Examination of Witnesses (Questions 40
- 59)
TUESDAY 17 JUNE 2003
MS BEVERLEY
LAWRENCE BEECH,
MS SARAH
MONTAGU, MS
ANNIE FRANCIS,
MS BELINDA
PHIPPS, MS
LOUISE SILVERTON
AND PROFESSOR
WILLIAM DUNLOP
Q40 John Austin: It has not become
a fashionable, lifestyle—
Ms Phipps: No. Some of our private
hospitals have very high caesarean rates and are frequented by
those people who tend to appear more regularly in the newspapers;
but it definitely over-emphasises the amount of choice there is
for caesareans. There are, obviously, valid reasons for a woman
choosing a caesarean section, the least of which is a very traumatic
vaginal birth, using forceps, or something that has been badly
mismanaged. I can fully understand and would want to support a
woman who felt that that was her best choice the second time around.
There are some women who do have phobias or whatever, and if they
are not resolved by other means, that may be her best option.
Some of those would not be counted as medical reasons, but they
are very valid reasons for maternal choice. However, many more
women have a caesarean section not by choice but by dint of not
being properly cared for, and a large number of emergency caesareans
come under that category, where the woman, to all intents and
purposes, could and should have had a straightforward birth, but
by the care not being what it should be, by midwives not being
available, by maybe junior doctors being a little more proactive
than they needed to be without a consultant there had the experience
and knowledge to wait, women are now having more caesareans than
they want or need.
Q41 John Austin: But the choice that
a woman exercises may be influenced by an assessment of risk.
That assessment may particularly be taken by an obstetrician.
Ms Francis: The woman should be
given the information. If she is choosing a caesarean, she must
know the effect on her risk of—
Q42 John Austin: So someone will
make an assessment of the risk and possible outcomes, and that
will clearly influence the woman's decision. Do you think that
a woman in exercising that choice should have access to information
about the rates of caesareans carried out in a particular clinic
by a particular obstetrician?
Ms Phipps: If she thinks it would
help her make the decision, yes, she should.
Professor Dunlop: No problem at
all, but of course it is important that you look at case mix when
you produce that information so that you are not preparing a very
high risk unit with a lot of tertiary referrals with a very low
risk unit which might have a low caesarean section rate.
Q43 John Austin: It may be that in
some units some obstetricians may be more inclined to carry out
caesareans where the risk may not be as great.
Professor Dunlop: We will of course
have a NICE guideline on caesarean section coming out next year,
and I would hope that that would lay down clearer indications
for audit of caesarean section and good practice.
Q44 Julia Drown: Some of us are not
entirely clear about how much NICE is going to make judgments
on these issues. One of our witnesses was quite relaxed that different
consultants would come up with different judgments on the same
woman in the same situation, about whether or not they should
have a caesarean. Some of us round the Committee felt uncomfortable
that it might depend on who you were with whether you end up with
a major op or not.
Professor Dunlop: I suspect that
is true throughout medicine; it is not just in relation to caesarean
sections.
Q45 Julia Drown: There are such large
variations
Professor Dunlop: I do not think
that you can legislate to change this. Changes in attitudes are
needed, informed by clear guidelines.
Q46 John Austin: We have seen a significant
rise in the proportion of caesarean deliveries, and a major variation
between—
Ms Phipps: The assumption that
has been built in here needs challenging. It is being assumed
that it is the consultant making the assessment and the decision
about the sort of birth a woman has. I think that does need to
be turned on its head. The woman needs to be party to the discussion,
and she needs to have the information so that she can, with the
consultant's information on risk, draw up, along with knowledge
about her own life and her own feelings, make a decision herself
about whether or not she is going to have a caesarean.
Ms Silverton: There is research
undertaken by CASPE, which shows that there is a link between
midwifery staffing shortages and caesarean section. We talked
about women feeling empowered to be pregnant, to be becoming mothers.
What has happened is that we have lost the time for antenatal
care. Women come to labour unprepared. They are terrified of labour.
They have got no idea of what it is. They try and control it.
A quarter of their friends will have had a caesarean section,
and perhaps a caesarean section in their mind gives them some
certainty; but they do not actually realise that it is major abdominal
surgery. There is some light at the end of the tunnel. In Wales,
with the normal care pathway, which they have been using to address
various aspects of care in labour, in one trust, where they had
a caesarean section rate of 18%, their caesarean section rate
fell down to 8%, and has now crept up to between 10 and 12. That
is Llandough, which is not the high-risk South Glamorgan Trust,
but has quite a good cross-section of women; it is not entirely
low risk. If that can be achieved there, by midwives simply having
to look at why they are deviating from the normal care pathway
for women, what could be achieved across the rest of the country?
