London Hospital where actress Helen George gave birth has ‘No Maternal Request Caesarean Policy’ and Different Birth Options for Private Patients

The irony.

The injustice.

Patients at Guy’s and St Thomas’ private Westminster Maternity Suite are offered “a wealth of birthing choices, giving you the freedom to give birth the way you want” with a “dedicated team…helping you to decide upon the right method to suit your individual needs so you feel more in control.”

“The options we offer range from a natural delivery, with or without an epidural, through to a caesarean section…All the team will be there to help you have your baby safely.”

The caesarean rate is 66% *for private patients.

Communication appears to be very different for the NHS Trust’s public patients…

(Note: the letter below cites safety, highest quality care, current evidence and best interests – not cost – as the reason for only offering an individualised care package to help women feel confident about a vaginal birth – when they request a caesarean):

This letter (found on the Trust’s website) is undated, and it’s not clear whether it’s been sent or given to women (I have emailed to ask*); however there is a 2016 date in the document’s Properties and it is accessible online, which is still concerning given:

NICE

In 2011, CG132 recommended support for maternal request caesareans, and cited an £84 cost difference between PVD and PCD.

“A sensitivity analysis suggested that the inclusion of adverse outcomes not reported, such as urinary incontinence, could make the conclusion regarding cost effectiveness less certain. On balance, this model does not provide strong evidence to refuse a woman’s request for CS on cost effectiveness grounds.”

LITIGATION

In 2015, a Supreme Court (Montgomery) judgment clearly stated:

“The principal choice is between vaginal delivery and caesarean section. One is, of course, the normal and “natural” way of giving birth; the other used to be a way of saving the baby’s life at the expense of the mother’s. Now, the risks to both mother and child from a caesarean section are so low that the National Institute for Health and Clinical Excellence (NICE clinical guideline 132, [new 2011] [para 1.2.9.5]) clearly states that “For women requesting a CS, if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS“.

“…in the extracts we do have Dr McLellan referred to explaining to a mother who requested a caesarean section “why it may not be in the mother’s best interest” and later expressed the view that “it’s not in the maternal interests for women to have caesarean sections“. Whatever Dr McLellan may have had in mind, this does not look like a purely medical judgment. It looks like a judgment that vaginal delivery is in some way morally preferable to a caesarean section: so much so that it justifies depriving the pregnant woman of the information needed for her to make a free choice in the matter…

“A patient is entitled to take into account her own values, her own assessment of the comparative merits of giving birth in the “natural” and traditional way and of giving birth by caesarean section, whatever medical opinion may say, alongside the medical evaluation of the risks to herself and her baby. She may place great value on giving birth in the natural way and be prepared to take the risks to herself and her baby which this entails. The medical profession must respect her choice, unless she lacks the legal capacity to decide (St George’s Healthcare NHS Trust v S [1999] Fam 26). There is no good reason why the same should not apply in reverse, if she is prepared to forgo the joys of natural childbirth in order to avoid some not insignificant risks to herself or her baby…”

‘CALL THE OBSTETRICIAN’

In a Radio Times interview published today, Call the Midwife actress Helen George insists “there needs to be a national conversation about how C-sections are alright and they don’t just have to be for emergencies.”

She describes a very positive birth experience at St Thomas’ hospital, and although it is not clear whether this was as a private patient or not, it is very clear that Helen’s decision to choose a caesarean birth was made long before pregnancy complications made one necessary; “even without that, I would have gone for an elective caesarean“.

Interviewer Kirsty Lang describes how ‘she nearly choked on her tea’ upon hearing this, and ‘expressed surprise that women can choose to have an elective C-section in NHS maternity wards’ (interesting in itself given NICE CG132 in 2011).

Evidently, this was not the first time Helen had had a similar reaction: “Lots of people were shocked by that decision… There’s a lot of shame around it, and people tried to

convince me not to have one…”

Obviously, Helen George’s reasons for choosing a caesarean birth are anecdotal (also see Why do some women prefer caesarean birth?), but her voice is an important one, and her views – and decision to express them publicly – could be another step forward in changing maternity culture, attitudes and official measures of health outcomes.

