Select Committee on Health Written Evidence


APPENDIX 8

Memorandum by The Portland Hospital for Women and Children

1.  INTRODUCTION

  This document has been prepared to add value and insight to the deliberations of the Maternity Services Sub-committee in its current inquiry into Choice in Maternity Services. We will provide further information and appropriate witnesses if required.

2.  CONTENTS

  We have provided information on The Portland Hospital demonstrating its expertise in clinical experience, facilities and patient outcomes as a "fact sheet" appendix, plus our analysis of current maternity choice, available statistics and our recommendations for future monitoring and assessment of that choice.

3.  ANALYSIS OF CURRENT MATERNITY CHOICE

  We firmly believe that pregnant women should have a comprehensive range of choices on the method of delivery of their baby to provide confidence and comfort in the decision and in the team who will provide support pre and post delivery.

  3.1  It is essential that individual decision-making is based on:

  3.1.1  Full information on the delivery options [home or hospital; with or without anaesthetic drugs; other pain management and relaxation opportunities; with or without surgical intervention; established and new procedures] including outcome statistics.

  3.1.2  clear understanding of the related risks for the mother and her child of the various delivery options.

  3.1.3  full, professional assessment by a specialist, qualified doctor in obstetrics of the mother and child's medical condition and the clinical indications for the various methods of delivery.

  3.2  At the Portland Hospital, all patients, including pregnant women, are under the care of a specialist consultant. Pregnant women are under the care of a Consultant Obstetrician, even if they choose to have a midwife-led birth and are seen personally by that consultant.

  3.2.1  That approach ensures that each patient has the full benefit of expert, professional clinical assessment, advice, support and, as necessary, intervention.

  3.2.2  This level of experienced clinical support and guidance provided to the pregnant mother ensures that the advice given is not predicated on emotion, nor on personal enthusiasm for a particular delivery method

  3.3  Maternity choice should be comprehensive—including the opportunity to be transferred to another centre that offers, for example, water births if that is the patient's choice and there is no clinical contra-indication

  3.4  There should be no circumstances under which a patient is driven to accept a particular method of delivery, other than because of the clinical risk to the mother or baby of alternatives.

  3.4.1  To achieve this on a national basis, the current shortage of midwives must continue to be addressed and there should be no reduction in obstetric bed and related staff availability without a clear analysis of the local population profile to determine resource need. In some parts of the country there may be some need to increase obstetric resources.

  3.4.2  In addition to obstetric bed and related staff resources, there is a shortage in some parts of the country of neonatal intensive care and special baby care units for the post-birth care of premature and other sick babies.

  3.5  Where there are obstetric and neonatal care resources, including in the private sector, they should be an integral part of care planning to ensure that maternity choice is maintained.

  3.5.1  The Portland Hospital is part of that planning for some central London Trust hospitals.

  3.5.2  It receives some NHS patients for deliveries each year when appropriate NHS resources are unavailable or fully used, including for insured or uninsured patients requiring a medically indicated caesarean section or to provide necessary neonatal intensive care facilities

  3.6  Any resource shortage—however temporary—may restrict patient choice in maternity services, particularly at the time of delivery

4.  DEFINITIONS

  The basis of data collection does not allow full analysis of the drivers of growing caesarean section rates in the UK and other western countries, nor does it allow clear analysis of delivery outcomes for each delivery option.

  4.1  At present all UK caesarean section data is sorted into two categories:

  4.1.1  Elective caesarean sections—those that are planned before or at the onset of delivery, whether for clinical reasons or by specific patient choice alone.

  4.1.2  Emergency caesarean sections—unplanned prior to the onset of delivery.

  4.2  The term "elective caesarean" has become an almost derogatory term in popular parlance, and is in no way understood to include clinically required planned procedures—public assumption and understanding is that "elective caesarean sections" are entirely a matter of complete patient choice.

  4.3  Department of Health Maternity Services Reports provide no breakdown on:

  4.3.1  The reasons why caesarean sections are planned.

  4.3.2  The clinical reasons for emergency caesarean sections.

  4.3.3  The statistical outcomes of delivery methods.

  4.4  At the Portland Hospital, our assessment is that around 50% of elective [planned] caesarean section births at the hospital are for clinical reasons.

