House of Commons - Health

Select Committee on Health Fourth Report

3 CAESAREAN SECTION RATES

How have caesarean section rates changed?

64. Just over one in five babies in England are now delivered by caesarean section. In the 1950s 3% of births in England were by caesarean section. This figure had risen to 9% by 1980 and has since increased rapidly, reaching 12% in 1990, 21% in 2000,[72] and 22.3% in 2001.[73]

65. Caesarean section rates at individual maternity units vary widely across England. Behind the 22.3% national rate[74] local figures range from approximately 12% to approximately 30% and differences between the rates of neighbouring hospital trusts and even neighbouring maternity units, may be stark.[75]

66. Lack of consistent data on maternity care is a problem in countries other than England and so exact international comparisons of caesarean section rates are difficult to make, although an overall increase has been recognised as a global phenomenon. Estimates for France and Germany suggest that rates in these countries are broadly in line with that in England. Caesarean section rates in Norway, Finland Sweden and Denmark (countries which produce reliable maternity care data) mirrored the position in England until the 1990s but while rates rose rapidly in England in the 1990s, in Nordic countries they remained at 12-14%. The caesarean section rate in Italy, which was comparable to that in England in 1980, had risen beyond the rate in England (to 22%) by 1995.[76]

67. In the United States, caesarean section rates rose steeply throughout the 1970s and 1980s, from 6% in 1970 to 17% in 1980 to 24% in 1990. However, in contrast to trends in European countries, US rates in the 1990s stabilised, falling to 22% in 1995.[77] In South and Central America, caesarean section rates are considerably higher than those in the US and Western Europe. It is estimated that rates in Brazil and Chile are currently around 40%.[78]

WHAT ARE THE IMPLICATIONS OF RISING CAESAREAN SECTION RATES FOR WOMEN AND BABIES?

68. In 1985 the World Health Organization (WHO) undertook a study of caesarean section rates and maternal and perinatal mortality rates. A WHO conference on caesarean section rates concluded that no additional health benefits were associated with rates above the range 10-15%.[79] For some women and babies, caesarean section may be a life-saving procedure. However, rising caesarean section rates give cause for concern with regard to health outcomes for mothers and babies because the operation is a major surgical procedure which is associated with some immediate risks and also has some longer-term health implications.

69. A great many of those who responded to our call for evidence on this aspect of our inquiry registered their concern about rising caesarean section rates in English maternity units, and sought to make clear to us the risks involved in the procedure. The RCN set out these risks in the starkest of terms:

70. An elective caesarean section carries almost a three-fold greater chance of maternal mortality over vaginal birth, if there is no emergency present.[81] Dr Soo Downe, from the Midwifery Studies Research Unit at the University of Central Lancashire also pointed out the "immediate but very rare" risk of maternal death, owing to a combination of the underlying reasons which indicated the need for the procedure, anaesthetic risk, and complications of surgery. Martin England recounted for us how his wife delivered triplets by caesarean section after a relatively trouble-free 36-week pregnancy but subsequently died from a rare condition associated with caesarean section (Acute Colonic Pseudo-Obstruction or Ogilvie's syndrome) which was not identified until the inquest into her death.[82]

71. Professional debate continues as to whether the mortality risks inherent in caesarean section are now so small, that the only relevant issues are morbidity differences between labour and elective caesarean section, for example, differences in recovery time, infections, and incontinence. However, there is little detailed work on morbidity and longer term outcomes. There is strong evidence that immediate serious morbidity is at least 30% higher for elective caesarean section than it is for labour, including vaginal deliveries followed by emergency caesarean sections. There is also professional consensus that caesarean section risks increase with each operation, whereas labour risks decrease with each delivery.[83]

72. Postpartum maternal infection is also a risk associated with caesarean section. The concerns about caesareans are not only related to the immediate operation and recovery period but longer term sequelae (that include repeat caesarean, scar dehiscence and rupture, and obstetric hysterectomy), adhesions complicating further surgery, ectopic pregnancy and haemorrhage and hysterectomy following uterine evacuation. There is some evidence that women who have had a previous caesarean section are more likely to have problems with fertility.[84] Dr Downe told us of the possible implications of caesarean section for babies. She identified an increased risk of respiratory distress in babies delivered by elective caesarean section before 39 weeks gestation and also an adverse effect on successful breastfeeding and bonding.[85] It is estimated that during the procedure itself there is a 1% risk of a knife laceration to the fetus (this increases to up to 8% if the fetus is not in the cephalic, or head-first, position).[86]

73. Increasing caesarean section rates have cost implications for the NHS. A caesarean section was costed in the mid-1990s at an estimated £760 more than a vaginal delivery. By this calculation, every 1% increase in the national rate costs the NHS £5million.[87]

HOW HAS THE GOVERNMENT RESPONDED TO THESE CONCERNS?