Ms Beech: One of the problems
with increased caesarean section rates—we are certainly
seeing many more women coming to us now who have been told, "you
have got a breech baby and thanks to the Hannah trial, you have
to have a caesarean section". They very much feel that they
do not have a choice, and that is happening with women with twins;
they too are told it will be a similar exercise.
Q47 Julia Drown: Women should be
told about the results of that trial.
Ms Beech: Absolutely.
Ms Montagu: Some of the results
of other trials show slightly different results as well. The Hannah
trial is not definitive by any stretch of the imagination.
Professor Dunlop: Do let us be
clear that it is the best available evidence. It is a prospective
randomised control trial which came to very clear conclusions
and was recently supported by another retrospective analysis from
the Netherlands suggesting that there is a substantial risk associated
with vaginal breech delivery. We should not try to pretend that
that is not the case. That does not mean that we should not be
making efforts to reduce the incidence of caesarian delivery—and
you can reduce breech presentation by 50% to about 2% at delivery,
by using external cephalic version.
Ms Beech: We are—
Professor Dunlop: So you are not
talking about ECV—it is significant, but it is not a huge
impact.
Q48 Julia Drown: In our first report,
the evidence showed that two-thirds of women were not being offered
the turning-round. Why is that?
Professor Dunlop: I think that
was the result of the national caesarean section audit. I think
you will probably find that things are changing. Can I just say
in relation to caesarean section, there is increasing evidence
that if you have an experienced obstetrician available in the
labour ward, that intervention rates reduce. That would be the
personal experience of many of us. You probably know that our
college, with the other colleges and midwives and the NCT, in
a report called Safer Childbirth recommended that there
should be a minimum of 40 hours' consultant cover in labour wards
for units delivering more than 1,000 births. At the time of the
national caesarean section audit, it was about 16% of units that
could achieve that. In 2001 the RCOG data suggests that that has
gone to 30%, and last year, 2002, up to 40%; so there is clear
evidence of increased consultant presence at least at delivery.
Ms Francis: I should like to suggest
a quite simple way of reducing the caesarean section rate. I heard
on Friday from somebody who works at St George's Hospital, Tooting,
where they have finally got rid of the admission trace, use of
CTGs routinely in labour. The first figures through after that
decision was taken shows a 5% drop down to 18% in sections. It
is one of those things that has been known about. All the research
has shown very clearly the effect of continuous monitoring, and
yet we are still seeing it happen in most units.
Ms Beech: Can I challenge the
comments that were made on the Hannah trial? Yes, it certainly
showed that vaginal deliveries by obstetricians have produced
far less satisfactory results than a caesarean section. What that
study has not shown, and what it has been severely criticised
for, is that it did not examine a midwife-managed vaginal birth;
and it is a very different technique. The midwives would say that
they have far better outcomes—and that is the study that
we need.
Q49 Julia Drown: What were they studying
as a comparison?
Ms Beech: The obstetricians who
were doing an obstetric breech delivery, ensure that the woman
is usually on her back, with her feet in stirrups, and she will
probably have a forceps delivery, and then the baby is manipulated
as it is born. When midwives deliver babies by the breech, they
encourage the woman to adopt a position that she feels happy with—and
she is usually on her hands and knees—and they do not manipulate
the baby's head as it is born.
Professor Dunlop: Let us just
get it absolutely clear. There is no evidence to support that
hypothesis that would bear comparison with the Hannah trial.
Ms Beech: And there is no evidence
to say that vaginal breech delivery is less safe than caesarean
sections. That trial did not show it; it showed that obstetricians
delivering babies vaginally when compared to caesarean sections
have far worse experiences. Experienced midwives have a different
approach, and this was not considered by the Hannah study.
Ms Phipps: The issue is not whether
the data is this, that or the other; the issue is that women who
have got a breech baby should be offered the opportunity to have
it turned, which they can accept or decline; and they need to
know the pros and cons. They should then be talked through the
results of that trial and the other evidence that exists, including
whatever we have from independent midwives, so that they can make
a decision. It is not about us making decisions for women. They
are adults and they are just about to become parents and care
for another human-being. Pregnancy is a very good time to start
to make sure that they are making choices for themselves and for
their future children.
