.

A recent study looking specifically at birth mode and a baby’s microbiome found there to be no lasting difference even as early as 4-8 weeks after birth, particularly if they are also breastfed. Chu 2017

Similarly, while some studies suggest there is a moderate risk of obesity in children born by caesarean, most fail to acknowldge that maternal BMI during pregnancy as well as maternal and paternal BMI post birth are also found to have an noticeable effect. A study attempting to evaluate a collection of studies on this issue still only found moderate risk and could not rule out the above confounding variables. Li 2013

And on the issue of asthma, studies are also contradictory and inconclusive, at best finding either no link, Maitra 2004, or include significant additional factors such as prematurity, maternal asthma, allergic parents, being born with respiratory difficulties etc. rendering the results unreliable. Debley 2005, Roduit 2008, Smith 2004

Despite this, the media continue to propogate such stories, despite the fact that even the research papers themselves rarely say anything more concrete than for example: It could be that C-section physically prevents newborns from acquiring microbes they would during vaginal births”.

Instead women are putting their babies at risk through inadvertent exposure to dangerous STIs including HIV, chlamydia, herpes and gonorrhoea.

Dr Patrick O’Brien, from the Royal College of Obstetricians and Gynaecologists states: there is “no robust evidence” that vaginal seeding actually has any health benefits to a baby. And a colleague leading the review of studies looking at vaginal seeding, Dr Tine Dalsgaard Clausen, Consultant obstetrician at Nordsjaellands Hospital, Denmark adds “Currently, there is no evidence to show that the potential long-term benefits of vaginal seeding outweigh the risks or costs associated,…it’s important that healthcare professionals promote other factors that are known to improve a baby’s colony of bacteria, such as early skin-to-skin contact, breastfeeding and a healthy diet.”

Until there is robust evidence that this technique is both safe and effective, parents could be well advised to evaluate the megre information presented in media stories and review current research for themselves.

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Women’s requests are being turned down

In 2011 the UK National Institution for Clinical Excellence (NICE) recommended that women be allowed to make a request for a caesarean delivery, even in the absence of any recognised medical need. Despite this, a recent Freedom on Information request submitted by the Daily Mail found that:

  • 21/91 hospitals do not offer maternal request caesareans
  • In four hospitals where Maternal request was supported, bosses rejected requests on cost grounds
  • Several hospitals insist on mental health counselling prior to giving agreement for a caesarean (this is unfortunately a recommendation in the 2011 NICE guideline – completely failing to recognise a whole group of women who have made an informed choice to request a caesarean)
  • Only four hospitals offer Maternal Request caesareans even though their Clinical Commissioning Group do not fund it

Kim Thomas, of the Birth Trauma Association, says in response to the findings: “Women usually have very good reasons for requesting a planned caesarean. Often they’ve already had one traumatic birth and want a less frightening experience next time round. Denying these women their request is cruel, and goes against Nice guidelines.”

Similarly, campaigner Pauline Hull, said: “Women are increasingly choosing a caesarean birth because they’ve decided it’s safer for their baby and safer for them. The maternal landscape has changed. Women are older, heavier, and having fewer babies; babies are heavier.”

Incredibly, Trusts are still using cost as justification for these rejections and define policies to drive down their overall caesarean rate. Trust managers are failing to join the dots…

The costs associated with a straightforward, uncomplicated planned caesarean are actually less than many medicalised vaginal births. This is because unless a vaginal birth is totally straightforward and natural (i.e. not involving any form of medical intervention or pain relief and Mum and baby leave hospital the same day), the costs immediately begin to creep up. Over 50% of UK births involve some form of intervention (NHS Information Centre statistics). In the USA, 67% of births involve anaesthetic, 30% of women are induced and 13% have an episiotomy (Listening to Mothers – USA). You can see how the cost arguement immediately starts to fall apart.

