Examination of Witnesses (Questions 20-39)
THURSDAY 6 MARCH 2003
PROFESSOR LESLEY
REGAN, MS
LYNNE PACANOWSKI,
MS CATHERINE
ECCLES, MS
BETTY LARKIN,
MS KAY
BARBER, MS
SELENE DALY
AND MS
CATHY ROGERS
Sandra Gidley
20. I am going to ask some questions about the
Caesarean section rates. I think the first question, following
on what you said about the accuracy of your data, is do you actually
think that your Caesarean rate is higher or lower than the 29.8%
which we have been given as a figure for you.
(Ms Pacanowski) I do not know what period that was,
but for 2002 ours was 27%.
21. So it could be a different year that we
are looking at.
(Ms Pacanowski) Actually, I think possibly your figures
include the Lindo unit. We have a private maternity unit within
St Mary's, the Lindo Maternity Unit. This is another situation
where data gets misinformed. Sometimes the data includes their
statistics.
22. Why should they be different?
(Professor Regan) Because the Caesarean section rate
in the private sector is significantly higher than in the NHS.
23. Is that women's choice?
(Professor Regan) Yes, I think it is partly women's
choice, it is partly different modes of practice as well. Over
the last year, on the NHS labour ward—we have done the figures
by hand—the Caesarean section rate was 27%.
24. Even if we take the figure as 27%, the Sentinel
Audit said that at least 6% were unnecessary. I think that was
on the average of 21 or 22. What have you actually done as a hospital
to try to decrease the rate of Caesareans because by any standards
your rate does seem exceptionally high?
(Professor Regan) I think there are two factors. First
of all it is very evident to us that when we have a high vacancy
rate in terms of midwifery staff the Caesarean section rate goes
up. Of course, in an ideal world we would have one to one care
for women in labour and I would anticipate a significant reduction
in Caesarean section rate. By a recruitment drive 18 months ago
we have actually managed to improve the rate, although it may
still be high, higher than we would wish to see. Interestingly,
having set up two community case load teams in the last year,
the first year of audit has shown that the Caesarean section rate—both
elective and emergency—in the case load team working in
the community in very deprived areas—so we are not hand-picking
low-risk cases—is only 15%.
25. Could you explain briefly why you think
that difference is apparent?
(Professor Regan) It is continuity of care and one
to one care in labour. These women are cared for primarily in
the community with hospital input for various screening tests
and investigations and reference for any complications or queries,
and then when they go into labour they are seen at home by their
midwife in this case load team and then brought into hospital.
They are delivered by one, two or possibly a third midwife from
that team with whom they will already have developed a relationship.
That midwife will stay on duty—unless some exceptional circumstance
occurs—until the baby is delivered.
26. So you would go so far as to say that the
biggest factor affecting the Caesarean rate is the availability
of midwives in your area.
(Professor Regan) In terms of normal pregnancies,
undergoing normal deliveries. You must remember as well that one
of the reasons that our section rate is higher than some other
hospitals is because of the case load we are looking after. We
would have in- utero transfers for a variety of complications.
We have a large miscarriage service, for example. We have a lot
of operative deliveries that are perhaps not commonplace to all
units. Certainly, when we are talking about normal pregnancies
and normal deliveries, undoubtedly the midwifery input and one
to one care is fundamental in achieving a normal outcome.
27. Do you have any figures to tease out that
aspect of the referrals.
(Professor Regan) I can give you plenty of figures
but I did not think you want minutiae, but if we say 27% overall
in a high tech/high risk unit and 15% section rate produced by
a case load team of midwives working in the community and then
bringing those women into our labour wards to deliver.
(Ms Eccles) I am here as a user of the maternity services.
I chair the Maternity Services Action Committee at St Mary's.
One thing that I know that women want and would produce better
results in labour is one to one care. Continuity of care as well.
Being supported all the time by a midwife, continuity of care,
actually having the same midwife who has seen you antenatally
and then is supporting you through labour with a relationship
of trust that has been evolved through pregnancy towards labour.
If that is achievable I think the Caesarean section rate will
definitely drop.
28. Can I just ask something of the Edgware
Centre here because obviously you do not do Caesarean sections.
Eleven per cent of your patients are transferred. Am I right in
thinking that they are a fairly self-selecting group and some
women would not be allowed to give birth if they were perceived
as being high risk? What follow-up do you have as to how much
of that 11% end up with Caesareans?
(Ms Rogers) We have analysed the actual data for the
last two years. I do not know if you have seen the original evaluation
report which was an independent evaluation of the birth centre.
What the report shows is that for women who intended to deliver
at the birth centre and women who met the same criteria but delivered
in a hospital, the women who delivered in the birth centre had
significantly lower rates of Caesarean section than the comparison
group. We believe that the philosophy of care at the birth centre,
the application of evidence based practice and the support offered
by midwives are major factors for the low intervention rates.
We do have women who require transfer and in terms of the 11%
of women that transfer in labour, the major reasons for transfer
is that they are not making good progress in labour. Some want
an epidural and sometimes the baby has opened its bowels, we call
it meconium.
29. Do you have any follow up as to how many
end up having a Caesarean section?
(Ms Rogers) Yes, we do. In the figures that I have
given you in our report, 85% of women who come into labour in
the Birth Centre have a normal delivery. Of those that are transferred
out, 5% have a Caesarean section. Of those women—the 5%
who have a Caesarean section—the majority reach the transferring
unit and are there for some time before they are sectioned. Many
of them would have had their labour augmented or have an epidural.
