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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Competitive Exhaustion

This destructive habit can cause significant problems between couples. Both feel that their daily life is the most difficult and that the other just doesn’t understand. It is easy to then let resentment fester under the surface and spend valuable time and energy arguing about who has the worse deal.

This behaviour can occur regardless of the type of birth you have had. Remembering that your birth partner has also gone through huge upheaval and stress is important.

They are sleep deprived, they are anxious, they witnessed their loved one in pain. They may have felt inadequate during the birth blaming themselves for not having prevented unwanted intervention. Then and once back at home they may be taking roles and making decisions on your behalf that they are not used to.

For example, unless discussed in advance your partner will, in the case of a general anaesthetic, be making decisions about feeding and clothing your baby for her first few hours. Unless you have discussed it in advance they are unlikely to know what you are planning to do and may not know the potential impact of giving formula instead of breast milk immediately after birth. Try not to criticise decisions, particularly if you did not discuss such eventualities beforehand – they will have done what they thought was right at the time.

Similarly, while you are recovering, some jobs you have previously done within the home probably now fall to them. Some may relish this, but others may feel the pressure, particularly if you are overly critical. This will all be in addition to their working day so quite quickly they are going to end up as exhausted as you. Appreciate what they are doing and try not to criticise when things are not done your way. Does it matter if the washing is left in the machine for 24 hours before going into the dryer? Probably not. Nor is it the end of the world if they gave the kids the wrong drinks in their lunchbox.

Ask each other for help and support and try to remember that you are both going through a huge learning curve while extremely sleep deprived.

It is only in truly believing the roles are totally different and have extreme and unique pressures of their own that you can hope to remove this barrier to emotional recovery.

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Book Sale – SOLD OUT


Caesarean Birth: A Positive Approach to Preparation and Recovery

We have spare copies following a recent conference. These can be purchased direct at a reduced rate (£4.50 plus postage of £2.80 UK).

If you would like a copy please email me and we can arrange payment and postage.

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UK Hospital speaks out against caesarean targets

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.

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Natural Caesareans – A UK trial

At long last there is a trial of the pioneering proceedure commonly referred to as a ‘Natural Caesarean’. Jenny Smith a senior midwife at Queen Charlotte’s and Chelsea Hospital in London developed the idea 10 years ago. There are many annecdotal benefits to the procedure and women report a much better experience of caesarean birth if they have been able to give birth this way. It is hoped that a successful trial will lead to this process being rolled out across the NHS.

We discussed this wonderful technique a while ago and there is an excellent video describing the process.

“It is about the mother. After the incision is made, the curtain is removed and the mother is able to see her little baby wriggle out. It is a special moment that is missed otherwise…The baby remains in the abdomen for up to four minutes and the mother can look at it, see its little face and eyes, and when it wriggles out it is the parents that first determine the sex.” Jenny Smith

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RCOG ‘State of the Nation’ report on Maternity Care

The Royal College of Obstetricians and Gynaecologists (RCOG) have published a report into the ‘State of the Nation’ with regards Maternity Care. It makes for an interesting if somewhat alarming read. It seems that childbirth is falling fowl of the ‘Postcode Lottery’ that is affecting so many aspects of British life.

The report is very careful to point out that while the data quality of many of the hospitals require significant improvement, they have attempted to provide a status nonetheless.

“Some of the observed differences could be due to differences in the quality of the data submitted by trusts…over 10% of hospital trusts failed all data quality checks and [we call] for greater NHS trust engagement in ensuring that IT systems are fit for purpose.”

During our work on the 2011 NICE Guideline on Caesarean Section, and  other organisations made a case for accurate reporting on births. In particular on the importance of separating out emergency from planned caesareans and the underlying indicators leading to each birth.

Media coverage of the recent report suggests that too many women are having planned caesareans prior to 39 week gestation-even in the absence of medical need. Once again the damning ‘Too posh to push’ label rears its head. However this may not be an accurate reflection of the report, for the reasons highlighted above and until such reporting is reliably undertaken by ALL hospitals in the UK it is not possible to say with confidence what the real situation is.

NICE Guidelines are clear-delivery prior to 39 weeks should be avoided unless there is a clear medical reason for it. A baby’s lungs are less well developed prior to this time and are therefore at increased risk of complications.