As far back as 2003, studies revealed that just adding induction using pitocin “nullified any cost differences; if epidural anaesthesia was also used, total costs exceed the cost of elective caesarean delivery by almost 10%. The cost of a failed attempt at vaginal delivery was much higher than elective caesarean delivery.” Bost 2003

“A culture of choice has been promoted in recent years, but contrary to the anticipated demand for less obstetric intervention by those promoting choice, there has been an increase in demand for delivery by caesarean section. With the balance in favour of benefit for the baby from delivery by caesarean section, it is now difficult to sustain the argument favouring vaginal delivery…A critical evaluation of costs indicates that there are probably few grounds for denying women their request for caesarean section for economic reasons”. Morrison 2003

And this is before you start looking at the cost to Trusts of longer term issues arising from vaginal birth. Studies reveal the long-term risk of stress urinary incontinence and pelvic organ prolapse surgery is significantly higher for women giving birth vaginally and of course there are significant costs associated with each repair work.

Come on hosptial pencil pushers – JOIN THE DOTS!

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Birth Plans

Flexibility is key!

You may have lots of ideas and preferences but they need to be just that – preferences.

“…have a plan A, have a plan B, go down to a plan G or K if you need to.” Elizabeth Duff (Senior Policy Advisor for the NCT)

In reality  no-one knows how things are really going to pan out on the day. Keeping preferences flexible ensures that the team looking after you have a good idea of the direction you hope your birth will go, but have the space to be able to suggest other things if it seems like the plan needs to change.

However, this is where your knowledge becomes most important.

For example: If you are hoping to avoid a caesarean, then it is useful to know that some hospitals place what can seem to be quite arbitrary timescales on 2nd stage labour. Knowing this you can ask very specific questions about your status before making a decision regarding drugs to speed up your labour.

Another example: If you know you want to hold your baby skin-to-skin while still in theatre, then it is important to specify this in your birth guide so your gown can be put on backwards and the screen positioned appropriately to make this possible. Both these things need to be agreed in advance. If it is your birth guide, the discussion cannot be forgotten.

Know your facts and if in doubt always ask more questions.

A google search will generate a list of lots websites discussing vaginal birth plans. Caesarean plans are a little more tricky to find, but not impossible and in ‘Caesarean Birth: A positive Approach to Preparation and Recovery’ there is a whole section dedicated to the issue of ‘Birth Guides’, including: possible content, structure and key things to think about.

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Call the Midwife star opts for planned caesarean

FANTASTIC!

A well known TV star (Helen George) from Call the Midwife has revealed she made a positive, informed decision to have a caesarean in an NHS hospital, stating it should be a valid choice for any woman.

“Helen George called for a national conversation about C-sections, saying they can be a positive choice for women and should not be restricted to medical emergencies…I’m not against natural birth, I’m pro whatever you feel is right for you.” (Radio Times)

While George reveals that the impetus for an alternative to natural birth arose prior to pregnancy as a result of her exposure to negative birth stories and themes while working on ‘Call the Midwife’, she says she went on to balance the fear with “lots of research” and decided that “if [she] ever got pregnant, that’s what [she] would do”. (Radio Times)

We wish her and her family all the best for her adventure into motherhood.

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RCM no longer promoting ‘normal’ birth!

The Royal College of Midwives (RCM) have announced they are ending their decade long campaign promoting ‘normal’ birth. ABOUT TIME TOO!

The campaign no doubt grew out of good intentions, in particular encouraging a return to more natural births. But as time has gone on, it has meant an increasingly unrealistic form of antenatal education has taken hold and become the norm. Incredibly with a caesarean rate of around 25% it is not unusual to attend UK antenatal classes which dismiss caesarean birth in a matter of minutes and which fail to talk about the implications of a ‘cascade of interventions’ and how to rationally manage this.

The RCMs change of heart has unfortunately come far too late for the many women who have had ‘normal’ birth promoted at the expense of informed guidance and whose expectations have been mis-managed to the extent they have experienced significant negative reactions to their birth. And let’s be clear about what this can mean:

  • delayed bonding
  • breastfeeding difficulties and early cessation of breastfeeding
  • no further pregnancies (even opting to adopt)
  • prophylactic caesareans
  • etc.

While I do not dispute the lack of sufficient funding in recent years has led to the woeful situation maternity care finds itself in, (which no doubt contributes to the increase in medicalised births-for reasons of both expediency and cost-effectiveness), this is however the current reality (albeit unacceptable). Women need information at their fingertips relating to ALL modes of birth and ALL interventions if they are to stand any kind of chance of coping with and feeling in control of their birth.

