A UK hospital has challenged targets handed down by others (in this case their Clinical Commissioning Group – those who set the targets for the hospital). The Royal Berkshire Hospital was told their caesarean rate was too high (27.1%) and they must get it down to 23%. When asked whether it was cost driving this target the interim Medical Director Brian Reid said “That would be the driver.”
Unfortunately this target led approach to hospital care of pregnant women is typcial rather than unusual. Targets are a major factor driving policy and practise in many places. Where targets are based on cost cutting this can only mean that the health and safety of pregnant women and their unborn child cannot take top priority.
The NICE guidelines on Caesarean Section have stated that:
- women wanting to request a caesarean where there is no medical need should engage in a detailed discussion with their practitioners. All the risks and benefits of both vaginal and caesarean birth should be fully discuss but if, after this, the woman still prefers a caesarean this should be granted
- women wanting to request a caesarean on the grounds of fear should be offered perinatal mental health support and if, following this, they continue to want a caesarean, this should be granted
So if more women are making an informed decision in favour of a caesarean birth over an attempted vaginal birth then the targets need to reflect this need.
The World Health Organisation retracted their recommended target 4 years ago when the studies on which they had based their recommendations were found to be flawed. They have now stated:
There is “no empirical evidence for an optimum percentage”, an “optimum rate is unknown,” and world regions may now “set their own standards”. ‘Monitoring Emergency Obstetric Care: a handbook’
Despite this, official bodies continue to use such figures to beat their hospitals into submission with unachievable targets.
And lets be clear many caesarean requests are from women whose circumstances are not clear cut, where a decision in favour of either birth mode is equally justifiable. So simply telling them no when they ask for a caesarean and the press labelling these women as selfish or too posh to push is simplistic and insulting.
Take for example a baby lying in the breech position. A breech birth can be delivered vaginally or by caesarean section. However any woman making an informed decision about her birth will know that a breech position can make for a more protracted birth. Protracted births can increase the need for pain relief and instrumental assistance or ultimately an emergency caesarean. Couple with this, the fact that in the recent past many breech births have been delivered by caesarean, so practitioners are getting less experience with these births and this may justifiably lead some women to choose a planned caesarean over a vaginal attempt. These women are not selfish, they are making informed decisions on behalf of their own bodies and their baby’s.
So if you are planning your birth, read the NICE guideline and arm yourself with the facts prior to requesting a caearean, particularly one where there is no clear medical need. In addition my book “Caesarean Birth: A positive approach to preparation and recovery” provides all sorts of information about both caesarean and vaginal birth so that you can make an informed decision about which way you would prefer to proceed.