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One in four births in the UK takes place by caesarean section. That means that 25% of mothers either need or want to have their baby by surgical operation. Some of these will try to give birth vaginally but find that concerns about their own or the baby’s health during labour make it safer to have an emergency c-section. Others may plan an elective caesarean delivery. Their choice will be discussed with their maternity team and may arise from concerns about their own physical or mental health, obstetric history or anxieties around labour. Under normal circumstances, as long as the mother has been properly informed about her birth options and the risks and benefits of each method of delivery, she has the right to insist on having a caesarean delivery.
Since COVID-19 hit the UK earlier this year, we have been forced to accept many changes to our lives. Our assumptions about the way we work, travel, socialise and educate our children have changed. As a nation we have accepted that the NHS’s priority response to coronavirus has temporarily reduced our access to less urgent types of healthcare.
Maternity rights charity, Birthrights, are concerned that some NHS trusts are unjustifiably using coronavirus as an excuse to refuse pregnant women elective (non-emergency) caesarean sections. Unless the hospital is suffering from ‘extreme circumstances’ affecting its obstetric surgical capacity or that of the other trusts to which the woman could be referred nearby, this goes against NHS and NICE guidance. Birthrights questions whether coronavirus is being used in some maternity units to promote the ‘normal birth obsession’ which has repeatedly been found by maternity scandal enquiries to be a contributory factor to shocking levels of maternity and neonatal harm.
Do women have the right to insist on a caesarean birth?
The National Institute for Health and Care Excellence (NICE) sets out national, evidence-based guidelines for NHS and other healthcare providers to improve standards in many areas of health and social care. NICE guidance on maternal requests for caesarean section says that:
- a woman’s request for a caesarean section should be explored and discussed and the specific reasons for her request should be recorded;
- if a woman requests a caesarean section when there is no medical indication for it, the risks and benefits of caesarean compared to vaginal birth must be discussed with her to explore her reasons and ensure that she has accurate information. If necessary, the discussion can involve other members of the obstetric team. The discussion should be recorded in her medical records.
- if anxiety about childbirth is the reason for the request, she should be offered a referral to a professional with expertise in perinatal mental health support to help her deal with her anxiety;
- if after discussion and the offer of support a vaginal birth is still not an acceptable option, she should be offered a planned caesarean section;
- if her own obstetrician is unwilling to perform her caesarean section, she should be referred to another obstetrician who will carry out the caesarean.
What difference has COVID-19 made to a woman’s right to insist on a caesarean section?
The NICE guidance relating to maternal requests for caesarean section has not changed since the COVID-19 pandemic began. Some other aspects of maternity services were amended by RCOG and RCM to allow for safe care during social distancing.
RCOG and NHS guidance and information on the reorganisation of maternity services during the pandemic warn pregnant women that water (birthing pool) births, home births and some midwifery-led maternity units may be limited. The stated reasons for this include the possibility of infection from faeces in the birthing pool and the possible lack of ambulance transportation of the woman in labour to a doctor-led maternity unit if complications arise. However, trusts are still required to do their best to follow NICE guidance in relation to caesarean sections and carry out all their planned caesareans even if some re-scheduling is needed. Caesarean sections may be prioritised according to clinical need but the trust cannot suspend these services without first satisfying a long list of criteria to demonstrate that the trust is suffering from extreme circumstances.
Why are Birthrights concerned?
Earlier this month, an article in The Independent reported that maternity rights charity, Birthrights, were concerned that some NHS hospitals were using coronavirus as an excuse to dictate to women how they should give birth. The charity had received multiple requests for help from pregnant women who had been refused caesarean sections during the Covid-19 outbreak, even though the guidance and NHS England’s advice was that these procedures should go ahead. Many NHS trusts have told pregnant women that requests for a caesarean section will not be granted due to the pandemic, leading to concerns that COVID-19 is being used as an excuse to promote a ‘natural birth’ ideology.
Birthrights have helped several women successfully challenge or clarify the advice they have been given by their hospitals, but told us that they continue to be concerned about women being told they cannot access caesarean sections. Programmes Director, Maria Booker said, "NHS guidance on managing services during the pandemic says that planned caesareans should only be withdrawn in "extreme circumstances" and that Trusts/Boards should make every effort to avoid this. And yet sadly, in the last few weeks, Birthrights has been contacted by women who have heart conditions, pelvic issues, mental health conditions, and who have previously lost a baby who have all been denied caesareans. We hope that the passing of the peak has given trusts time to reflect on the impact this has had on women and birthing people. Rationing of caesareans should never be pre-emptive and must be driven by evidence based, dire need, and not ideology. We hope to see all trusts observing NICE guidance on caesareans going forward."
Concerns about women being denied caesarean births based on ideology – where the midwifery staff pursue a campaign to promote vaginal birth – are not new. Earlier this year, former Health Secretary, Jeremy Hunt, called for a maternity safety enquiry and voiced concerns about whether the safety of mothers and babies was being put at risk by a mistaken obsession with ‘normal births’ leading to delayed caesarean sections. In 2017, the Royal College of Midwives (RCM) claimed that they had finally brought to an end their outdated 12-year-campaign to promote ‘normal’ births.
Between November 2017 and January 2018, Birthrights carried out its own research into how NHS trusts responded to maternal requests for caesarean section births. The charity asked every NHS trust in the UK and every Clinical Commissioning Group (CCG) in England for their policy on maternal requests for caesarean. They found that:
- 15% of trusts’ policies or processes were explicitly opposed to maternal request caesarean;
- 47% of trusts’ policies or processes were problematic or inconsistent;
- only 26% of trusts complied with NICE guidelines in offering caesareans to women on request.
They then analysed the enquiries they received from women asking for advice on maternal requests for caesarean section from November 2016 to May 2018. They found that a third of those women wanted a caesarean owing to a previous traumatic birth. Other women’s reasons included underlying medical conditions, mental health concerns, past trauma, such as sexual assault, whilst others had examined the evidence and made informed decisions.
Birthrights’ continue to promote women’s rights to receive evidence-based care that conforms to the best medical and midwifery standards. The charity promotes adherence to best practice rather any particular ideological agenda.
Boyes Turner support Birthrights’ concerns about the distress and potential harm that women and their babies may suffer if they are denied their right to information and choice about caesarean section. Women who give birth in an environment which is closed to caesarean section, whether in mindset or skills and resources, are unnecessarily put at risk of harm to themselves and their babies.
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