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NHS maternity services in England must stop limiting the number of caesarean sections they perform to meet ‘unsafe’ targets. According to media sources, including The Guardian newspaper and the BBC, a letter from NHS maternity chiefs has asked hospitals to stop promoting unassisted ‘normal births’, and instructed them to treat women’s childbirth choices on an individual basis in accordance with NICE guidance.
The letter from NHS England’s Chief Midwifery Officer, Jacqueline Dunkley-Bent, and Dr Matthew Jolly, Clinical Director for Women's Health, has been quoted as saying: "We…ask all maternity services to stop using total caesarean section rates as a means of performance management, as we are concerned by the potential for services to pursue targets that may be clinically inappropriate and unsafe in individual cases."
The instruction follows concerns that the pursuit of so-called ‘normal’ deliveries may have contributed to harm to mothers and babies caused by poor maternity care. On average, one in four babies in England is born by caesarean section, but the percentage of vaginal births varies between hospitals and target-driven care has been associated with dangerous culture in some maternity units. Shrewsbury and Telford Hospital NHS Trust had one of the highest ‘normal’ delivery rates in England between 2010 and 2018. A formal report is expected next month following the investigation of nearly 2,000 maternity safety incidents, including the deaths of dozens of babies, at the trust.
When will NHS maternity care stop labelling physiological (spontaneous vaginal) birth as ‘normal’?
The dangers of promoting physiological birth as ‘normal’, with the implied suggestion that the mother has failed if she delivers her baby by caesarean section delivery, have been recognised for many years.
In 2015, the Morecambe Bay investigation found that “a growing move amongst midwives to pursue normal childbirth at any cost” contributed to the deaths of three mothers and 16 babies.
In 2017, we reported on The Royal College of Midwives’ (RCM) decision to end their 12-year-long campaign to promote “normal” births.
In 2021, we reported that the Parliamentary Health and Social Care Committee inquiry into maternity services in England, chaired by Jeremy Hunt, found that women and babies were still suffering harm from midwifery culture promoting ‘normal birth at any cost’. The inquiry urged maternity service leaders, including NHS England and Improvement (NHS E&I), the RCM and RCOG, to ‘stamp out’ the damaging ideological focus on, and use of the term, ‘normal birth’. The inquiry called for an immediate end to penalising maternity services for high caesarean rates and asked NHS E&I to write to all maternity units, ensuring that they are aware of the change. They also emphasised that every woman should be fully informed about her birthing options, including the safety risks for her and her baby.
Common reasons for having a caesarean section
During a caesarean section (sometimes called C-section) the baby is delivered surgically through an incision into the mother’s abdomen. The decision to deliver the baby by caesarean section may be made earlier in the pregnancy, either for medical reasons (planned) or at the mother’s own request (elective). An emergency caesarean section is sometimes needed, even where physiological or vaginal delivery has been planned, if unexpected complications or problems arise during labour.
Common reasons for delivering a baby by caesarean section include:
- maternal choice;
- problems arising in previous pregnancies;
- risks from previous surgery or caesarean sections;
- the size of the baby, whether large or small for dates (IUGR);
- the position of the baby in the mother’s womb, such as breech;
- the position of the placenta (placenta praevia);
- twin or multiple pregnancy;
- pre-eclampsia, gestational diabetes and other conditions affecting the mother during pregnancy;
- maternity emergency situations, such as:
Mothers should be advised about their birthing options and understand the risks and benefits to them and their baby, so that they can decide how they want to give birth on the basis of full and correct information.
Removal of caesarean targets welcomed
NHS England’s confirmation that targets limiting caesarean sections must now be abandoned has been welcomed by professional organisations, including the Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG).
Gill Walton, Chief Executive of the RCM is said to have confirmed that decisions about clinical care should be made in the best interests of the woman and her baby, “not because of an arbitrary target. While we welcome the decision by NHS England to remove targets that penalise maternity services for higher caesarean section rates, it’s a shame it’s taken so long…Those running local services will be delighted that this target has finally been removed.”
Dr Jo Mountfield, Consultant Obstetrician and RCOG Vice President is quoted as saying; “We welcome this clarification from NHS England. These targets are not appropriate in individual circumstances. Both vaginal and caesarean births carry certain benefits and risks, which should be discussed with women as they choose how they wish to give birth. Women giving birth should feel supported and their choices should be respected. The RCOG does not support one method of birth over another.”
Delivery decisions should be governed by accepted standards of practise in line with recognised guidance for the safe delivery and healthy outcome for mother and baby, based on their individual needs and informed maternal choice. Safe maternity care for the individual should not be compromised by political or ideological agendas, hospital culture, communication and teamwork issues or shortages of trained staff and resources. When individual patients’ maternity care pathways are required to fit within allowed quotas to satisfy targets, whether from financial concerns or pressure on women to have ‘normal’ births, safety is compromised. This hampers midwives’ and doctors’ ability to make the correct and timely decisions that are needed for the safety of mothers and their babies, and increases the risk of severe injury or death as a result of negligent care.
Women have a right to choose their preferred method of delivery. Their choices should be fully informed, following correct advice and with an understanding of the risks and benefits associated with their decision. The decision-making process should be open and free from hidden agendas, allowing for flexibility if changes are needed to manage unexpected complications.
Too many lives have been lost or devastated by brain injury and severe disability as a result of negligent decisions related to childbirth and delivery. Despite the dangers identified by repeated inquiries, formal and informal targeting (limiting) of caesarean sections in NHS hospitals continues to threaten the safety of mothers and babies. We welcome the news of NHS England’s clear message to NHS maternity services that caesarean section rates must no longer influence decisions about how mothers deliver their babies.
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