High rates of intervention?

[LorlieS]

The C-Section rate is 40-something percent in my local NHS Trust. This seems remarkably high when considering labour and birth are in essence natural processes? Why might it be? What are rates like nationally I wonder?

I've had 8 pregnancies and 3 births. First birth - hospital induction (in hindsight should have declined). Second birth - "normal" delivery in hospital. Third birth (decade after second!) - "normal" delivery at home with no intervention (no internal exams, natural delivery of placenta etc) with an Independent Midwife.

Every hospital I’ve worked at as a midwife provides 1-1 care for women in established labour and 2 midwives at the actual birth. I have always been able to provide 1-1 care for every woman I’ve cared for in Labour in the last 15plus years. We have to listen in to the FH every 15 mins for a start! Yes, I might nip out to the loo, or to get something but I’m gone a matter of minutes.

i can think of one sort of exception where I left a room to nip and grab the syntocinon and within ten seconds of stepping out the room a post natal woman staggered out another room and collapsed in front of me. As I was dealing with her and yelling for help I was aware my first woman was pushing. I could hear the tell tale sounds but couldn’t go to her…..but I did yell at another midwife to go and she got there just in time.

I also have no issues with interventions, all I care about is that baby/babies are born safely

This

The NICE guidelines are quite clear that 1-1 care should be provided and women in established labour should not be left on their own apart from for short periods. This is bread and butter audit and CQC inspection stuff…..I’d be amazed if any hospitals weren’t doing it apart from the odd awful shift and even then they’ll be calling community midwives in, etc and closing the unit.

DS was born last December and I had a 1:1 midwife with me at all times. NHS hospital.

I’m not why the %s matter to you? You say you want babies to be delivered safely with people being able to make informed choices. Surely that’s what people are doing? People are more informed than ever now, so maybe that’s why %s have increased. So there is no optimal % especially if the sample size is just your own trust?

@Torganer But there is an optimal percentage and it's a lot lower than 40-something percent.
www.gov.scot:

• Caesarean section rates of 10-15% are thought to be associated with decreases in maternal, neonatal and infant mortality. When they increase above 10-15%, rates of caesarean section are thought to be no longer associated with lower mortality rates.

UNICEF/WHO/UNFPA recommend a C-section rate between 5 and 15 percent of all births, based on estimates from a variety of sources.

Parliamentary Office of Science and Technology (UK):
Developing policy
Approaches to policy development
There is a general consensus amongst clinicians that a
high CS rate is undesirable. One way to respond to this
would be to set targets for a reduced CS rate. In 1985,
the World Health Organisation (WHO), prompted by
concern over rising CS rates, stated that there were no
additional health benefits associated with a CS rate over
10-15%. This range was based on the CS rates in those
countries with the lowest mortality rates. At the time,
the CS rate in the UK was 10%. However, few countries
now have CS rates below 15% and, were WHO to repeat
the exercise now, it would arrive at a rather higher range.
This highlights the difficulty of setting valid and useful
targets. Nevertheless, the United States set targets in
1991 to reduce the primary CS rate to 15% and to
increase the VBAC rate to 40% by 2000. Progress was
made towards these targets until 1996 when, for reasons
that are unclear, the trend reversed. By 2001, CS rates
were the highest ever reported in the US at 24%.
The Royal College of Midwives (RCM) is concerned that a
high CS rate does not represent best quality care. RCM
are looking to DH and the National Institute for Clinical
Excellence (NICE) to define best care standards and
clinical practice, with the expectation that this will lead
to a reduction in CS. DH has decided that the wide
variation in practice that has resulted from local decision
making on CS is unacceptable and sees a need for
national policy across England.

@SouthLondonMum22 That's a good thing. I wonder how many other women can say the same? Maybe I was just unlucky...

@LorlieS that first quote is from the WHO and referees to worldwide lscs rates. You can’t extrapolate that paragraph and apply it just to the U.K.

For example one thing which noticeably increased lscs rates in the U.K. a few years ago was the uptake of personalised growth charts following the original Saving Babies Lives recommendation. Suddenly we were picking up more growth restricted babies, estimates from the Saving Babies Lives authors were that using personalised growth charts could prevent I think 80% of still births.

But if we’re picking up those growth restricted babies antenatally what do you think the obstetricians and paeds want to do…….nothing and hope the baby doesn’t die or hang on as long as possible, administer steroids and either induce or do a lscs?

Does WHO recommend a specific caesarean section rate at hospital level?
No, WHO does not recommend a specific caesarean section rate in hospitals. The need for caesarean section at each hospital can vary dramatically depending of the type of population served by the hospital. For example, larger hospitals tend to receive referrals of most complicated pregnancies or deliveries which in turn, may need more caesarean sections. On the other hand, some small facilities may not even be equipped to conduct caesarean sections. Recommending a caesarean section rate for all hospitals would be inappropriate.

