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, csections.org 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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UK hospital challenges caesarean targets

Finally a UK hospital has had the sense to challenge targets handed down by others (in this case their Clinical Commissioning Group). The Royal Berkshire Hospital has been told that their current caesarean rate (27.1%) is too high 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 clearly 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 (and it is not clear that this group of women can be ‘blamed’ for the continuing rise in the caesarean rate) then the targets need to reflect this need.

The target recommended by the World Health Organisation in 1985 is frequently quoted by policy makers and yet WHO retracted their target 4 years ago when the studies on which they had based it 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 by giving them unachievable targets, legitimising their requirements by quoting the old, unsubstantiated advice of WHO, when in reality the targets being handed down are based on cost cutting – putting the lives of mothers and babies at risk.

So if you are hoping to plan a caesarean, read the NICE guideline and arm yourself with the facts and references prior to discussing your ideas. Whether you are hoping to avoid a caesarean and need evidence as to why it is not necessary or you want to plan one and there is no clear medical reason for ir, you are likely to face a battle in order to make your choice about your body and your baby.

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Does a caesarean affect the way we bond with our babies?

It is often reported in the media that having a caesarean affects a mother’s ability to bond with her baby.

However, what is frequently missed in such statements is that research actually suggests it is the circumstances around the birth not the caesarean itself which can lead to problems. In fact planned caesareans have a better psychological outcome for women than instrumental vaginal births and unplanned caesareans.

It seems where bonding is affected, negative thoughts and feelings about the birth itself, rather than the practicalities of the caesarean, play a significant role. The following issues are thought to be particularly influencial:

It is important to understand that increased levels of stress may delay milk coming in, for some women and that for some this can have a knock on affect on how they perceive their bond developing, but for many there is no impact at all.

What is very clear is ANY birth perceived by mum to be traumatic can produce such an outcome.

It is simply not true that it will be impossible to look after your baby after a caesarean. You will be encouraged to pick up your baby and carry them as soon as you are out of bed (and you are expected to be up and walking within 12 hours of a caesarean). Unless you or baby are ill there is no reason why your baby cannot be in your arms or next to you for the whole period prior to getting out of bed. Discomfort from little kicking feet over the incision area can be easily managed by resting baby on a small pillow when breastfeeding (sitting or lying) and this does not prevent skin-to-skin contact. Proactive, positive support from midwives should mean that your experience of your baby in the hours following surgery should be no different from that of any other mother.

Such sweeping statements from health care professionals and the media lead to misunderstandings and cause women to fear caesareans, setting them up for difficulties post-operatively. It is such unnecessary negativity and fear mongering that contributed to my desire to write Caesarean Birth: A positive approach to preparation and recovery. I wanted to improve women’s understanding of caesarean birth so it is more likely to be viewed purely as another way baby arrives and not something to be feared. Unfortunately antenatal education rarely talks about caesarean birth in anything like a balanced and informative manner so many women go into their birth knowing next to nothing about caesareans.

Ways to improve your bonding experience:

  • Skin-to-skin contact as soon as possible, in theatre if you and baby are both well enough (put your gown on backwards before you go in so it opens at the front)
  • Focusing on feeding, with full eye contact and skin-to-skin contact ensures valuable one to one time with your baby is protected
  • Re-visit your birth and where necessary, seek support in coming to terms with any negatives thoughts about the birth itself
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Ideal gap between caesareans – new research

A new study by Soroka University indicates that there may be reasons, other than risk of scar rupture, why a longer interval between caesarean births is ideal. Up to now recommendations have suggested that a gap of 15-18 months or more be planned to reduce the likelihood of scar rupture during subsequent pregnancies. However Kessous et al discovered during their review of 3176 births between 1988 and 2010 that in fact scar rupture was no more likely in any of their groupings (less than 12 months, 13-18 months and more than 18 months gaps).

However they did find an increased likelihood of premature birth in the group of women who had a second caesarean within 12 months of the first. This risk was 12%  whereas those who waited longer had only a 5% risk.

Premature birth has significant implications for baby in particular. Low birth weight and the immaturity of baby’s lungs are just two of the complications that can occur and the earlier the baby arrives the more likley they will need assistance in a SCU (Special Care Unit).

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No connection between caesarean delivery and obesity in later life

In the past studies have suggested there may be a link between being born by caesarean section and being obese in later life. The hypothesis is that caesarean babies may not be exposed to useful bacteria during birth causing weight problems in later life

This latest study from Mamun et al  finds no such connection. The study carried out an assessment of all mothers and their babies born between 1981-3 in a Brisbane hospital. Researchers found that on reaching 21 years of age, 21.5% of all the babies were over weight (12.4% obese). However there was no relationship between this group and the manner in which they were delivered.

