Examination of Witnesses (Questions 200-219)
TUESDAY 11 MARCH 2003
PROFESSOR DAVID
JAMES, MRS
SHONA ASHWORTH,
MRS ELAINE
PARKER, MRS
SIOBHAN HARGREAVES,
MS SHEENA
APPLEBY, MS
HELEN SHALLOW
AND MISS
ALISON FOWLIE
200. To draw a parallel, say with pilots, you
are talking about actual flying time.
(Professor James) Flying hours—exactly the same.
Sandra Gidley
201. Going back to the barrister, there are
a couple of points in that. Firstly, are you able to separate
out women who say, "I demand my right for a caesarean section;
that is what I want". The next part of the question would
be about what efforts you make to persuade a woman it is in her
best health interests to—
(Professor James) The majority of cases we are faced
with are—obviously, if you have a higher caesarean section,
you have a lot of ladies subsequently coming through pregnancy
with a caesarean section scar on their uterus. Therefore, a lot
of debate and discussion centres on how subsequent delivery should
be handled. Numerically, this is the biggest group we have. This
is where people are using, understandably, the experience they
have had the first time, perhaps, in an emergency caesarean section,
saying, "I don't want to go through that again". You
have sympathy with that. Where people ask us, we try to inquire
into the concerns and risks—or the reasons they are asking
for it, if there is no medical reason.
Andy Burnham
202. You are saying it is self-perpetuating.
Once you have a high caesarean rate, because people are presenting,
if they are having a second or third child there is a fair chance
that they will have to have another section.
(Professor James) Not have to, but they will be more
inclined to request it, whereas if they have had a normal delivery,
the barrister is not likely to be a common experience. The majority
of people who have had a vaginal delivery would be advised to
have a vaginal delivery.
(Ms Shallow) From the midwifery perspective, we talk
about caesarean section ever increasing, and it is ever increasing.
I think it is a downward spiral in terms of intervention. What
becomes the norm becomes normalised practice, and it is what clinicians
know best. What we are missing here is the aspect of midwifery
care within that, or the lack thereof, that then leads to our
colleagues to have to bail women out in terms of taking them for
a caesarean section. We know that the only single intervention
that will improve outcomes is one-to-one for women in active labour.
We know that; it is well researched. However, we cannot provide
it. Nationally, in most big hospitals, one-to-one care is, in
the main, not happening or not achievable. I think it is achievable,
or we are going to carry on having this rise in the caesarean
section rate.
203. Just explain clearly why you think that
is the case because, presumably, often it is a clinical decision.
The clinician would say, "we have noticed the heart rate
and we recommend it"; so it is a decision that is instigated
by the clinician mainly.
(Ms Shallow) It is, but it is at what point that decision
is made because there is a whole journey through labour, and it
is a long way through the journey that that decision is made that
a woman has to have a caesarean section. Along that journey, the
woman is often left on her own, unsupported, or her care is shared
by one midwife who is doing her best to look after two or maybe
three women in labour, and sometimes maybe more. It is completely
unacceptable and unethical that that should be the situation that
midwives find themselves in because there are not enough of us.
Our establishments may not be able to fund more midwives. It is
unacceptable to everybody working in that environment, but most
of all it is unacceptable to the women themselves.
Sandra Gidley
204. This is what was raised last week as well.
Although we were sidetracked slightly by the choice issue, in
fact nationally the two top reasons are failure to progress and
fetal distress. For the record, would you say that if midwives
had more input, that would reduce those reasons?
(Ms Shallow) I believe that if midwives had more input—it
is not just a matter of throwing more midwives at the service;
but it is about looking at how we work and looking at different
ways. If a woman is confined to bed for fetal monitoring for no
real reason, her pain is worse. She requires an epidural because
her pain is excruciating and there is nobody there to support
her. If you change that model and encourage women to move around
and be in a nicer environment, a more relaxed environment, where
somebody is supporting you, then we know that that makes a difference
to how that women labours. We know that. We have the evidence.
We can practise evidence-based, but we are not able to in the
main because of the constraints placed upon us. We are all living
under this guise of litigation and fear in defence of practice,
but our medical colleagues often have to bail out a situation
that is no fault of their own either; but the situation exists,
because of the lack of investment. If we invested now, we could
save money in the future.
Andy Burnham
205. Nottingham and Derby are two comparable
cities, not far from each other. Why do you think there is a fairly
marked difference in the caesarean rate?
(Mrs Ashworth) I think one is about the population
and the other about high risk, which are both similar. I think
it is a cultural thing. I came to Nottingham three years ago and
I would say that childbirth was extremely medicalised—it
was the culture and midwives were not challenging . . .
206. Do you recognise the problems that Ms Shallow
referred to?
(Mrs Ashworth) Yes. Now, these are the role models
for our new midwives who are being taught about normal physiological
childbirth and all that that means. They come out and they cannot
practise it. We also have not got an integrated service in Nottingham,
so they do not experience the follow-through from conception to
birth and post-natal, and the experience is flawed from the outset.
You have not got people who are going to challenge, and they need
to challenge right from the beginning as to education of women
about why they should have a caesarean section or may need one;
and also about whether they need to be induced—and the induction
rate, we know, can influence the caesarean rate. Then pain relief—because
we have not got the midwives to offer one to one care and to challenge,
so women end up with increasing epidurals and all that goes with
that—all those things—it is the culture, as we said.
207. The culture of the organisation. Professor
James, you said that you do not doubt that some are unnecessary.
Do you audit the rate, and do you both agree roughly about ones
which are necessary—or is there any professional disagreement?