The prevailing belief is that a high caesarean rate = worse health outcomes, so at 66%, it would be interesting to discover the rates of patient satisfaction and/or litigation rates among Guy’s and St Thomas’ private patients.

It would also be interesting to learn how the 66% breaks down into elective and emergency surgeries (my guess is fewer of the latter).

IS IT REALLY A QUESTION OF SAFETY (AND BEST INTERESTS)?

IF SO, WHY ARE THE OPTIONS SO DIFFERENT FOR PAYING PATIENTS?

As a general rule worldwide, the richer you are, the greater access you have to the best healthcare advice and treatments available, both in terms of preventative/prophylactic courses of action, and remedies for injury or illness (note The Westminster Maternity Suite describes itself as a ‘Centre of Excellence‘.

So why do the Birthing Options for private patients at Guy’s and St Thomas’ NHS Foundation Trust include caesarean choice, but not home birth, while for non-private patients, it’s the exact opposite?

“SPECIALIST BIRTHING CHOICES” for private patients include:

• Normal birth, Assisted birth, Caesarean section (Home birth is not listed)

“SPECIALTIES” for non-paying patients include:

• Our tocophobia clinic is for women with specific anxieties about labour and birth run by a midwife who is also a qualified psychotherapist**.
• Our one stop breech clinic is for women who have a baby presenting in breech (bottom first) at 36 weeks gestation.
• Our birth options after previous caesarean section clinic (VBAC clinic) is for women who had a previous caesarean section to discuss birth options.
• Our debrief-birth reflection clinic is for women who require a debrief on their previous birth experience.
• Our individualised care planning clinic is for pregnant women to discuss alternative birth options and/or wish to deliver in the low risk midwifery unit despite pre-existing medical obstetric risk factors.

The Trust has also produced a patient leaflet for non-private patients (Home birth – why not?), which encourages (not just offers) home birth to certain women:

“Giving birth at home reinforces the importance of birth as an integral part of family life. At St Thomas’ Hospital we are committed to supporting your informed choices. We encourage home birth for women who have a normal, uncomplicated pregnancy at the onset of labour. For women having a first baby, a planned home birth increases the risk of a poor outcome for the baby by a very small amount, compared with giving birth in hospital. This includes a slightly higher risk that the baby will be injured, become seriously unwell or die during or just after birth. These outcomes are very rare among healthy women with uncomplicated pregnancies, and they can happen in any birth setting.”

Interestingly, risk of death for the baby is not listed in the hospital’s Elective caesarean section patient leaflet, yet this choice is not offered to non-private patients, and women  who request a caesarean appear to be refused access or offered a ‘tocophobia clinic’ instead.

Helen George is right when she says there needs to be a national conversation “So if you do feel you want one, you have the confidence to talk to your doctor or midwife about it“, but in my experience of hearing from women, it’s not always this first step that’s the problem.

It’s navigating their way around maternal request refusal without the funds available to pay privately – including driving hours cross-country to find a hospital that will support your request – that is still proving the hardest challenge for these women.

The postcode lottery needs to end.

*February 1, 2018

A spokesperson from Guy’s and St Thomas’ NHS Foundation Trust said:

“Our aim is to provide the highest quality care to expectant mothers and their baby. We promote natural birth where possible and this approach is agreed by our commissioners.

“There are often specific reasons why women are anxious about giving birth. We offer them support and a chance to talk about their concerns with a specialist midwife or an obstetrician so they can agree an individualised care package to help them feel confident about the birth.

“A caesarean is a major operation that carries a number of risks and long term consequences, however, we always offer a second opinion to women who, after consideration, still wish to have a caesarean.”

February 6, 2018

A spokesperson from Guy’s and St Thomas’ NHS Foundation Trust added:

“The letter is [currently] sent to expectant mothers choosing to have their baby at Guy’s and St Thomas’.”

“Of the private patients who had a caesarean in 17/18, 57.4% were elective and 20% were emergency.”

“The Trust follows the 2011 NICE recommendation and can refer externally if required.”

**A psychotherapist interacts with patients to initiate change in the patient’s thoughts, feelings, and behavior through adaptation.

• Written by author and journalist Pauline Hull