That while we would like to trust our practitioners have our best interests at heart (and that of our baby), the presence of a ‘postcode lottery’ reveals that advice given to women may be biased by a combination of hospital policy and personal opinion. The hard truth is COST is a major factor in the type and level of care you might receive.


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“We make sure the baby is alive and then we leave”

“We need to build bridges between midwives and doctors so we can all work together better for the best interests of the patient,” says Skinner. “At present we have a very short-term view. We make sure the baby is alive and then we leave, with little consideration for the long-term physical and emotional wellbeing of the mother.”

Anecdotally most women will know at least one friend who has required reconstructive surgery following their vaginal birth. In my case I have two friends who waited years before they had the courage to see their doctor in order to have serious issues fixed.

Why is it we don’t talk about it? Why do we seem to think that physical trauma is just all part and parcel of birth to be endured in secret?

Skinner is a co-author of a new piece of research looking into the psychological consequences of tramatic vaginal birth.

The women Skinner (an experienced midwife) interviewed were all low risk first time mothers. From a population of 850 births evaluated, 70 were identified as having major pelvic floor trauma (1 in 12) and 40 agreed to participate in the study. Of these 40 some had given birth without intervention (14), some with ventouse assistance-vacuum (8) and some with forceps (18). Of these women 100% suffered ‘levator avulsion’ (where part or all of the pelvic floor muscles are pulled off the pubic bone on one or both sides – resulting in urinary incontinence and/or urterine and/or bladder prolapse) and 55% suffered major obsetric anal sphincter tears.

Co author University of Sydney’s Professor Dietz says “Only about 25 per cent of women get a non-traumatic normal vaginal delivery that did not do serious damage to their pelvic floor or their anal sphincter” and continues “The forceps rate has doubled in NSW over the last 10 years. At some hospitals quadrupled”.

Dietz suggests that in trying to reduce the caesarean rate, other forms of intervention are once again on the increase.

Once again the lack of balanced information is making it very difficult for women to make an informed choice about their mode of birth.

The following findings from the study make very depressing reading…

  • Inadequate antenatal education (reported by 72.5% of respondants)
  • No information from clinicians regarding the possibility of postnatal pelvic floor issues (reported by 90%)
  • Conflicting advice before, during and after birth (reported by 87.5%)
  • Partners traumatised by events (reported by 52.5%)
  • Long term sexual dysfunction / relationship issues (reported by 67.5%)
  • An absence of postnatal assessment of injuries (reported by 90%)
  • Multiple symptoms of pelvic floor dysfunction causing lifestyle alteration (reported by 87.5%)
  • Putting up with the symptoms quietly (reported by 90%)
  • Symptoms of PTSD (Post Traumatic Stress Disporder) (reported by 67.5%)
  • ‘Dismissive reactions from clinicians’ (reported by 65%)

Skinner and Dietz believe that physical and psychological birth trauma is a major public health issue with “forceps being the main risk factor. Only a small proportion of anal sphincter trauma us optimally repaired, and major levator trauma is rarely diagnosed and never repaired”.

If postnatally your pelvic floor exercises do not appear to be improving symptoms it may be you have suffered ‘levator avulsion’. A simple explanation of this tramua can be found here. Go to your GP and request further investigation and support – there are options.

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NHS – joined up thinking

An update to the Antenatal and Postnatal Mental Health Guideline has been issued and is catching up with the caesarean guideline in recognising that a fear of childbirth can be a major challenge to some women. The guideline now recommends that:

“For a woman with tokophobia (an extreme fear of childbirth), offer an opportunity to discuss her fears with a healthcare professional with expertise in providing perinatal mental health support in line with section 1.2.9 of the guideline on caesarean section (NICE guideline CG132).”

In a step towards joined up thinking this, in theory, means that women should be able to discuss their fears of childbirth, increasing their likelihood of getting the support they need.

However automatically steering them away from a request caesarean in favour of vaginal birth should not be the focus of this support. Rather it should aim to help women develop the confidence to make informed decisions for themselves. Hopefully practitioner interpretation of the guidelines will recognise this. Of course specifying the term ‘tokophobia’ may give some the get out they want in order to turn away requests from women without the diagnosis. However knowing about these two guidelines and what they really mean, prior to antenatal appointments, give women a new advantage.

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