  4.5  Increasing maternal age has been identified as a factor in growing Caesarean section rates.

  4.5.1  The Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit published the National Sentinel Caesarean Section Audit Report in 2001 identified an increased incidence of Caesarean section births in line with increased maternal age.

  4.5.2  For example in London, it identified that the rate for women in London aged 35-39 was 31.6% and for those over 40 years was 37.5%, against a London average rate of 24.2% and a national average rate of 21.5%.

  4.5.3  The Parliamentary Office of Science and Technology [October 2002] acknowledges the same point.

  4.5.4  No correlating data is routinely available on maternal age [Department of Health Maternity Services Report for 2001-02 published in May 2003 provides no data on maternal age and enquiries reveal that none was collected for this report.]

5.  STATISTICS

  Caesarean section rates have been increasing for more than a decade in many western countries. The current rate in some institutions in Brazil is now 60% and more than 30% in the USA.

  5.1  In the UK, according to the Department of Health Maternity Services Report for 2001-02 published in May 2003, the caesarean section rate has increased

    —  From10.1% of 574,600 NHS births in 1982.

    —  To 12.9% of 652,100 NHS births in 1991-92.

    —  To 22.3% of 541,700 NHS births in 2001-02.

  5.2  There is greater growth in "emergency" caesarean sections than in "elective" procedures in the period shown in these national NHS figures.

  5.2.1  Growth in emergency caesarean sections from 1982 to 2001-02 of 122.83%.

  5.2.2  Growth in elective [planned] caesarean sections in the same period of 90.6%.

  5.3  There is no breakdown available in these national statistics to allow analysis of the reasons for emergency elective caesarean sections to help determine the drivers of growth.

  5.4  There is no breakdown available in these national statistics to allow analysis of elective caesarean sections to determine what proportion is clinically indicated and the reason for the clinical indication.

  5.5  There is no statistical breakdown in these national statistics of the age profile of the mothers.

  5.6  These national statistics are for NHS births only and for a total picture, the same data could be easily collected from the limited number of private hospitals registered for obstetric procedures to provide a complete set of data for analysis and publication.

  5.7  This national NHS data identifies a number of regional variations and even greater variation from one hospital to another.

  5.7.1  Total Caesarean section rates vary from 20.1% to 24.5% by region.

  5.7.2  Elective [planned] Caesarean section rates vary from 8.3% to 10.1% by region.

  5.7.3  Emergency Caesarean section rates vary from 11.5% to 14.4% by region [those who planned "normal" delivery but needed an unplanned Caesarean].

  5.7.4  No data is published on the individual NHS hospital breakdown of Caesarean section rates between elective and emergency.

  5.7.5  No data is published on the age profiles of birth mothers in the current report. In the 2000-01 figures, it was identified that.

  5.7.5.1  Among 25-34 year old mothers, Caesarean section rates were 23%.

  5.7.5.2  Among the over 35s, Caesarean section rates were 32%.

NHS hospital deliveries: method of delivery by region, 2001-02—percentages



Total
Spontaneous
Forceps
Caesarean
Vertex
Other
Low
Other
Ventouse
Breech
Breech
extraction
Total
Elective
Emergency
Other

England
100
65.6
0.9
2
1.5
7.2
0.3
0.1
22.3
9.3
12.7
0.3
East of England
100
63.1
1.3
2.1
1.3
7.0
0.2
0.1
24.5
10.1
14.4
0.5
London
100
64.4
0.7
1.8
1.0
8.2
0.3
0.1
23.3
9.2
14.1
0.2
South East
100
63.5
0.6
2.3
2.0
7.5
0.2
0.1
23.2
10.0
13.1
0.7
West Midlands
100
66.8
1.2
1.9
1.3
6.0
0.4
0
21.9
9.6
12.3
0.4
South West
100
64.2
0.7
1.4
1.8
8.9
0.3
0
21.8
10.0
11.7
1.0
North West
100
67.9
1.7
1.8
1.0
6.3
0.2
0.1
20.6
8.8
11.8
0.2
Yorkshire & Humber
100
68.0
0.4
2.6
1.5
6.2
0.5
0.2
20.5
9.0
11.5
0
East Midlands
100
66.1
0.6
1.9
2.6
7.6
0.3
0.2
20.4
8.4
12.0
0.2
North East
100
66.3
1.1
2.6
2.1
7.5
0.2
0.1
20.1
8.3
11.8
0


