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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