Five per cent of our transfers in the last two years required
Caesarean section. The outcomes of our women ares very positive.
(Ms Barber) I would also say from a midwife's point
of view that it is the continuity of care and the one to one care
in labour which is the biggest point, namely why the Caesarean
section rate is so low. It is that constant support, knowing the
women through their pregnancy and giving them one to one care.
There is somebody there supporting them.
30. Yvette Cooper was on record as saying something
like 91% of women have one to one care in labour. I have tried
to get a definition from the Government as to what one to one
care in labour is. To my way of thinking it is not just being
there when the baby is born. Could you define what you mean by
one to one care in labour.
(Ms Daly) One to one care for me is when you go into
the Birth Centre—and I have had two children there—you
stay in one room; you do not get trolleyed between labour, theatre
and everything else. You stay in one room and virtually the whole
time you are in there through your labour, through the delivery
itself and then post-delivery, your midwife is with you. Sometimes
they also have a midwifery assistant. That is the one to one care.
It is not just the presence of the midwife; it is also knowing
that you have an expert with you. It is that confidence to know
that you are in the presence of an expert who is going to look
after you. But they let you get on with your birth; they do not
interfere. They try to encourage lower intervention of drugs,
pain relief and also equipment intervention. We have fewer episiotomies,
we have less tearing (especially in birthing pools, because they
are very keen on using birthing pools as well). If you get more
women into this kind of model of care I believe you will reduce
Caesarean section. I am absolutely convinced of that as a user.
It is all that. It is being in the presence of the expert, having
that wonderful midwife there; she is there all the time. You are
part of the decision making process. If there is a decision to
be made it is not done to you. It is not an intimidating environment.
You feel very safe because it is like being at home. There are
no huge monitors and big beds. It is like being in your own room.
It is the whole holistic approach to that. It is very, very safe.
It puts women at ease. That is the kind of one to one care. It
is not just the midwife being there, which is absolutely fundamental;
it is the whole idea of that, going into the room as if you are
going home and the whole process progresses as it should without
anybody else. I delivered both my babies myself. That is the one
to one care. You must look at it from a holistic point of view.
(Ms Barber) I think the woman's lower anxiety levels—because
of everything that Selene explained—is one of the main reasons
that they manage with a lot less pain relief—just using
mainly the birthing pool and breathing techniques and being able
to be active during their labour—which then goes on to reduce
the intervention rates. Feeling relaxed is a major influence in
birth.
31. Before I ask St Mary's about this, can you
tell me how many midwives are based in your unit? Is it easier
for you to get midwives?
(Ms Barber) We have seven whole time equivalent midwives
who work on the core staff of the birth centre. We provide 24-hour
cover but because we are working with three hospital trusts—we
collaborate with three Trusts in the local area—women who
are in the community would be booked to come to the Birth Centre
but are visiting their community midwife and staying out in the
community. Those community midwives then come in with these ladies
so our staffing works depending on how busy it is.
(Ms Daly) It is also important to say about the staff
retention. Although I do understand that it is easier to get staff
into a birth centre environment and it is easy to keep them. The
morale is very high which I believe is very unusual for the NHS
even in midwifery. They must be doing something right.
(Ms Rogers) I would just like to correct myself. I
gave a figure of 5.1% of women who required transfer had a Caesarean
section. That figure—5.1%—relates to women who come
into labour at the Birth Centre, but I can supply you with the
actual pecentage of overall women who are transferred that have
a Caesarean section.
32. I want to ask St Mary's what they meant
by one to one. Would you agree with what has been aid already?
(Ms Pacanowski) Yes. That's fine.
(Ms Eccles) Your original question was what has St
Mary's done to address the Caesarean section rate. Something we
have not covered yet is the issue of electronic fetal monitoring.
There are some nice guidelines which show that with low-risk births
there is no positive outcome for the admission trace and through
the work of the MSLC the protocols at St Mary's have now been
changed and it is all being implemented at the moment to stop
doing the admission trace because it has been shown to be the
first step towards intervention and therefore the first step towards
possible Caesarean but with no positive outcome. That is being
implemented at the moment.
Dr Taylor
33. Who makes the decision when a mother has
to be moved from your Centre to a consultant unit?
(Ms Barber) The midwife with the mother and her partner
as well. We keep them informed constantly throughout labour. Nothing
is ever a surprise.
34. Is it cut and dried, obvious when that has
to happen?
(Ms Barber) Yes, but it is not always cut and dried;
there are grey areas.
35. And in those areas?
(Ms Barber) In those grey areas we would transfer.
Geographically how far in time and miles are you actually away
from the consultant units you transfer to?
(Ms Rogers) Seven miles.
36. Do any of you—on either side—see
a problem with birth centres that are much further away from consultant
units?
(Ms Barber) Your guidelines and your practice would
reflect how long your transfer time is and also your acceptance
criteria.
37. You mean if you were further away you might
have stricter criteria?
(Ms Barber) I think if you are further away you would
have a lower tolerance to transfer. There would be a higher rate
of transfer.
(Ms Rogers) Which could be a good thing or a bad thing,
actually.
38. As with a consultant unit, there are a number
of births that are necessary to keep everybody skilled. I think
you have about 250 a year. Is that right?
(Ms Rogers) Approximately over four hundred last year.
39. Is there a minimum number to keep the midwives
skilled.
(Ms Rogers) There is not a set number of births that
one must do as a midwife to say whether they are competent or
not.
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