Ms Silverton: The increase in
caesarean section rate is further worsening the workload on midwives
because it takes a lot longer to look after somebody who has had
a caesarean section. It does, bizarrely, result in midwives caring
for those women who are having caesarean sections, whereas women
at low risk in normal labour are often left alone. This is what
troubles them. I think it is the fear of being left alone which
is very bad for midwives. We know Grantly Dick-Read's work on
the cycle of fear; and fear causes pain, and pain makes labour
dysfunctional.
Ms Beech: Women feel comfortable
in different settings. There are women who feel comfortable in
a hospital, in a high-tech unit with all the technology you can
possibly have and it is no good giving them other kinds of care
because they will not do as well.
Q50 Dr Taylor: Are there enough vaginal
breech deliveries for obstetricians and midwives to keep up their
expertise?
Professor Dunlop: That is not
part of a midwife's normal duties.
Ms Beech: It used to be but it
became taken over by obstetricians who said this was now a high
risk situation, so midwives lost their skills.
Q51 Dr Taylor: Are there any midwives
delivering breech babies vaginally now?
Ms Francis: Yes. I would question
the use of the word "delivery". Women are birthing breech
babies usually at home with independent midwives because we are
unable to go into trusts. They are being born very successfully.
Q52 Dr Taylor: These are breech births
of which you are aware which have not been turned?
Ms Francis: Absolutely. They are
breech births where the woman is aware that it is a breech presentation.
She has looked at the options. We are very clear about talking
through the options and the woman making the choice. We will support
her in that choice. What we are missing is that the number of
breech babies who are undiagnosed in labour is absolutely crucial.
It is crucial that midwives know how those babies are best born.
That is a big area of morbidity.
Q53 Dr Taylor: There are still, despite
scans and everything, a number which come the wrong way round?
Ms Francis: Yes. It only takes
a few minutes for a baby to decide to turn round.
Professor Dunlop: There have been
some quite high profile legal cases in recent times of breech
babies dying at home.
Ms Francis: Statistically, everybody
is aware that breech babies may be presenting breech because of
problems. It is very easy to look with hindsight and say, "It
was because of this and that" and that is one of the difficulties.
If women and their independent midwives could go into hospital
and have those babies born in hospital with an independent midwife
and there was a different issue, we could then have a helping
hand to call. We are being denied that.
Ms Montagu: It is not just that
independent midwives are not able to go in with women; it is also
that the women know, if they go into hospital with a baby presenting
by the breech, about the amount of pressure they will come under
to conform to the generally accepted way of giving birth and if
they do not want a birth like that they often will stay at home
even though home is not the ideal place. Yes, the idea would be
to go into the hospital with someone skilled in attending an ordinary
birthing of a baby by the breech and to have all the assistance
on hand, should it become necessary. That is very often not available
and the woman does not feel that there is any choice.
Q54 Dr Taylor: One of the things
that has come out of our inquiry so far is that the standard of
data collection is abysmal pretty well across the country and
it is crucial. We were impressed with the Scottish data system.
People seem to approve of that. If we had that system here, would
the attitude to the importance of data collection alter? I got
the impression that you, Professor Dunlop, were very keen on it
and some of the others felt it was rather less important.
Ms Phipps: We are very keen that
data is collected. It is not right that the data is poor because
then we end up with arguments because we do not have the information
upon which to base it. However, we must not assume that the data
set is the only information out there because it is not. There
is a great deal of research. The data set should be complete and
the Scottish model is very good, and the way we do it in England
is poor. If you go into an NHS trust, the front end users are
collecting data for multiple purposes, many of whom never see
the data to use it again. It is a well known part of any IT knowledge
that if you want people to collect good data they have to have
access to that data in a way they can use for themselves and we
do not do that in England.
Q55 Julia Drown: Could we just adopt
the Scottish system?
Ms Phipps: I do not know it well
enough just to say yes, but it needs close attention paid to it.
I think it would be a useful thing to do.
Professor Dunlop: It is a simple
system. It relies on a small amount of data collection and it
is consistently done. I have no doubt we should be looking at
this but it is important to remember that Scotland is a small
country. It has a long history of data collection in this area
and it also has a larger health budget.
