News that an investigation may have uncovered at least 60 maternity deaths and injuries at The Shrewsbury and Telford Hospital NHS Trust has shocked many today, and is being widely circulated online.

What may be less well known, is that on July 3, 2018 a report by the Royal College of Obstetricians and Gynaecologists (Report of the Review of Maternity Services at Shrewsbury and Telford Hospital NHS Trust) was published online, in which the RCOG team advises a Trust with high stillbirth rates to “address” (i.e. reduce) its “high induction of labour rate“, and cites its “Low caesarean section rate” and “High proportion of vaginal births following a primary caesarean section” as “Strengths of the maternity services.

In fact, the RCOG review team goes further, and reports: “The maternity clinical dashboards have thresholds and targets set… From the evidence provided, local obstetric guidelines were in line with best evidence-based practice and national guidance. The audit programme should incorporate projects to address the clinical indicators of maternity care where the Trust is an outlier,...

Clearly, the Trust was not deemed to be an “outlier” for its caesarean rate, as this was praised for being low, but in other hospitals and trusts, where their caesarean rate is higher than average, they are pressured to act, and reduce it.

2017 CQC Royal Shrewsbury Hospital Quality ReportSimilarly, on August 16, 2017, the Care Quality Commission published its Quality Report for the Trust’s Royal Shrewsbury Hospital, and rated maternity care as ‘Good’.

Patient Outcomes (p.76) reads: “Shrewsbury MLU demonstrated 100% normal delivery between April 2016 and November 2016 which was better than the local target of 85%.

2017 CQC The Princess Royal Hospital Quality ReportOn the same date, the CQC’s Quality Report for The Princess Royal Hospital rated maternity care as ‘Requires improvement’.

However, in answer to the question, “Are maternity services effective?” (p.84), it reads: “We rated effective as good because: The caesarean rates were below (better than) the trust and national targets.” and “Despite high levels of activity within the consultant led unit (CLU), the trust was achieving higher than average vaginal birth rates.

Patient outcomes (p.87) reads: “The elective caesarean section rate for the same period was 10%, better than the trust target of less than 12% and better than the national average of 11%.

In news reports today, parents “claim that a caesarean or forceps delivery would have stopped their babies suffering brain damage.

As shared previously, the Trust website states: “We promote normality in childbirth.

2017 Shrewsbury and Telford Hospital NHS Trust - Review of Maternity ServicesAt this point, it’s worth noting that on June 27, 2017, in the Trust’s own Review of Maternity Services 2007-2017, it asked, “Are our maternity services safe?” and answered, “Caesarean section rates are 13-20.2% – this is lower than national level of 25% and is generally believed to be a good indicator of quality and safety.

I cannot stress enough how fundamentally flawed this widely held belief is.

These statements are from a November 2015 inquest report about a baby who died at the Princess Royal Hospital after his mother’s caesarean request was denied (Oversized baby died after medics ‘ignored mum’s wish to have Caesarean’ inquest told, The Mirror):

…medics “ignored the wishes” of his mum to perform a Caesarean section… [Mother] had been concerned about giving birth naturally because [he] was a big baby so was booked in for a Caesarean near her due date… [She] unexpectedly went into labour almost a month earlier… was given an epidural and…asked medics for a Caesarean but the next day…was delivered by forceps… “I felt my wishes were ignored.” [Father:] “I feel that our wishes as parents to have a Caesarean section were ignored…” [Grandmother,] who is a midwife and was at the hospital with her daughter, told the coroner her daughter had not been given a choice about the delivery. [She] had repeatedly asked for a Caesarean section, but was ignored. “I firmly believe if [she] had had a Caesarean section, [baby] would be here with the family today.” [Trust medics] believed the safest option was to see if [the] birth could progress as normal. [An independent medical witness] told the court the mother’s wishes should always prevail and to go against her request for the caesarean birth was “inappropriate.”…“It’s my independent view that a c-section should have been carried out.