74. Since the 1920s the Department has played a key role in monitoring the risks associated with pregnancy and childbirth by commissioning studies of maternal mortality. In 1952 the Department (then the Ministry of Health) established the Confidential Enquiry into Maternal Deaths in the United Kingdom in response to concerns about deaths in childbirth. The findings of the Enquiry, a centrally-directed self-audit for health professionals involved in maternity services, are incorporated into Government health policy and obstetric practice.[88] As mentioned above in Chapter 2, CEMACH will continue the work carried out since 1992 by CESDI to collect and analyse data on deaths in late fetal life and infancy and so ultimately to reduce the number of such deaths.

75. These projects have audited caesarean sections in relation to maternal and infant deaths, but while mortality rates have decreased, concerns about the rising national caesarean section rate and about the variation in rates between maternity units in light of the risks associated with the procedure, have intensified. Concerns about caesarean section rates pertain not only to the safety of the procedure itself but also to the perception that caesarean section might not be the most appropriate option for some of the women who undergo the operation; that it might represent an unnecessary intervention in the natural process of childbirth.

76. In January 2000 the Department commissioned the National Sentinel Caesarean Section Audit "to accurately determine the current caesarean section rate, factors associated with variation in the rate and quality of care."[89] Data were collected from maternity units in England and Wales between 1 May and 31 July 2000. The aim of the Audit was not to judge obstetric practice but to gather the data required to inform the development of guidelines for caesarean section which the National Institute for Clinical Excellence (NICE) has been commissioned to provide.

77. NICE guidelines on caesarean section are expected in December 2003. In the mean time, the Department has commissioned NICE guidelines on two other forms of intervention in labour which might increase the likelihood of a decision to perform a caesarean section: the use of electronic fetal monitoring (EFM)[90] and the induction of labour. After repeat caesarean sections which contribute 29% to the overall caesarean section rate, the most common reason for performing the procedure is presumed fetal distress, diagnosed by EFM, which contributes 22% to the overall rate.[91] The guidelines on EFM and induction of labour are intended to support maternity unit staff in making decisions about interventions, to reduce variations in clinical practice and with particular regard to EFM, to reduce "unnecessary caesarean sections and instrumental deliveries."[92]

WHY ARE CAESAREAN SECTIONS CARRIED OUT AND WHY ARE RATES INCREASING?

78. In the evidence it provided for this part of our inquiry, the Department drew on the results of the National Sentinel Caesarean Section Audit. During the Audit over 70% of caesareans carried out were attributed to one of four factors:

previous caesarean section(s) [29%].

dystocia (slow birth) [20%]

fetal distress [22%]

breech presentation [16%].

79. The National Caesarean Section Audit noted failures to use good practice guidelines dealing with these four indications in a substantial proportion of cases: Syntocinon was not used in dystocia or 'failure to progress' (in cases accounting for 2.6% of the overall caesarean section rate), fetal blood sampling which can halve the caesarean section rate for 'fetal distress' was not used (in cases making up 4.6% of the overall rate), external cephalic version, which turns approximately half of breech babies to head-first, was not offered (to 67% of women having elective caesarean section for breech presentation) and on the discussion of labour with women who had one previous caesarean section was highly variable across units (suggested by the wide range of vaginal birth achieved after caesarean section in 6-66% of women). Thus there is strong evidence that simply adhering to present standards should reduce unnecessary caesareans by at least 5%.

80. Around 63% of caesarean sections carried out were identified as emergency procedures, while 37% were identified as elective. The Department noted that, in the Audit, 7% of caesareans were attributed to maternal request. However, the Audit Report itself indicated that such classifications might be misleading:

Caesarean section has traditionally been divided into two groups, either elective or emergency procedures. The emergency category is broad, as it may include procedures done within minutes to save the life of a mother or baby as well as those in which mother and baby are well but where early delivery is desirable … In some centres this has led to an ad hoc local adaptation … This has resulted in data inconsistencies between hospitals.[

81. With regard to the 'maternal request' category identified by the Department, the Centre for Family Research at the University of Cambridge found that individual obstetricians used different definitions of a maternal request, with some recording this as a reason for undertaking caesarean section even if it had been recommended by clinical staff as the best course of action.[94]

82. We recommend that in undertaking caesarean section audits, all hospitals should classify the degree of urgency of a caesarean section in the same way. We further recommend that the classification scheme used by the National Sentinel Caesarean Section Audit be considered as a standard scheme and that the data items needed to construct it should be included in the Maternity Care Data Dictionary.