Ms Beech: There is however a major
flaw in the data collection and that is when they are collecting
data on the numbers of normal births. Ask hospitals how many normal
births they have and invariably they will claim to have 60, 70
or 75%. The research that Soo Downe did looked at what was defined
as normal and it did not include artificial rupture of membranes,
inductions, accelerations, epidural anaesthesia and episiotomy.
If you remove that, you get the figure closer to what is a normal
birth. If we are going to be talking about an objective of having
a good number of women with normal births, we need to get away
from the data collection which merely talks about vaginal delivery.
Q56 Julia Drown: I wanted to ask
you whether you would agree on what a normal birth was and I was
going to ask Louise what she thought a normal birth was and then
see if anybody else had a view.
Ms Silverton: I am going to talk
about the Scottish maternity data system first. I do not think
we could just lift it and use it. There is a maternity minumum
dataset which has been developed in England. Where it has gone
nobody knows but our College did contribute to developing that.
I think it is important to remember that the system has to be
able to collect the model of care with agreed definitions that
we are giving now. It has to be able to record the midwife-led
care and not only where somebody is booked under an obstetrician.
It has to be able to record home births. At the moment, the Scottish
system is not good enough for that but it does integrate with
the child health system. They have very good breast feeding statistics
which continue. As to a normal birth, this is something on which
we have had very long arguments. The induction of labour has not
tended to be considered as normal so that can be ruled out. The
issue of epidural anaesthesia is very difficult because now in
some units more than 50% of women have that and it does interfere
with the physiology of labour. You can again rule that one out.
We are minimising the number of women. Artificial rupture of membranes:
again, we need to look at the research and ask why that has been
done. We have to wait for the outcome of the RCM's Institute for
Normal Birth which we are currently developing as a virtual institute,
which is to do with promoting those aspects of care which enhance
normal outcomes and include things like women being mobile during
labour, having access to food and drink, having access to the
use of water and the feeling of a supportive environment for her,
whatever that is.
Q57 Julia Drown: I can tell even
from your description that I am not going to get an agreement
from you all about what a normal birth is. In terms of us as a
Committee making recommendations, when we talked to the individual
units one of the things that came across was they all wanted to
do more particularly to look at the Caesarean rates, to try and
give more choice to the women but they were all under huge pressures
to do so. It was as if they did not have the time to think, to
change. One obvious solution to that would be to have a change
team in each trust that wanted it to help support them, perhaps
using independent midwives or other medical staff, to give the
people there time to think about their model of care and how they
could change it. Would you think that sort of thing would be a
good idea? I know that happened with Changing Childbirth and it
did not deliver. I do not want us as a Committee to give exactly
the same recommendations as happened 10 years ago and fall into
the same trap.
Ms Francis: That is why we wanted
to put forward our model of care, sitting parallel to the existing
structure. The difficulty is that when you look at the whole system
as it stands at the moment it is overwhelming. Where do you start?
How could you start to change it? The idea of critical mass is
very much part of that. There is a very simple step, if it was
to be offered as an option, so that women could choose the model
of care that independent midwives offer. The midwife is paid a
set fee by the trust, or whatever organisation could best do that,
and that midwife then looks after a set number of women. The midwife
is able to decide for herself. That way, midwives are happy; the
women are happy and, in the long run, what will happen, we very
strongly believe, is that those numbers will grow. Word of mouth
etc., will be such that more and more will opt for that.
Q58 Julia Drown: The issue is still
to solve the various insurance issues?
Ms Francis: Yes, except that if
we were able to contract in, in the same way as pharmacists do,
into the medical model, we would be able to be covered by vicarious
liability. The midwives at the moment are short within the system.
As a starting point, we would be offered vicarious liability in
exactly the same way. However, we would like to see a change in
the system towards no compensation or something similar.
Q59 Julia Drown: You would be covered
by the trust insurance in that case. Would that be an honorary
contract for each independent midwife?
Ms Francis: No. It would be about
contracting in. It would be an agreement but the midwives are
self-employed and agree a set number of women that they would
look after. We believe it would be very simple to set up.
Ms Silverton: I think a change
is a good idea but you need to give them some resources. If you
look at what is happening in Scotland with the Expert Group on
Acute Maternity Services for their maternity services framework,
they have put quite a lot of money in for training midwives to
be able to move from being medicalised and hospital based to being
much more women centred and working in free-standing maternity
units.
| 