Does WHO recommend a specific caesarean section rate at country level?
No, as explained in this statement, WHO does not recommend a specific rate for countries to achieve at population level. The work conducted by WHO found that as countries increase their caesarean section rates up to 10%, maternal and neonatal mortality decrease. However, caesarean section rates higher than 10% are not associated with reductions in maternal and newborn mortality rates. Despite this, mortality is not the only outcome to consider. Other important outcomes would be short- and long-term maternal and perinatal morbidity, for example, obstetric fistula, birth asphyxia, or psychosocial implications regarding the maternal¬–¬infant relationship, women’s psychological health, women’s ability to successfully initiate breastfeeding and paediatric outcomes. Lack of data prevented the inclusion of these and other outcomes in the WHO analysis.

I’m not sure why you’re saying the WHO recommends a 15% lscs rate, they clearly don’t.

@CormorantStrikesBack Really important information, thank you for the dose of accuracy. Most people would think that the risk of birth asphyxia was deeply relevant, as this can result in lifelong disabilities. The OP may think it's a risk worth taking for a lower CS rate, but I doubt many would agree.

The Parl8mentary paper you quote is from 2002. Times have moved on from then as research and investigations have demonstrated how dangerous a blind pursuit of lowering LSCS rates is. I assume you’ve heard of Morecambe Bay and what happened at the hospital there where they tried to pursue “normal birth”. The Kirkup report was quite clear how dangerous this could be. The RCM don’t even use the term normal birth anymore.

@CormorantStrikesBack Sorry - should have given the source for that: https://www.measureevaluation.org/rbf/indicator-collections/health-outcome-impact-indicators/cesarean-sections-as-a-percent-of-all-births.html

Yes the OP cut her quote off at the interesting bit in her post. The whole quote makes the WHO’s stance far clearer.

Sorry, but I prefer the original source which I’ve already linked to. If you’re going to try and quote what the WHO have said I find it far more reliable to actually go to the WHO document/website and take it from there rather than read someone else”s take on it. I have never heard of the Measure Evaluation website and my years of research training tell me to avoid such sites. Primary sources are key when looking at evidence.

So this is an interesting paper from Gov Scotland and I think it’s what the OP has looked at.

https://www.gov.scot/publications/best-start-review-caesarean-section-rates-scotland/pages/3/

I would absolutely take issue with how they’ve misinterpreted/misused the WHO statement. It’s actually NHS Scotland who have cut the WHO quote off early (see my earlier point about not using the original source, it even stands for Gov scotland), they also don’t seem to appreciate the quote refers to global rates.

I do like their acknowledgment of how rising maternal age and rising BMI levels could contribute to rising LSCS rates…..that’s something the evidence shows.

I also like the quote below in it.

That said, it is important to note the recent findings of the Ockenden Report which found that caesarean section rates, at the NHS Trusts in England subject to the Ockenden review[c], were between 8 and 12%, consistently below the English average of 24%. The review found a culture of trying to keep caesarean section rates low because of a belief that this demonstrated good maternity care. But the review found that earlier decisions to use caesarean delivery would have avoided death and injury in many cases[39].

The review found a culture of trying to keep caesarean section rates low because of a belief that this demonstrated good maternity care. But the review found that earlier decisions to use caesarean delivery would have avoided death and injury in many cases[39]

That is absolutely shocking and precisely the reason why setting a C Section "target" is absolute nonsense.

Exactly.

Not to mention the fact that it's very important for women to have choices too. This includes those who want elective c-sections.

I think we'll just have to agree to disagree; I am still of the opinion that a 40-something percent C-Section rate in my Trust is too high. For this reason (and for many more) I chose not to birth any of my children there (although my first two were hospital births) but I accept that this is solely my opinion of course.

@SouthLondonMum22 I agree, providing that this choice is fully informed.
When in labour with my second, for example, the midwives decided to artificially break my waters (they needed the labour room so wanted the baby born) without explaining the risks involved. Stupidly I agreed and it caused a lot of problems, including permanent hearing difficulties for my son.

Absolutely. Though there does seem to sometimes be an assumption that women who opt for a intervention free birth = informed and those who opt for a c-section or any other intervention = misinformed.

Like I said, I requested an elective c-section this time because I'm having twins and with my son, I had him vaginally but labour was induced and I had an epidural. Fully informed, I just don't see interventions as this big, negative thing but then I was never particularly interested in giving birth intervention free because I always intended to have an epidural ASAP.

@LorlieS Has it been confirmed that the hearing loss was caused by the artificial breaking of your waters?

@ilostmyhearttoastarshiptrouper Yes. His heart rate dropped rapidly, causing trauma and ABO incompatibility which resulted in his hearing problems.

You've lost me there OP. How did your waters being broken cause ABO incompatibility?