83. The Department told us that the reasons for the rise in caesarean rates were "complex and not well understood" but suggested the following as contributory factors:

Technical advances have enabled obstetricians to identify complications at earlier stages [for example, through EFM], so that intervention may constitute a more appropriate option than it once did
Increased safety of the procedure
Changes in the age profile of the obstetric population [women over 35 years old form a larger proportion of all maternities than they did twenty years ago, and the caesarean section rate increases with maternal age][95]
Women's choice[96]

84. Perhaps the most contentious and least understood of these factors is women's choice. The British Association of Perinatal Medicine (BAPM) told us that "greater consumer choice in choosing when and how to deliver", is a factor which contributed to rising caesarean section rates.[97] However, several others detected a perception, fuelled by media coverage of private practice, that the rise in caesarean rates is largely a consequence of maternal request for the procedure. Dr Soo Downe of the Midwifery Studies Research Unit, University of Central Lancashire, told us that:

85. Caesarean section rates in private hospitals are often higher than in the NHS (the Portland Hospital in London has a caesarean section rate of some 44%). As we have noted, while these rates have little impact on national statistics, the levels of public awareness of celebrities who deliver their babies by caesarean section in private hospital may have a disproportionate influence on culture and perceptions.[99]

86. According to the Centre for Family Research at the University of Cambridge, the RCOG and many others who provided written evidence for our inquiry, pregnant women want more information on the risks and benefits of caesarean section and wish to be involved in the decision-making process.[100] A survey carried out between 1999 and 2002 by the Centre for Family Research at the University found that that maternal requests for caesareans were made mainly because of fears about the health of mother or baby.[101] In their most extreme form, these fears constituted a phobia of giving birth (tokophobia), and a small number of seriously traumatised women may need surgery in order to avoid severe psychological problems.[102]

87. Another contentious issue afforded a great deal of attention in the press, is that of litigation related to maternity care. The NHS Litigation Authority (NHSLA) had potential liabilities for clinical negligence of £5.2 billion at 31 March 2002 and as the NHSLA attests: "obstetrics is responsible for a disproportionate number and cost of clinical negligence claims with damages awarded often exceeding £3million."[103] Dr Luk Yun Chang from Mayday Hospital, Croydon, told us that the rise in caesarean section rates reflected concerns regarding the risks of litigation if a vaginal delivery is seen to be difficult or might be considered in hindsight to have been managed inappropriately.[104] The BAPM identified "an increasing tendency to practise defensive medicine."[105] This view was supported by evidence submitted by the Centre for Family Research at the University of Cambridge.[106]

88. The RCOG emphasised the finding of the National Sentinel Caesarean Audit that lower caesarean section rates could be associated with aspects of staffing policy, such as continuous support for women in labour, and dedicated consultant time on labour wards.[107] The BAPM also argued that the staffing structure of labour wards had a bearing on caesarean section rates, stating that if less experienced staff were responsible for decisions about the mode of delivery, rates tended to rise.[108]

89. We were keen to hear at first hand the views of health professionals and user representatives on these issues, to explore their perceptions of caesarean rates, nationally and at their own units, and in particular to try to find out why caesarean rates varied so much among maternity units in England.

What is the experience in maternity units?

WHAT CONCERNS DO STAFF AND USERS HAVE ABOUT RISING CAESAREAN RATES?

The woman's role in the decision to undertake a caesarean section

90. We put the various possible reasons for the increases in caesarean section rates to obstetricians, midwives and user representatives from maternity units in each region of England. Our witnesses addressed the well-publicised aspects of the maternal choice controversy but also helped us to explore in greater depth women's perceptions of the procedure and of their role in the decision to undergo it. Although caesarean sections undertaken at maternal request make up a small proportion of the total number carried out, the issues raised by discussion of these cases in respect of provision of information and support for pregnant women relate to all aspects of maternity care.

91. Some maternity care staff told us they had noticed a change in women's attitudes to caesarean section and to childbirth in general. Siobhan Hargreaves, a user representative from University Hospital, Nottingham said that "until the last couple of years" she had never known women to talk about undergoing a caesarean section "because of the convenience of arranging childcare and getting back to work." Mrs Hargreaves registered her concern for these women, asking "are they fully aware of the implications of major abdominal surgery?"[109]

92. We heard from maternity care staff who felt that the portrayal of maternity care in the media had had an effect on women's aspirations and expectations with regard to childbirth. Marie Pearce, a Community Midwife working for West Hertfordshire NHS Trust told us:

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93. This image of birth does not refer at all to the health of the mother or the baby but a positive outcome is assumed. In turn, then, the portrayal of this scenario can play not only on women's lifestyle aspirations but also on their deepest concerns about childbirth. As Elaine Parker, another user representative from University Hospital, Nottingham, told us:

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94. Several witnesses told us about the kind of fears associated with childbirth which, while they might not constitute tokophobia, could still influence women's attitude to caesarean section. Elaine Parker told us that many women were so anxious about the prospect of a forceps delivery that they would rather have a caesarean section.[112] Livia Mitson, representing women who received maternity care at the Rosie Hospital, Cambridge, summed up:

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95. It was clear to us that women's perceptions about caesarean section and their fears with regard to childbirth were of considerable concern to maternity care staff, who felt a sense of obligation to respect a woman's choice but also to protect her from the risks associated with surgery if at all possible. Many maternity care team members and user representatives argued that providing women with adequate information about caesarean section represented the best way forward. As Ann Geddes, Head of Midwifery at St James's University Hospital Leeds told us:

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Sheena Appleby, Head of Midwifery Services at Derby City General Hospital also felt that women "need the information on which to make the choice … they need the support", particularly as "a lot of women's experiences have been so poor in the last ten years that they are scared."[115]

96. Several witnesses acknowledged that work was required in this area, in the first place to establish what kind of information and advice women received on caesarean section, and then to ascertain how best to provide this. Siobhan Hargreaves, as a user representative, argued that "women should be made fully aware":

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97. Jennifer Fake, Head of Midwifery at Watford General Hospital, felt that women sometimes received conflicting advice and information, and that maternity care staff might be selective in imparting information. Although staff could not go through every risk with a woman, she said "I think we need to look at that again, the type of information we give them … I think that is something we should do, look at more patient evaluation to see what their feelings are after the birth."[117]

98. The issue of women's choice in undergoing caesarean section when there is no clinical need is a fraught one. The NHS does not generally provide other major operations for patients when there is no clinical need, nor does the NHS tend to offer choices of treatment to patients when one costs on average £760 more per patient than the alternative, since it is obliged to make the best use of NHS resources. It remains to be seen whether the National Institute for Clinical Excellence will allow choice for caesareans when in other areas of the NHS patients do not have comparable freedom. We would like to see a distinct shift in emphasis to ensure that elective caesareans as a 'lifestyle choice' are not supported by the NHS and that caesarean section should be a procedure undertaken only when medically or psychologically necessary and after appropriate support and counselling.

99. We look forward to the publication of NICE guidelines on caesarean section and recommend that these should serve to support maternity care staff not just in assessing the medical indications for caesarean, but also in giving consistent advice and information to women considering the procedure.

100. We share the concerns of maternity care staff who wish to protect women from the risks associated with caesarean section. We are particularly concerned for those women who choose caesarean section because they are anxious about delivering their babies. While their fears about childbirth should not be compounded by new anxieties about the risks of caesarean section, these women should be made aware of the implications of surgery for women and babies and of services which help to reduce anxiety. We recommend that maternity units examine how women who request caesarean section are cared for, what kind of information and advice they receive, and how the women themselves feel about their discussion of caesarean section with midwives and consultants.

101. Just as some women have a preference for caesarean section, so other women wish to avoid the procedure. Several of the user representatives we heard from were concerned that women did not receive sufficient information about the other interventions in labour which might render more likely the decision, not by a woman but by her obstetrician, that caesarean section was the appropriate method of delivery. Catherine Eccles, Chair of the Maternity Services Liaison Committee at St Mary's Hospital, Paddington told us that women should be advised in more detail about EFM, induction and epidural. These, she told us were all:

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Katy Waters, a user representative from West Hertfordshire NHS Trust agreed that "there is quite a lot of misunderstanding about how intervention starts at quite a seemingly low level with an epidural."[119]

102. Induction and epidural, like caesarean section, are both associated with very rare, but potentially very serious risks to mother and baby. Some methods of inducing labour, such as use of synthetic versions of the hormone oxytocin to encourage contractions, may cause the uterus to contract too much. This may affect the pattern of the baby's heartbeat.[120] Women who receive oxytocin-type drugs in labour are more likely to have an epidural.[121] Epidural is associated with a small risk of a drop in blood pressure, bleeding, and an intense headache. Permanent paralysis resulting from epidural analgesia during labour is so rare that clear figures on its incidence are not available, but anaesthetists regard blood clots which could cause injury to the spinal cord, and damage to the spinal cord as a result of infection, as very rare but very serious complications of epidural.[122]

103. We heard it argued that information and advice about caesarean sections and other interventions should not only enable women to assess for themselves the risks of the procedure in considering a request but also empower them to question a recommendation by maternity care staff. Thus Rosemary Connor, Head of Midwifery and Service Manager at Trafford General Hospital asserted:

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124

104. We understand that in some cases interventions in labour are necessary to protect the health of mother and baby. However, women should be made aware that interventions such as EFM, epidural and induction may increase the likelihood of a caesarean delivery. Raising a woman's awareness in these areas should not entail merely the transmission of clinical information but rather it should involve discussion with a health professional in the context of the individual woman's background and concerns.

