Shrewsbury and Telford Hospital Trust with significantly lower CS rate in scandal.

[RedToothBrush]

Shrewsbury and Telford NHS Trust has got themselves embroiled in a huge scandal over their maternity unit. It now seems that 100 deaths are under review.

Why does this concern me particularly?

The main reason is because there is only now stuff coming out questioning this.

You see in 2016 the Royal College of Obstetricians and Gynaecologists published a report on regional variation on outcomes in childbirth based on information relating to 3rd / 4th degree tears and CS rates. This was based on data from 2013/14.

From this data it was glaringly obvious from the data that questions should have been raised.

Shrewsbury and Telford not only had one of the lowest CS rates:

Proportion of deliveries by caesarean section (ALL CS)
National average Primiparous deliveries: 22.1%
The Shrewsbury and Telford NHS Trust: 12.8%

But it also had one of the lowest levels of CS rates from induced labour:
Proportion of induced labours resulting in emergency caesarean section
National average Primiparous deliveries: 29.9%
The Shrewsbury and Telford NHS Trust: 15.1%

Annoyingly the site that had all this data has been taken down, so it can't be compared easily but its out there. (And I'm glad I took the time to make a note of this at the time).

Shrewsbury's rates were abnormally low against other Trusts. It immediately begged a simple key point;

Either they were doing something amazing that other hospitals should be following to improve their own outcomes
or
They were doing something VERY wrong

(It also raised the question of whether they had a population which was particularly low risk but there isn't really anything about the area in terms of demographics which makes it distinct from other areas, so its relatively easy to dismiss).

If this data was like this for a single year, it looks bad. If its part of a similar pattern, its worse.

Its the type of stat that you look at going WHY? What ARE they doing there.

And here we are:
www.dailymail.co.uk/news/article-6186371/Shrewsbury-baby-scandal-covers-100-deaths-Probe-NHS-trust-grows.html

And the following lines immediately jump out at me.
Yet a number of families insist their babies died needlessly because midwives missed treatable infections or complications.

Other women claim they were forced to have natural labours without the use of caesareans or forceps.

Telford CCG has also recently introduced a blanket ban on maternal request CS against NICE guidance. The CCG are a separate body to the Trust, but my question here in the context of things going on, is to ask whether the CCG introduced this after a steep rise in requests in the area - following traumic births or women hearing particularly troubling stories?

This stinks to high heaven, and I hope that if there are any lurking journalists out there, they look into this angle. If this pans out to show that there really is a scandal like Morecombe here, then there seems to be a case to answer by BigWigs higher up the NHS food chain. Did they ignore stats that jump out, shout and do a little dance whilst they invite some attention.

I really hope this inquiry does not turn out the way I fear it is.

I know this message perhaps should be in another section, and maybe its just shouting into the abyss. But it is relevant to feminism and frankly I'm sick to death of maternity services being one of the sections of the NHS which is most neglected in terms of political interest, in part because women have been so conditioned into accepting sub standard care and new mothers being one of the groups least able to advocate/raise a complaint at the time.

I am maybe just hoping that a lurking journalist bumps into this one, and keeps an eye on it, cos if this does turn out to be another Morecambe, the story isn't about individual midwives and managers.

It would seriously suggest that this would be about something very much bigger, indicating a systematic failure to ask simple questions at the highest levels of the NHS. I want to make damn sure that there something out there posing those particular questions whilst hoping that these cases are properly reviewed.

I hope to god, I'm wrong about this and my spidey senses are just malfunctioning.

Oh god, this is horrifying. The thought of knowing you need a section, being denied one and then having your baby die... unspeakable. Why why why are so many trusts obsessed with low section rates even when the costs are so apparent?

I know people who have delivered there and regrettably their experiences vs my own were shocking

Thankyou OP for highlighting - I've just moved into this area and want another child!!

Why why why are so many trusts obsessed with low section rates even when the costs are so apparent?

Because for so long certain groups, often women's groups , have been banging on about natural births ; midwife led births; midwife only units ; the need to demedicalise birth; articles about "failed birth experience" because there was intervention; talking up how awful c-sections are; denigration of women who choose c-sections.

Those reading the thread may also be interested in this:
caesareanbirth.org/2018/08/30/shrewsbury-and-telford-rcog-and-cqc-praise-low-caesarean-rates-and-targets-and-trust-promotes-normality/

Lass

I wonder about that too. Certainly when I had my two, 18 years ago, the message I got was to avoid CS. And indeed I did feel like a failure after the EMCS birth of DS1, and was determined to try VBAC after DS2 (it 'worked') I was really surprised when I Found out about the NICE guidelines only very recently. I now think CS should be available on demand.