And on April 22, 2017, in a highly critical news report (Is an NHS obsession with natural childbirth behind the deaths of seven babies at one hospital trust? Pressure on women to avoid caesarians and anaesthetics may lead to tragedies, Daily Mail), the Trust’s chief executive was quoted, defending its maternity care services:

The Care Quality Commission (CQC), Healthwatch and independent experts have all described our service as good,…

CBCAN Nicola Prentis - Quote - fought long and hardJust one year later, on June 26, 2018 (likely buoyed by the RCOG’s and CQC’s praise of its low caesarean rates and wanting to keep on track with its targets), the Trust announced that maternal request caesareans will no longer be supported.

Importantly, cost savings is not the key driver, but a reduction in the caesarean rate is cited (2018-19 CCG Governance Board Executive Summary Sheet – Excluded and Restricted Interventions Policy Amendments (formerly known as Procedures of Limited Clinical Value policy)):

The decision was taken at PPQ in May to remove the ability for patients to choose to undergo a caesarean section without clinical reasons. This report was presented to PPQ committee on 26th June 2018 and members agreed to: Support the changes to the wording in relation to caesarean section

Financial Implications: There are no significant financial implications identified.

There are minor implications in relation to: Reduction in caesarean sections

Equality & Inclusion: No EQIA has been completed in relation to these changes

Patient & Public Engagement: No patient and public engagement has been completed in relation to these changes

Legal Impact: There is always the potential for legal challenge in relation to excluded and restricted interventions

New wording: Undergoing a Caesarean Section carries risks and the CCG will only fund if there are clinical reasons for the surgery. Elective caesarean for non-clinical reasons, including maternal request, will not be routinely funded.

This Trust is not listening to its maternity care patients (“No patient and public engagement has been completed in relation to these changes“), but it is listening to the RCOG and CQC inspectors.

I stress this because I am certain the majority of criticism on social media today will be leveled at The Shrewsbury and Telford Hospital NHS Trust (@sathRSH; silent since 2016), but I believe the bulk of responsibility for ending caesarean rate targets lies elsewhere.

CBCAN - Cornelia Van Onselen Potgieter - BW pic - Quote - favourite pic

I’ve written about this numerous times before (WHO 2008 and NHE 2016 are just two examples), and have contacted various Departments of Health and MPs over the years (including a 2011 open letter sent via my then MP, Jeremy Hunt, to no avail).

I know how frustrating it is to be ignored, and to continually read “lessons have been learned” when evidently they have not, and I can only imagine how much more frustrating it must be for the parents and families who are directly affected by loss and injury.

However, there is reason to be hopeful.

On April 27, 2018, The Department of Health and Social Care confirmed to me (again):

The Government has set no targets for the rates of caesarean section (CS) or vaginal deliveries in England.  A woman’s request for an elective caesarean section should be managed in accordance with the National Institute for Health and Care Excellence clinical guideline.

Also, on August 17, 2018, in response to criticism by the Health Service Journal and patient safety campaigner James Titcombe on Twitter, the CQC press office responded with a statement from its Chief Inspector of Hospitals, which said:

Inspectors concerns were not about the number of normal births – which CQC would neither comment on or encourage trusts to increase – but the lack of support and care pathways to ensure safe care for low risk mothers.

I know for a fact that CQC inspectors do regularly comment on and encourage trusts to increase their ‘normal birth’ rates, and to reduce their caesarean birth rates, but its press office reaction this month suggests that perhaps this could change.

ec logoAction needed now

More than anything, we need the government, the CQC, the RCOG, the RCM, individual staff, and anyone else in a position to help put an end caesarean rate targets, to speak up, and to act.

There are (thankfully) many positive examples of trusts, hospitals and maternity care staff who do not focus on birth process rates and targets, and who respect autonomy and focus on outcomes.

But until national policies and attitudes change, personal stories, coroner inquests and unprecedented levels of litigation claims will continue for all the caesarean surgeries that are delayed, denied or simply not done.

Rates may remain low and targets may be met, but the cost (in every respect) will remain high.

  • Written by author and journalist Pauline Hull