Maternity care staff and the decision to undertake caesarean sections

105. We asked obstetricians how they arrived at the conclusion that caesarean section was the best course of action for a woman and her baby, and how they explained rising caesarean section rates. We heard from several obstetricians who attributed part of the increase in caesarean section rates to the advances in clinical facilities and practice which had made caesarean section a safer procedure. Professor Walker from St James's, Leeds explained how this had altered the decision-making process:

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106. Professor Walker was among several witnesses who told us of the value of experience in weighing the balance of risks and benefits of caesarean section to women and babies. Whilst we were assured by Professor Walker and others that the prospect of litigation did not outweigh clinicians' determination to provide the best possible care and the best possible outcome for mothers and babies, there was considerable concern that for less experienced doctors, anxiety about litigation might have some effect. Professor David James from University Hospital, Nottingham identified the threat of litigation as an influence on less experienced doctors, and in turn as a factor which may contribute to rising caesarean section rates:

126

107. All of our witnesses insisted on the importance of experience in coming to a decision on caesarean section and some worried that without an experienced consultant on-site in the maternity unit, women who might otherwise deliver their babies vaginally would undergo caesarean section. These worries, we were told, had been intensified by changes in staffing levels, training and working hours. Cathy Rogers from Barnet and Chase Farm Hospital said that changes in specialist training made it important for decisions about caesarean sections to be made in the presence of a consultant rather than "just being seen by somebody who talks to the consultant on call in terms of confirming the decision or not."[127]

108. Maternity care staff at all of the units we heard from took part in audit processes to review caesarean sections and the validity of the decisions which led to the procedure being undertaken. Christoph Lees from the Rosie Hospital, Cambridge described how decisions were "put under the microscope at risk management meetings and at our junior doctor meetings" and Antony Nysenbaum from Trafford General Hospital outlined a multi-faceted and multi-disciplinary caesarean section audit:

128

109. These audit processes resulted in development of guidelines for good practice as Professor Walker from Leeds explained:

129

110. Junior doctors played an important role in audits at the maternity units and consultants saw this as an important form of training for junior staff. However, we heard evidence that staffing issues such as the limits imposed on working hours by the European Working Time Directive, could restrict the role played by junior doctors and in turn jeopardise the audit process. We look below in Chapter Four at the implications of the Directive. Rick Porter, Clinical Director of Maternity Services at Royal United Hospital, Bath explained how routine audit at Bath, which he viewed as "a very important part not only of good housekeeping but actually of training the junior staff as well" had stalled:

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111. One of the most significant aspects of the audit process seemed to be the spirit in which it was undertaken. According to Professor Walker, this could be the factor which determined whether or not the audit yielded useful results:

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Undertaken in this way, audit might represent not just an attempt to review cases where caesarean sections might have been avoided, but to "share good practice, so that we do not reinvent the wheel all the time."[132]

112. We were disappointed to hear that so few caesarean section audits involved the views of users. The woman's experience is an important facet of the analysis of caesarean section rates and we recommend that maternity units consider this aspect of the audit process, even if women's views can only be sought through questionnaires.

113. We agree with those witnesses who told us that ideally the decision to undertake a caesarean section should be made in the physical presence of a consultant. Whilst this is not practicable within current staffing levels we believe that consultants should always be consulted over the decision to undertake a caesarean section except in the rare cases where immediate section is necessary. Although caesarean section is now a much safer procedure than it once was, we are concerned that some women undergo unnecessary sections on the recommendation of doctors who lack experience owing to the time limitations imposed by the New Deal and the European Working Time Directive on their training. This situation renders the process of auditing caesarean sections at individual maternity units all the more important as a form of training for junior staff as well as a means of ensuring that decisions made by consultants have been appropriate. We recommend that the forthcoming NICE guidelines on caesarean section should be supported by advice on audit procedures.

WHY DO CAESAREAN SECTION RATES VARY SO MUCH BETWEEN MATERNITY UNITS?

114. Beyond decisions on the individual cases subject to audit, we asked doctors and midwives to comment on what they saw as the underlying reasons for comparatively high or low caesarean section rates at their units. We heard again about the inadequacies of data collection methods as many staff members took issue with the caesarean section rates recorded by the Department of Health Statistical Bulletin, by guides based on these figures, such as those produced by Birthchoice UK, or by independent guides, such as those produced by Dr Foster.[133] For example, Lynne Pacanowski, Head of Midwifery at St Mary's Hospital, Paddington told us that figures for St Mary's had been artificially high as they had included caesareans undertaken at a privately-run maternity unit within the hospital.[134] Helen Jones, Midwifery Manager at Royal United Hospital, Bath said that rates had been skewed because the configuration of services in Bath, namely seven community units and an acute unit, could not be accommodated by the system used to generate statistics from the Maternity HES.[135]

115. Notwithstanding these discrepancies, the doctors, midwives, and user representatives we heard from were all aware that caesarean section rates at their units were higher or lower than the national average, and indeed than units in close proximity to their own. One reason given for high caesarean rates was the location and the nature of the population served by the maternity unit. Christoph Lees acknowledged the high caesarean section rate (26%) at the Rosie Hospital, Cambridge. He said that the rate was high because Addenbrookes Hospital (to which the Rosie Hospital is affiliated) was a tertiary referral centre, a centre of expertise for neonatology, obstetrics and fetal medicine and so "we have a much higher proportion of women who are delivering pre-term, who have severe pre-eclampsia,[136] who have babies with abnormalities and problems that have required help in the antenatal period."[137] Professor Lesley Regan, Consultant Obstetrician at St Mary's, Paddington, said that the 27% caesarean section rate at the unit could be explained in this way:

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116. We also heard from staff at other tertiary units who felt that this status might contribute to lower caesarean section rates. Dr Tracy Johnston, Clinical Director for Obstetrics at St Mary's Hospital for Women and Children, Manchester (which has a caesarean section rate of 18%) emphasised this:

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117. However, as Professor Walker from Leeds told us:

140

118. Dr Johnston from St Mary's, Manchester went on to say that "the other reason … that we have got such a low section rate for such a busy high-risk unit is that we have a massive consultant presence on the labour ward."[141] Staffing levels at obstetric units were acknowledged as a key influence on caesarean rates, not just in terms of dedicated consultant cover on labour wards, but also in terms of the midwifery establishment. Professor Regan from St Mary's told us starkly that in her view there was a direct relationship between high vacancy rates for midwifery staff and high caesarean section rates.[142]

119. Caesarean section rates can be influenced by individual obstetricians. Again, we heard the concerns raised by discussion of the decision-making process which led to caesarean section. Antony Nysenbaum from Trafford General Hospital compared his hospital's caesarean section rate of over 24% to that of St Mary's, Manchester:

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Beyond the issues of experience and confidence, the views of individual consultants may also have an impact on caesarean section rates. Mr Nysenbaum said that the presence of "two major interventionists for some years" constituted "one of the causes" of a high caesarean section rate.[144]

120. Rick Porter indicated that even in areas such as Bath, where normal births in community and midwifery-led settings tended to be encouraged by clinical staff and one third of deliveries took place in the community without assistance from a consultant, individual consultants might hold very different views on caesarean section and intervention in labour:

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121. We were concerned that in planning and booking their maternity care, women might not be fully aware, or indeed might not be made fully aware, of this variation in clinical practice or of the effect it could have on how their baby would be delivered. Julianna Beardsmore, representing women who used maternity services in Bath confirmed that:

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122. Such variations in clinical practice, while they might not compromise a woman's safety, may affect her role in making decisions on the mode of delivery for her baby if she does not have access to information on the risks and benefits of caesarean section. We are not convinced that it can be justified for women to have a significantly increased chance of a major operation because of an individual consultant's judgement of the risks of caesarean against normal birth and we hope that the NICE guidelines will create a consistency of approach across the country. Although we recognise the sensitivity of releasing individual consultant data we believe this data should be given to all users together with national and local comparisons so that women are aware of their consultant's caesarean section rate.

123. However, we also heard evidence that in a number of areas women were very much aware that there were different thresholds and beliefs over intervention in labour, and that they planned their care accordingly. These were the areas with maternity units in which individual consultants and their midwife colleagues seemed to work together according to a certain ethos which was apparent, and attractive, to women seeking low-intervention maternity care. Several units told us that they believed that such an ethos was the decisive factor in achieving comparatively low section rates. Professor Walker from St James's University Hospital, Leeds suggested that differences in caesarean rates could "relate to the attitude within the environment of the women themselves, the midwives and obstetricians … because of a philosophy that comes from within the hospital. Also, to some extent, women choose which hospital fits their philosophy."[147]

124. Dr Tracy Johnston from St Mary's, Manchester, outlined this philosophy in terms of its direct relationship to policy on caesarean section:

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Professor Walker also talked in specific terms about a collective belief that unnecessary intervention should be minimised, for example through encouragement of vaginal delivery of babies in the breech position (seen by some clinicians as an indicator for caesarean section), and through involving the women themselves by "following" their feelings.[149]

125. David Redford, a consultant obstetrician working for Royal Shrewsbury Hospitals NHS Trust, which had a caesarean section rate of under 11%, told us that once such a philosophy or culture was in place, it became self-perpetuating for two reasons. In relation to staff he stated "we have low intervention rates and once that is known we attract both midwives and obstetricians who like to practise in that way" and concerning the women cared for within the Trust, Mr Redford pointed out that:

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126. While this trend is most encouraging for those units in which staff are trying to maintain a culture of low intervention, it presents a serious obstacle for staff trying to reduce caesarean section rates in those units in which rates have historically been high. As Antony Nysenbaum from Trafford told us, "we know where we are going wrong; it is the ability to change that that can be very, very difficult."[151]

What can be done to reduce caesarean section rates?