For a long time now, those of us monitoring maternity care have taken issue with the use of the term ‘normal’ with its implication that anything other than a totally natural birth is therefore ‘abnormal’. Women hear a lot about vaginal birth and coping techniques and practically nothing about interventions and caesarean birth. This absence has left many women so poorly informed that expectations rarely match reality. No wonder then that the incidence of emotional trauma has been rising.

It is great that the rhetoric around birth will be removing reference to ‘normal’ birth. However, I take issue with the blame the RCM appear to be placing at the door of the women themselves. On the one hand saying they don’t want to “contribute to any sense that a woman has failed” but then adding “unfortunately that seems to be how some women feel.” They do not appear to acknowledge the role their campaign has played in encouraging midwives to emphasize one mode of birth over another to the extent that balanced information is almost impossible to come by in many UK classes, ostensibly setting women up to fail.

As the Guardian article points out “the campaign was criticized in an inquiry into the deaths of 16 babies and three mothers at Furness general hospital in Cumbria between 2004 and 2013.” and found that the campaign appeared to influence a group of midwives to such an extent as to contribute to “unsafe deliveries due to [the midwives’] desire to see the women give birth without medical interventions “at any cost”.”

At its most extreme the campaign appears to have contributed to the loss of life-though the RCM strongly deny this. But at the very least it is clear the campaign has actively encouraged women to write birth plans specifying little or no pain relief and to be distrustful of all interventions thereby failing to prepare them adequately for the current realities of birth in the UK.

This change in rhetoric is very welcome, but only time will tell whether those midwives who strongly emphasize natural birth will actually adapt to offer a more balanced, open-minded approach to education, birth planning and the support of birthing women.

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Reviews

I haven’t checked Amazon for a while to see the latest reviews. It was a lovely surprise to see several new ones, all which had such lovely, positive things to say.

Thank you readers, I am glad it is proving so useful to so many.

Here are some of the comments that have just made my day:

Franca: “I read this book from cover to cover – it is the first unbiased, non judgmental, evidence based book I have ever read on the subject. An absolute must-read for anyone who might end up with a caesarean e.g. basically everyone who is pregnant! Brilliant book.”

Mazi: The book is written in a very non-judgemental way and its only agenda appears to be to inform and support women (and birth partners). I certainly felt much more knowledgeable after reading this book. I would definitely recommend `Caesarean Birth’ for all mums to be, especially as despite being an outcome for many women it is so often given only lip service at ante-natal classes. I particularly liked the chapter on recovery as it gives excellent, practical advice on what to expect afterwards and how to cope, even if your section wasn’t planned.

Anonymous Amazon customer: Fantastically informative guide to c sections, all you need to know to be prepared.

Jennifer: Brilliant prep before I had my planned c section. Felt much calmer as having read this.

Agnieszka: “You only need this one book if you are considering an elective C-section or you need one for medical reasons. Finally facts not old women’s tales about the procedure. Also no breast feeding ‘propaganda’ in this book which is a nice change from other publications.

Helen: This book was really helpful with my decision on whether to have a c-section second time round. Definitely worth reading before giving birth.

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Do women want to know the CS rate in their hospital?

The surprising results of a recent study suggests they don’t want to know.

The study looked at women with low risk pregnancies who were planning a vaginal birth the majority of whom did not want a caesarean delivery if there was no medical need.

  • When asked whether they had checked out the caesarean rate in the hospital they planned to give birth in, the majority had not
  • 55% did not believe that their choice of hospital might affect their chances of having a caesarean
  • When asked whether a high caesarean rate would lead them to change hospital 75% said no, they would rather stay with practitioners they had developed relationship with

The truely surprising result suggested that when women were told that whether or not they had a caesarean could actually depend more upon administration issues and hospital policies than whether they actually needed one or not, they still preferred to stay with the hospital.

Dr. Neel Shah, of Boston’s Beth Israel Deaconess Medical Center, one of the researchers said:

“If [women] see a hospital with a 50 percent C-section rate, they don’t see their own chances of having a C-section as being 50 percent. Our research suggests they see it as an abstraction.”

It is unfortunately the case, in the current cost cutting climate, that medical need is not the only factor influencing practitioner decisions about caesarean birth. Ironically while there appear to be women having unnecessary caesareans in some cases, there are also those who want to make an informed choice in favour of a planned caesarean who are being refused that option.

