Pauline Hull, author, and editor of Caesarean Birth, says:
“I welcome Birthrights’ report today, and am unsurprised that only 26% of Trusts offer maternal request support in line with NICE guidance.
“Despite a huge effort by NICE Stakeholders in 2010-11 to publish new evidence-based guidelines that support maternal request, medical opinion remains divided, and women continue to contact me in anger and despair when their requests are refused.”
I first wrote and tweeted about the Oxford University Hospitals NHS Trust’s leaflet for women requesting a caesarean on April 12, 2017, and on May 24, 2017, Birthrights launched its campaign to engage with Trusts, beginning with OUH.
The OUH leaflet was originally sent to me by Vicky Bullet, who today shares her own frustrating and stressful maternal request journey; one that ended in the same Gloucester hospital as another mother whose request was refused in London.
A letter was also sent to women by OUH, with this added emphasis:
“Our policy is not to support maternal requests for Caesarean birth…”
Birthrights has asked OUH and its commissioners to work together constructively, and to change the existing policy.
Otherwise, the human rights charity says it will explore the option of Judicial Review.
Unfortunately, OUH is not alone
Birthrights says 15% of NHS Trusts do not offer maternal request, and 47% only partially offer it or offer with concerns; 11% could not be categorised.
Interestingly, in one London hospital that does not support maternal request, its private maternity care unit (“noted as one of the best private maternity units in the UK by the Quality Care Commission) has a 60% rate of planned caesareans for 2017-18, and a total 76% caesarean rate overall.
This is not an issue of (£) cost
NICE CG132 is clear on maternal request: “On balance, this model does not provide strong evidence to refuse a woman’s request for CS on cost effectiveness grounds.”
There are many Trusts that agree too; for example, in 2013, when South Gloucestershire Clinical Commissioning Group decided “patients will be offered a full choice on delivery methods“, specifically maternal request caesarean, it concluded, “there are no financial implications to this proposal.”
In fact, NICE calculated only an £84 difference in cost between a planned caesarean and planned vaginal birth (with urinary incontinence costs factored in), and estimated the cost of “Mental health support for women with anxiety about childbirth” is £1,053.
Therefore, given that so many Trusts are willing to spend money on treating maternal request as a mental health issue (even setting up special ‘choice‘ clinics), rather than scheduling the surgery as requested, this indicates that cost is not their key concern.
Change and clarity
It is evident that NHS policies, attitudes and hospital websites are long overdue an overhaul to ensure NICE recommendations are followed (especially post-Montgomery) and maternal autonomy respected.
But until policies on maternal request are standardised in all NHS hospitals, Caesarean Birth believes that women should have access to information making it clear which hospitals, and which obstetricians, are willing to support this legitimate birth choice.
Anything less is disingenuous, wastes NHS time and resources, and creates unnecessary stress and anxiety for women.
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Birthrights has created a new interactive map highlighting NHS Trust levels of support for maternal request (green, amber, red) throughout the country.
Call to action (pg.13)
- Every trust embracing the human rights principle that every woman has the right to make an informed choice over what happens to her body during pregnancy and birth
- Urgent clarification from NICE that larger NHS Trusts referring women to another NHS Trust to access MRCS are not complying with guideline CG132
- A better understanding of the diverse reasons women ask for maternal
“…some Trust policies on maternal request caesarean appear to be based on the assumption that all maternal request caesareans are motivated by a fear of childbirth, as opposed to a rational reading of the evidence and how they apply to an individual’s circumstances, or concern as to the impact on another physical health condition, for example. Some women have told us that they are surprised and concerned to be treated as if they have a mental health issue, if this is not what is driving their request.“
- Unbiased, evidence-based and up-to-date information for women
“Women need balanced information that differentiates between risks of planning a
caesarean birth to a woman and her baby compared to a planned vaginal birth and
also explains what is known about longer term outcomes for both mothers and babies
for each mode of birth.“
- Pathways that are co-produced by women and healthcare professionals, so that they feel supportive to women rather than heightening anxiety.
- An agreed nationwide method to categorise and record maternal request caesareans consistently in every NHS Trust’s maternity statistics.
The RCOG’s response to Birthrights’ report
Dr Alison Wright, Vice President of the Royal College of Obstetricians and Gynaecologists, said: “The RCOG welcomes this important contribution. We are disappointed by the findings which suggest that some Trusts do not appear to offer women ‘maternal request’ caesarean births, with variation in Trust policy and guidance across the UK. This denies women choice about their birthing experience and highlights the importance of Trusts updating policies and guidelines to ensure women have access to safe and personalised care.
“We strongly believe that women’s voices and choices should be respected and supported to ensure a good birth. It is important women are fully aware of the risks and benefits of all methods of giving birth when considering their options during pregnancy.
“The reasons some women request a caesarean birth may include a fear of having a complicated vaginal birth, or having had a previous traumatic experience. Talking to a midwife or obstetrician and accessing support from a counsellor or psychologist, may help address any concerns they may have. Some women may still choose a caesarean birth, which should be respected and supported.”
The RCM’s response to Birthrights’ report
Gill Walton, Chief Executive and General Secretary of the Royal College of Midwives (RCM), said: “We support NICE recommendations on this issue and these are the recommendations and guidelines that midwives and doctors work with.
“Midwives should listen to women who want a caesarean section and discuss the risks and benefits of caesarean section and physiological birth in a way that is understandable and accessible to them.
“Women must be given the information to explore their views and feelings about caesarean birth, to enable them to come to an informed decision about their preferred type of birth. This information should reflect the individual woman’s current and previous medical, obstetric and psychological history.
“Midwives have an important role in supporting women who request caesarean section and respecting their reasons.”
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Maternal Request FOI in 2011/2012
Shortly after NICE published its CG132 maternal request recommendations, together with author Leigh East, I contacted (then) Primary Care Trusts in England to ask what their caesarean maternal request policy was, and whether they would be updating it in light of NICE.
The response rate was low (less than 25%), but there were certainly similarities with the feedback Birthrights has received. Eight Trusts said it was their policy to ban maternal request caesareans, and of the 38 that didn’t, comments still included, “We don’t encourage it” and “Only medical indications will be considered.”
I really hope that today’s excellent Birthrights report, and the responses to it, will have a genuine impact on the provision of and support for maternal request caesarean birth in NHS hospitals, and that more organisations and professionals will speak up for much needed improvements.
I’ve been campaigning for almost 15 years for women to be given genuine choice and support in terms of how they give birth as well as where they give birth, and while (incredibly) we’re still not there yet, I am looking forward to working with the RCOG on updating its 2015 Choosing to have a caesarean section patient leaflet in the months ahead.
- Written by author and journalist Pauline Hull