REVIEWING MATERNITY CARE FOR WOMEN WHO HAVE HAD A PREVIOUS CAESAREAN SECTION

127. For staff at maternity units where the caesarean section rate is currently "probably higher than it needs to be", a major component of the strategy to reduce caesarean section rates is a careful review of provision of care for pregnant women who have undergone a previous caesarean section.[152] For many years it was accepted clinical practice for women who had delivered their first child by caesarean section to deliver all of their children in this way. However, there is now strong evidence to suggest that at least 70% of women who have had a previous caesarean section can go on to have a successful vaginal delivery.[153] The National Sentinel Caesarean Section Audit found a direct link between low rates of vaginal birth after caesarean section and high rates of caesarean section and recommended that in the absence of complications vaginal birth should be considered by all women who had undergone a previous caesarean section.[154]

128. The Audit also cited evidence that counselling after caesarean section and during subsequent pregnancy had an impact on the decisions a woman took in delivering her second child.[155] Christoph Lees told us that vaginal birth after a caesarean section for the first child was actively encouraged at the Rosie Hospital, Cambridge. He reported that over half of women who had one caesarean section attempted a normal delivery in their next pregnancy under the care of the unit: "we know that the risks are quite low for having a vaginal delivery after one Caesarean section and it is something we encourage and many women are very happy to do it with, of course, appropriate monitoring."[156]

129. Professor David James from Derby General Hospital confirmed that women undergoing repeat caesarean sections constituted the largest group within the overall total number of caesarean sections undertaken at the maternity unit. He said that staff at the unit made special arrangements to meet women who had delivered a baby by caesarean section to discuss their concerns about vaginal delivery.[157]

130. Other maternity units took similar approaches to care for pregnant women who had a caesarean section. Cathy Rogers from Barnet and Chase Farm Hospital argued that helping women to consider vaginal birth after a caesarean section depended on making contact with them at an early stage:

158

Antony Nysenbaum told us that "careful discussion about mode of delivery … does take time" but that "most women" would often then "opt for aiming for a normal birth—successfully."[159]

REVIEWING POLICY ON INTERVENTION IN LABOUR

131. Maternity units have used caesarean section audits to develop a number of other strategies to reduce rates. One of these strategies has been to review practice with regard to electronic fetal monitoring (EFM), which is directly associated with caesarean section. While it may be a vital aspect of care for women who have had difficult pregnancies and where there are complications in labour, use of EFM does not lead to better health outcomes for women who have had low risk pregnancies and guidelines issued by the NICE in May 2001 recommended that EFM should not be used with low risk women on admission to a maternity unit.[160]

132. This recommendation marks a shift in policy and practice relating to fetal monitoring as until recently every woman arriving in hospital in labour was routinely monitored using EFM for 20 minutes, a practice known as the 'admission trace'. A great many midwives doubted the benefit of EFM on admission to hospital as they saw that the monitoring equipment could restrict a woman's choices with regard to her position and movement, and worried that the reassurance of EFM might permit doctors and midwives in busy wards to leave women unattended in labour. As Helen Shallow, Midwife Consultant at Derby City General Hospital explained, lower levels of intervention combined with higher levels of support in labour might reduce the likelihood of caesarean section becoming necessary:

161

133. For these reasons, NICE guidelines on EFM were welcomed by members of maternity care teams who have used them to implement and support a change in policy. Catherine Eccles, Chair of the Maternity Services Liaison Committee at St Mary's Hospital, Paddington, told us that women welcomed the change to the policy of 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."[162]

134. Similar developments have taken place in respect of induction and augmentation of labour using drugs and in June 2001 NICE issued guidelines on induction in order to reduce the risk of stillbirth in ongoing pregnancy "without increasing the caesarean section rate."[163] Once again, caesarean section audits had indicated a direct relationship between high induction rates and high caesarean section rates, and a renewed focus on induction policy was seen as a way of reducing the likelihood of caesarean section. Rosemary Connor, Head of Midwifery at Trafford General Hospital, described the rationale behind her unit's review of induction policy:

164

This policy has had a dramatic impact on the induction rate, which was approximately 28% in 2000-01 but has since fallen to 24.2%.[165]

135. Reducing induction rates involves discussion and counselling as well as revised policy on clinical procedure. At St Mary's Hospital for Women and Children in Manchester, no woman is induced until she is ten days beyond the full term of her pregnancy (term plus ten). After that, Dr Johnston told us, the woman is given "informed choice" on how to proceed: "It is a case of sitting down and giving the options … quite a lot of women will say: 'that is fine. As long as you are monitoring it, it will be fine and I will carry on."'[166] At Bath, where labour is induced at term plus 12 days, Helen Jones, Maternity Services Manager, told us of a new initiative whereby women booked inductions with a midwife rather than a consultant. The midwife's counselling, it was thought, might help women to consider all the available options.[167]

136. We strongly endorse innovative approaches to reducing caesarean sections which involve women in detailed discussion about their maternity care and help to raise awareness of the risks and benefits of the different kinds of intervention in labour. We believe that this involvement is key to a positive experience of childbirth and of maternity care, and that the development of strong relationships between women and well-trained, confident midwives is crucial. The information gathered from discussion of previous experiences could be vital to the development of maternity services, particularly in relation to caesarean section. We recommend that information from women on their previous caesarean section should be incorporated into audits.