If you have a preference of one birth mode over another it is fundamentally important to arm yourself with enough information to support your choice. Being able to demonstrate an informed opinion and knowing what really constitutes a medical need can significantly affect your birth experience.

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NCT and WI survey women’s experiences of birth and postntal care

The NCT and WI commissioned a survey in 2013 to understand women’s perception of their birth and postnatal experiences. As a result of that survey they have launched a national campaign for 2017 targetting ‘red flag events’ called ‘Support Overdue’

Red flag events are instances where levels of staff support for women is so low it is considered dangerous. The survey found that half the women surveyed (nearly 3,000) had experienced a red flag event during their birth. E.g. no one-to-one care during established labour, waiting for more than an hour to be stitched following vaginal injuries.

“The aftercare was awful, I was alone and in a lot of pain” (a quote from the survey)

Another key finding highlighted adequacies in postnatal care. E.g. 1 in 5 women unable to see a midwife postnatally as frequently as they felt necessary and for some leading to a notable delay in the diagnosis of health problems for either Mum or baby.

In a climate of policies driven by cost cutting, the results from the survey are no great surprise. E.g.

  • 79% of Trusts did not meet recommended staffing levels
  • 88% of women had never met the midwife that attended them for their birth

Elizabeth Duff (Senior Policy Advisor at the NCT) commenting on Woman’s Hour (Jan 2017) stated that understaffing was a significant problem and despite increases in the number of students training to be midwives their research is finding that many trusts simply  “do not have the money to employ the midwives that they know they need.”

The first step for ‘Support Overdue’ is to present the survey findings to the Health Select Committee in Parliament requesting:

  • Review staffing with a view to fulfilling the standard, set by the four medical and midwifery royal colleges, of a midwife-to-birth ratio of 1:28 per year;
  • Take action to ensure continuity of care: NICE postnatal guidelines are robust, but seem to be implemented inconsistently across different areas. One trust in London reported it offered women three postnatal visits as standard, a neighbouring trust offered women just one – yet both reported they were delivering in line with the guidance. Poor data and recording hampers proper analysis and means it is difficult to get a comprehensive picture of care standards and service provision.
  • Enable women to build and maintain a relationship with their midwife: many women give birth in locations chosen by them and known to providers months beforehand; facilitating a relationship between midwives and women in their care would help provide much valued continuity of care from the antenatal period into labour and postnatal care. NCT Press release Jan 17th 2017

What is incredible is the inability of decision makers to connect astronomical maternity litigation costs with the radical cost cutting experienced by the NHS. How many deaths and near misses (never mind the cases of PTSD) do there have to be before they ‘get it’.

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Maternity litigation cost the NHS 450 Million in 2014/5

“Every year in England there are almost 700,000 live births. In 2012/13, the associated maternity care cost the NHS around £2.6 billion. Having a baby is the most common reason for a hospital admission, but maternity is a unique area of the NHS because the services support predominantly healthy women through a natural life event that does not always require doctor-led intervention.

While most of these births are successful, in 2014/15 the NHS Litigation Authority reported that maternity claims represented the highest value of clinical negligence claims and the fourth highest by volume. Obstetrics claims equated to approximately 41% of the £1.1bn paid by the NHS Litigation Authority last year.” 2015 Survey of women’s experiences of matenity care, statistical release  – Care Quality Commision (NHS)

What we should be asking is-what is going wrong with the care that there is such high levels of litigation every year. All too often the media blame those women requesting caesareans in the absence of medical need for rising costs and stretching resources. (Remember NICE themselves found that the cost of a vaginal birth that requires an anaesthetist (epidural or spinal pain relief) and any additional intervention e.g. episiotomy, tear repairs, prolonged hospital stay (2 nights or more) etc. bumps the cost to almost exactly the same as a planned caesarean with no medical emergency. Blaming these women and labelling them too posh to push is ignoring the elephant in the room – not enough midwives.

Despite an overall increase in the number of midwives there is still a shortage of 2,300 that are required to meet current birth rates – a truly worrying figure. Rt Hon Margaret Hodge MP, Chair of the Committee of Public Accounts 2014

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