Source: HES Published by Department of Health Maternity Services Report, May 2003

  5.7.6  The National Sentinel Caesarean Section Audit Report of 2001 identified that the overall rate for Caesarean section births in London was 24.2%. The Department of Health Maternity Services Report for 2001-02 identifies a rate of 23.3%.

  5.7.7  Central London hospitals' total Caesarean section data in the Department of Health report shows higher rates.

  5.7.7.1  Overall Central London hospitals' rate of 27.51%.

  5.7.7.2  Range of rates from 19.7% to 31.43%.

  5.7.7.3  There is no breakdown between elective and emergency available from the published statistics.

Central London NHS Hospitals : Total Caesarean Section Rate 2001-02


Royal London Hospital
19.70
Chelsea and Westminster Hospital
29.60
Queen Charlotte"s and Chelsea Hospital
31.43
St Mary's Hospital, Paddington
30.30
Guy's Hospital
26.91
King's College Hospital
26.57
University College Hospital, London
28.03
Average
27.51


  5.7.8  In common with obstetric admissions at The Portland Hospital, we believe and studies indicate, that throughout Central London the profile of maternal age is higher than elsewhere.

  5.8  At the Portland Hospital, over 70% of pregnant women giving birth [around 2,100 per annum] plan to have what is commonly known as a "natural" birth—that is without surgery.

  5.8.1  Around 16% of pregnant women giving birth at The Portland Hospital [around 350] subsequently need to have an emergency caesarean section [22.67% of those planning a "natural" birth].

  5.8.2  About 28% of pregnant women giving birth at The Portland Hospital [around 630] have an elective caesarean section delivery—that is a planned caesarean section delivery because this method is clinically indicated or because of specific patient choice.

  5.8.3  The split between clinical indication and specific patient choice at the Portland Hospital is around 50:50.

  5.8.4  The age profile of women giving birth at The Portland Hospital is older than national averages.

  5.8.4.1  Over 80% of deliveries at the hospital are to mothers aged between 30 and 40 years.

  5.9  In 1985, following a specialist meeting of around 50 people, the World Health Organisation suggested that there was no justification for a Caesarean section rate higher than 15%. That same report recommended or asserted that:

  5.9.1  The induction of labour should be reserved for specific medical indications.

  5.9.2  No region should have rates of induced labour higher than 10%.

  5.9.3  The whole community should be informed of the various procedures in birth care so as to enable each woman to choose the type of birth care she prefers.

  5.9.4  If a patient is to be enabled to choose, the concept of target rates for various delivery methods is entirely inconsistent.

  5.9.5  The Parliamentary Office of Science and Technology [October 2002] says on this subject:

  5.9.5.1  At the time [1985] the CS rate in the UK was 10%.

  5.9.5.2  [the recommendation] was based on the CS rates in those countries with the lowest mortality rates.

  5.9.5.3  Few countries now have CS rates below 15%.

  5.9.5.4  Were WHO to repeat the exercise now it would arrive at a rather higher range.

  5.9.5.5  This highlights the difficulty of setting valid and useful targets.

6.  RECOMMENDATIONS

  To evaluate existing and future choice in maternity care among women, it is essential that clear definitions and statistical data are made available. In particular, we recommend that:

  6.1  "Elective" Caesarean section is re-defined into two categories:

  6.1.1  Clinically indicated.

  6.1.2  Informed patient choice.

  6.2  Clinical indication data is collected and correlated for "elective" and "emergency" Caesarean procedures.

  6.3  Maternal age data is collected and correlated for all delivery methods

  6.4  All delivery methods are included in the data including for example, water births and ECV [External Cephalic Version].

  6.5  Common statistics are collected and published for NHS and independent hospitals.

June 2003






 
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Prepared 23 July 2003