137. We are encouraged to hear that maternity care staff value NICE guidelines and evidence based on research commissioned by the Department as tools for developing strategies to reduce caesarean section rates and to increase 'normal' birth rates. We recommend that the Department continue to support research and evidence-gathering initiatives and in particular the work on caesarean section audit.

INCREASING CONSULTANT SUPPORT FOR WOMEN IN OBSTETRIC UNITS

138. The key to all of these strategies for implementing policies to reduce caesarean section rates is time spent with a pregnant woman; discussing her care and advising her of her choices. Consultant input in discussions can be particularly important, both in the initial stages where women are making choices about their care, and during labour. Alex Silverstone, a user representative at St Mary's, Manchester was certain that caesarean rates at the unit were kept lower (18%) than the national average (21.5%) on account of consultant availability:

I think a lot of it is that they have easy access to consultants, and the consultants do sit with them and talk to them. They explain it. They do not talk them out of it. There is definitely informed choice … if she is very worried—she might have had a very traumatic experience the time before with a caesarean—they will listen to her and will continue to listen. It is not just that one point at the beginning; when she goes back again she is listened to and supported.[

168

Dr Johnston, Clinical Director at the same hospital emphasised the importance of a consultant presence on the labour ward, particularly if less experienced doctors were caring for a woman:

169

139. Along with all of the other consultants who spoke to us during our inquiry, Dr Johnston stated that a woman's choice with regard to caesarean section must be respected. However, she was insistent that making time to provide women with information on which to base their choices, did yield results in terms of keeping caesarean section rates under the national average rate:

170

INCREASING MIDWIFERY SUPPORT IN COMMUNITY AND IN OBSTETRIC UNITS

140. There was consensus amongst our witnesses that continuous midwifery support, antenatal and intrapartum, was just as important, if not more important, than consultant presence on a labour ward or in a clinic. Lynne Pacanowski, Head of Midwifery at St Mary's, outlined the unit's strategy to reduce caesarean section rates by creating more community-based caseload teams.[171] Professor Regan from St Mary's Hospital, Paddington, having linked a high midwifery vacancy rate to a high caesarean section rate said that "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."[172] The proof of this, we were told, could be found in the results of an audit of a case load team of midwives working with women in the community. The caesarean section rate for women cared for in this way was 15%, as opposed to the 27% rate overall.[173] Professor Regan outlined for us the system of care which yielded such a substantial reduction in caesarean section rate:

174

141. Once again, the key to reducing caesarean section rates seems to be time spent with a pregnant woman, advising and reassuring her, supporting her from the time she makes contact with a unit to book her maternity care through to the early stages of her baby's life. Indeed this kind of support is vital to a healthy outcome, not just in terms of mode of delivery but also in terms of the development of early bonds between a new mother who is relaxed and confident in her care, and her baby. However, as we heard from all too many maternity units, this kind of support can be difficult, or even impossible, to provide if services are blighted by staffing problems.

142. Based on evidence we heard from maternity units, we see a relationship between high rates of caesarean section and low levels of staffing. It seems to us unacceptable that a woman should undergo a surgical procedure that might have been avoided had she been better supported during pregnancy and/or during labour. It is clear from strong evidence that one of the most important means of reducing the caesarean section rate is to provide adequate support for women in labour. The level of staffing and organisation of care should enable women to be supported at all times.

72 Ev 163 Back

73 Department of Health, Statistical Bulletin NHS Maternity Statistics, England 2001-02. 2003/09, May 2003 Back

74 Ibid. Back

75 Caesarean Sections, POSTnote 184, Parliamentary Office of Science and Technology, October 2002. Caesarean section rates in private hospitals are often higher than in NHS maternity units. For example, the Portland Hospital in London has a caesarean section rate of approximately 44%. However, only around 0.5% of births take place in the private sector and so this has little impact on national statistics. Back

76 Thomas, J., and Paranjothy, S. Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. National Sentinel Caesarean Section Audit Report. RCOG Press, 2001, p 2 Back

77 Ibid. Back

78 Caesarean Sections, POSTnote 184, Parliamentary Office of Science and Technology, October 2002 Back

79 Having a Baby in Europe, World Health Organization, Copenhagen, 1985 Back

80 Ev 207 Back

81 Hall, M.H. and Bewley, S. "Maternal mortality and mode of delivery", Lancet 354 (1999), pp 776-79 Back

82 Memorandum from Martin England (MS6) (not printed) Back

83 Hall, M.H. and Bewley, S, "Maternal mortality and mode of delivery", Lancet 354 (1999), pp 776-79; Hofmeyr, G.J., and Hannah, M.E. "Planned caesarean section for term breech delivery." Cochrane Library. Issue 4, 2001. Back