This is an important study for women. The guilt felt by some women when their planned vaginal birth concludes with a caesarean delivery can be profound. The reasons for their feelings of guilt are varied, but the on-going impact of a caesarean delivery on the health of their child is one that is sometimes reported after the fact. This study could go a long way to reducing such fears and guilt.

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Urinary Incontinence guideline issued

NICE have issued an update to the Urinary Incontinence guideline. “Since the publication of the 2006 guideline, new methods of managing urinary incontinence have become available on the NHS…Urinary incontinence (UI) is a common symptom that can affect women of all ages, with a wide range of severity and nature. While rarely life-threatening, incontinence may seriously influence the physical, psychological and social wellbeing of affected individuals. The impact on the families and carers of women with UI may be profound, and the resource implications for the health service considerable.”

Instrumental deliveries are associated with increased risk of bowel problems, urinary and anal incontinence. The amount of damage can be perceived as greater than a caesarean and certainly more than a straightforward vaginal birth,[i] affecting movement and causing significant pain during recovery. Ventouse seem to cause less damage and pain than forceps,[ii] with forceps particularly linked to increased incidence of pelvic floor issues. There is some suggestion that women should be counselled to consider a caesarean rather than forceps intervention when experiencing a birth that requires instrumental assistance[iii]

Bear in mind when assessing childbirth risks that while vaginal birth seems to increase the likelihood of pelvic floor problems, particularly where forceps are involved, it is not the only factor. Obesity, smoking, HRT and hysterectomies are also thought to be factors, as is the extra weight of pregnancy itself exerting pressure on these muscles. McDonagh Hull talks in more detail about this issue.

[i] S. Paterson-Brown, ‘Elective Caesarean Section: A Woman’s Right to Choose?’ Progress in Obstetrics and Gynaecology J Studd, Ed. (2000)14:202-15

[iii] S.A. Farrell, ‘Cesarean Section Versus Forceps Assisted Vaginal Birth: It’s Time to Include Pelvic Injury in the Risk–Benefit Equation’ CMAJ, 166/3 (2002)

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AIMs review Caesarean Birth: A positive approach to preparation and recovery

Chloe Bayfield an AIMS midwife recently reviewed Caesarean Birth: A positive approach to preparation and recovery.

“The book is easy to follow and explores almost every aspect of the thought processes you are likely to go through when making decisions about your birth…Using this chapter, [“How Can I Improve My Recovery”] along with Appendix A (“The caesarean procedure”), will go a long way towards preparing you for your operation.”

Thank you for your supportive words.

(AIMS -Association for Improvements in the Maternity Services objectives are: working towards normal birth, providing independent support and information about maternity choices, raising awareness of current research on childbirth and related issues.)

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Dads suffer during birth too!

Professor Marian Knight from Oxford University speaking about her new research reveals that “pregnancy complications…can have long-term effects on mental and physical health, as well as on family relationships.”

Of course Mum experiences the pain and worry of childbirth, but it would be incredibly naive to assume that it is a walk in the park for the partner. The birth partner (often the father to be) witnesses the person they love in pain and are powerless to stop it. Yes they may be given ideas of how to help during labour but they cannot stop the pain and they have to watch hour upon hour of it without any idea of when it will end or indeed how it will end … and those are just the straightforward births.

Add to this those practitioners who treat partners with impatience, indifference and/or a general lack of respect and you have individuals feeling totally inadequate and traumatised by the whole experience. For those suddenly excluded from theatre if an emergency arises requiring a caesarean (it is not uncommon for the partner to be left in the corridor alone with no news of mum and baby for considerable time periods) there is a particular risk of trauma and flashbacks.

When I interviewed dads for the book Caesarean Birth: A positive approach to preparation and recovery I repeatedly came across descriptions of events where they felt completely out of control, horrified and unprepared. Some described months of nightmares afterwards, others confessed they hoped not to have more children and still others revealed that they were relieved their wife had a caesarean. One father contacted me begging me to convince his wife to have a caesarean as he could not face a third natural birth.

It is wonderful that partners are encouraged to participate in birth but they too require support and understanding in order to remain effective during the birth and beyond.

While I believe that it is entirely reasonable for Mum to be focused inward during pregnancy and particularly birth this should not be to the total exclusion of the partner and their feelings.

In an ideal world antenatal education would encourage families to recognise the needs of everyone involved in the birth. For the sake of family relationships going forward it is crucial both parties are helped to recognise the long term effect on relationships where partners have been excluded, emasculated and traumatised. For these families far greater support is needed postnatally than is currently available.

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