(Professor James) There is usually reasonable agreement
on the unnecessary ones. Certainly, the issues which have been
touched on here—the unnecessary induction of labour, induction
of labour for flaky reasons—invalid reasons—I think
the repeat caesarean section rate is an issue around failure to
understand fully fetal monitoring. I think there are strategies
within the two examples, namely failure to progress, which is
related to process—and that is where induction of labour
can be a big issue; and the other is how we interpret fetal monitoring,
and being prepared to do full blood sampling to back it up, and
only use it where it is indicated. Interestingly, the electronic
fetal monitoring guidelines which came out a little while ago
have demonstrated that you can reduce intervention for fetal distress
if you apply it properly.
208. Can I ask a question of the user representative.
What is your perspective on some of the things you have just heard?
Do you feel that it is too high? Do you hear people saying that
they have had a caesarean when they really had hoped that they
would not have to?
(Mrs Parker) Definitely. All the issues that have
been mentioned, particularly support, may help reduce that in
the long term. Women want a perfect birth. They want a perfect
outcome, and if there is any slight risk then they see caesarean
section as an easy option to get that birth, without always understanding
the consequences of aftercare and subsequent pregnancies.
209. Were you involved in this home-from-home
unit and the establishment of it? Do you think that initiatives
like that will help drive down the caesarean rate?
(Mrs Parker) Definitely. If the woman is supported
and comforted in labour, and is feeling she is getting the care
she needs, that can only help the outcome.
(Mrs Hargreaves) Not coming from this background or
having any of the statistics at all, all I know is my experience,
over the last couple of years, of friends of mine around me. I
have never known before people say they had had an elective caesarean
until the last couple of years; and the reasons they have given
is because of the convenience of arranging childcare and getting
back to work, etc., etc. It worries me slightly that it is seen
as this. Obviously, if there is no risk to the child—are
they fully aware of the implications of major abdominal surgery?
210. Do you think that practice should be discouraged
across the NHS?
(Mrs Hargreaves) I think they should be made fully
aware. I am sure they are told about the risk to subsequent pregnancies
or what-have-you, but it is not something that can be lightly
undertaken because at the end of the day it is major surgery.
211. Most people say it is for convenience,
but most people, however busy they are—childbirth is a fairly
major thing, and it is clearly that for most people, let us be
honest.
(Mrs Hargreaves) But people like to know—"next
Wednesday, I am going to have a baby".
212. I am sure you are right.
(Mrs Hargreaves) That makes me uncomfortable, that
side of it. Looking at the statistics before we came in, something
like 10% of caesareans were elective caesareans. That is a pretty
high percentage.
213. Would you like to see us recommending that
the NHS should discourage that?
(Mrs Hargreaves) Yes, I think I would.
(Mrs Parker) There is another issue of the forceps
rate. A lot of women can be very afraid of having a forceps delivery
and prefer to go for a caesarean section rather than risk having
a forceps delivery.
(Mrs Hargreaves) It is not cheap either. You have
got the anaesthetist, the surgeons, tied up, and all the theatre
staff.
214. The overall figures about bringing the
rate down just a couple of percentage points saves a significant
sum of money for the National Health Service. Moving to Derby,
I am going to put the same questions to you. Presumably, the rate
is what you would roughly expect it to be; or do you still believe
it is too high, and are you working to bring it down?
(Miss Fowlie) When we look at caesarean section in
the way we do, we find ones where we feel something different
could have been done. I think that the rate could therefore be
somewhat lower. I do not know how low is low. We all talk about
our populations. We have an increasing refugee population in Derby,
and they have very high morbidity and mortality rates within that
population, so that is something that has changed for us. We all
know that the whole country is getting fatter, and our obesity
rate in Derby is particularly high. I cannot compare it with other
places, except to say that there are certain procedures that I
used to do when I worked in London and in Birmingham, where I
was able to use a much shorter needle than I have to do in Derby!
We are hoping to be able to look into that as part of an audit.
I would also like to say a word about patients choosing caesarean
section. It is very difficult, sitting in the consultation room,
with someone saying "I want a caesarean section". You
ask them why and you go through the risks and procedures. You
try to say it is much better for them generally, for their health
and future pregnancies not to. You go into all of this, and many
will still be absolutely insistent.
215. Mrs Hargreaves was suggesting that you
should discourage or talk, but not necessarily say "not at
all".
(Miss Fowlie) You cannot refuse. I suppose you can,
but patients tell us these days they have a choice, and so they
should have; but it would often come down to insisting—
216. Are you saying that that is a bigger driver
than "no win/no fee" fear of litigation, and a professional
environment that is very different?
(Miss Fowlie) I find it very difficult. I spend quite
a lot of time with them in clinics where you have a 5-10 minute
slot. They may take an hour and still you are left with this problem.
217. What percentage of your caesareans are
elective?
(Miss Fowlie) Elective can be for not just patient
requests; it is proposed for breech presentation or a baby that
has a problem. Out of our 21% I think roughly 9-10% are elective
and 12% are emergencies. It is only a small proportion of elective
who are patient requests. I cannot tell you what that proportion
is.
Jim Dowd
218. You actively discourage, where you can,
the choice of caesarean—is that right?
(Miss Fowlie) If somebody is requesting it, and there
is no medical indication, I try to discourage.
219. Is there not a conflict between that and
another oft-cited complaint—not just with these specialities,
but generally—that doctors know best, and their views just
do not count?
(Miss Fowlie) I do not think that is fair criticism
because I am saying that I try to give them all the evidence.
The evidence is that it is safer for the mother to have the baby
vaginally. If there are no problems with the baby, there is no
particular evidence either way. We are talking about different
choices, not a "the doctor knows best" attitude. We
are trying to give them the facts and figures, as we know them
at the moment.
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