Caesarean section
98. In our first report, we discussed the issue of
rising rates of caesarean sections in considerable detail.[71]
Around 63% of caesarean sections are classified as "emergency
procedures". Health professionals and academics vary in their
explanations for the rise in numbers of emergency caesareans,
which include the use of continuous electronic fetal monitoring,
the use of protocols which specify that labour must proceed to
a set timescale, and the de-skilling of both midwives and junior
doctors in 'normal' birth. Given nearly all women who have no
need for a caesarean section prefer not to have one and given
the evidence that the current rise in caesarean sections does
not improve outcomes in maternity services, the rising rate of
caesarean sections suggests women are not being able to follow
what would be their choice of delivery method.
99. The Department's evidence to us suggested they
wished to resist getting involved in whether the rising caesarean
rate was a good or bad thing. They told us they were "well
aware of the debate", that there was "not sufficient
evidence or medical consensus about the desirability and what
the optimum caesarean section rate should be" and that the
National Sentinel Caesarean Section Audit "did not show that
caesarean section is unsafe".[72]
However the evidence does suggest that if it is not clinically
indicated vaginal births are safer than caesareans and have fewer
long term adverse consequences for women. The evidence we received
suggested a consensus that more needs to be done to tackle the
rising rate and the variation in rates across the country and
we would again urge the Department to tackle this issue.
100. Elective caesarean rates have risen, in part,
perhaps, because of the increasing inclination of obstetricians
to perform a caesarean for a breech or a twin birth. It is not
within our remit to comment on the efficacy or safety of different
clinical practices. However, many witnesses have argued compellingly
that the increase in the caesarean rate reflects the effective
removal of informed choice from a large number of women who would
have preferred to be given the option to give birth naturally.
101. Informed choice here may be compromised in two
ways. First, choice may be restricted if units implement policies
effectively prohibiting certain types of clinical practice, for
example vaginal breech births, or vaginal birth for twins. For
example, in our first inquiry we found that around two thirds
of women were not being offered the turning round of a breech
baby.[73]
Applying predetermined clinical policies will often mean that
women will only receive information about that hospital policy,
and finding out about possible clinical alternatives will be very
difficult. Secondly, although different clinical choices may be
offered to the woman during delivery (for example between opting
for a caesarean section on the basis of a trace abnormality, and
taking a 'wait and see' approach), the options may be presented
in such a way that the woman feels that the only decision which
is 'allowed' is that favoured by the health professional advising
her. This is clearly particularly important given the extreme
vulnerability of women giving birth and given the natural tendency
of many people to defer to 'experts'. While the lead health professional,
whether a midwife or an obstetrician, has a professional duty
to give advice based on what he or she judges to be the most appropriate
course of action, it is vitally important that the woman is able
to receive clear and unbiased information about the risks and
benefits of both, so that she can make an informed choice.
102. A birth story printed in the Daily Telegraph
to coincide with the publication of our first report, illustrates
well how information can contribute to positive experiences and
outcomes: Jane Dawson knew that her baby was breech, and after
an unsuccessful attempt to turn the baby, and discussions with
her clinicians, Ms Dawson chose a planned caesarean, and reported
that "Knowing all the options and being talked to as an equal
partner in the birth team was crucial. I felt I was well cared
for".[74]
103. The evidence we have received suggests that
women-centred care would be best achieved by the Government adding
to the weight of opinion we have heard in favour of an increase
in normal births. We recognise that for some women—probably
less than 20%—medical interventions including caesareans
are desirable and will improve outcomes. But given that the national
rate of interventions is now well above this we would like to
see maternity service managers setting themselves objectives to
increase normal births as part of an audit cycle. This could include
actions to improve facilities, control and choice for women in
the birth environment, to ensure women receive one to one support
during labour and training to promote normal birth to all staff.
NICE guidelines and the forthcoming NSF should emphasise that
birth is a physiological process to be facilitated and not a medical
problem and should reflect this consensus to see an increase in
the normal birth rate.
Choice in neo-natal and post-natal
care
104. First Class Delivery noted that women
made more negative comments about hospital postnatal services
than any other aspect of their maternity care. It recommended
that trusts should have flexible policies on length of stay and
that they should consult women about their postnatal care. The
report also recommended that trusts should provide support, information
and practical help so that parents of babies in neonatal units
could be involved in their baby's care.
105. The NCT drew our attention to a range of problems
in postnatal care.[75]
In their view, while the length of stay of a woman in hospital
had been "cut dramatically" over the last few years,
there was no evidence that there was adequate support in the community
to replace in-hospital care. The NCT pointed out that some women
might want more support in, for example, breast feeding in the
days after birth, and that it was wrong always to assume that
someone would be there to support a woman at home. They noted
that in busy consultant units women were seldom offered choice
as to length of hospital stay, whereas in smaller midwifery led
units length of stay after birth was often four or five days,
and breast feeding rates (and confidence to breast feed) were
often high.
106. We hope
that the NSF will include choice for women on the length of time
they can stay in hospital or in a midwife-led unit after birth
and allow for flexible support in the community for up to eight
weeks from midwives and health visitors working as a team.
50 Appendix 3, para 3.3 (RCM). Back
51
Ibid. Back
52
Appendix 1, para 2.3 (Department of Health). Back
53
Ibid., para 2.4. Back
54
Ibid., para 2.6. Back
55
Ibid., para 2.2; Appendix
5, para 2.2. Back
56
Appendix 15. Back
57
Ibid. Back
58
Q 48; cardiotocographs measure fetal heart rate relative to the
woman's contractions. Back
59
Appendix 5, para 2.3. Back
60
Appendix 5, para 1. Back
61
Appendix 14. Back
62
Appendix 14. Back
63
Appendix 5, para 2.6. Back
64
Q 133 Back
65
Q 134 Back
66
Inequalities in Access to Maternity Services, Q 70. Back
67
Appendix 4, para 16.2. Back
68
Q 79 Back
69
Q 80 Back
70
Q 80 Back
71
For the Committee's discussion of the fraught issue of choice
in caesarean section, see Provision of Maternity Services,
paras 90-104. Back
72
Provision of Maternity Services, Ev 162. Back
73
Provision of Maternity Services, Q 48. Back
74
The Daily Telegraph, 24 June, "Pleasure, pain and
complicated deliveries". Back
75
Appendix 5, para 4. Back