The narrative in the media, , for as long as I can remember has been the aim to reduce the number of CS births .

Thanks for this Red. It's terrifying though

PMHull - that blog post is well worth reading, thank you for posting it.

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.

The post explores some of the complexity behind the state of affairs in hospitals that are pushing to reduce the C-sections rates and its wretched to read how so many other preferences take precedence over the expressed wishes of mothers.

I watched the BBC report on this last night. There's just a torrent of awful stories where women and children are being actively harmed - and deliberately it seems through the implementation of 'policy'.

Thank you for posting this Red.

This is just horrific.

In 2011 I had my daughter by emcs in a struggling east London hospital. I was left to labour for days and days after my waters had broken and they had started inducing me. They were very reluctant to do a cs, but in the end, they did, and thank God my dd is healthy. I was quite traumatised by it all, though, and I do think it was close to being a catastrophe for my daughter. But I now realise that they were trying desperately to lower their c-section rate, as there were financial implications of having a high rate (and they had massive debts). There were other cost cutting factors too, like the midwives having to constantly go and get the drug keys for pain relief topups instead of a continuous drip, and the fact the monitor was broken, so not picking up my contractions properly. I have no doubt that women and babies are suffering because of this kind of economics, combined with an anti-csection ideology.

When I had my next baby, I had moved to Australia and chose an elective csection with no issues at all. My treatment (still in a public system) was a completely different world; kind, empathetic, empowering. Something needs to change in the UK for mothers.

My sister gave birth to her two DC at Shrewsbury hospital. She lives in Telford but had to travel to Shrewsbury because she was a high risk pregnancy. One DC was born by emergency CS 11 years ago and the other by elective CS because of complications in pregnancy eight years ago. She had an awful time, with the first especially. It really set the tone for a difficult first year of motherhood for her. She’s also had to have two hernia operations because of complications with the Caesarian, although I don’t know whether that’s a normal-ish thing or not

It might be worth writing directly to the Ockenden Inquiry to highlight this. I'm not saying that will be enough, but it's an opportunity that's there.

I'm trying to find contact info for them, but you may get there first.

The Ockenden Inquiry's being run by a body called NHS Improvement, and here's their contact info:

improvement.nhs.uk/contact-us/

In fact NHS Improvement plugs its project "Making Data Count" on its front page, so you may be pushing at an open door there. Maybe.

improvement.nhs.uk

Diane Taylor writing in the Guardian seems to have been looking at processes which affect patient safety at Shrewsbury, last year, though not Caesarian rates. So might also be interested in the CS data.

www.theguardian.com/society/2017/apr/21/nhs-maternity-units-testing-shrewsbury-telford-trust-hopeless

A senior figure in an NHS trust’s maternity unit under investigation over avoidable baby deaths has admitted that some practices in the unit were “hopeless”.

Andrew Tapp, medical director of women and children’s services at Shrewsbury and Telford hospital NHS trust, said in an email to a GP: “I think there are real problems here.” The GP had raised concerns about the maternity’s unit’s communication of test results.

The emails, seen by the Guardian, were sent in May 2016. The GP says his concerns about the safety of patients persist, citing a recent incident he was involved in that could have risked the life of an unborn baby.

The problem is the dominance of ideology in medicine.

Women's groups are pushing the overly simplist ideological message that CS = bad.

CS ARE a harm and undesirable outcome compared to a natural birth. BUT and this is the point they are a more desirable outcome than other injuries and death. And this seems to have got lost in the establishment of CS target rates. Its a fundamental point that has been totally overlooked.

I've been keeping an eye on how this is playing out in the NHS for a very long time, as its given me a lot of concern. I do think there is a MASSIVE political blind spot here. I noted the RCOG figures back in 2016 for a reason.

We KNOW that the scientific data supports the point that women NEED to give birth in an environment that they are comfortable in. This is why home births work for low risk births despite being counter intutitiave about being away from a medical setting. Because of the role of anxiety inhibiting the natural birthing process.

That would suggest that how you manage anxiety and how you listen to ALL women - not just a select group who are able to advocate - should be your number one top priority. Its not. And the reason its not, is a hugely political one.

If you are setting a very low CS target AND you are running your hospital on low staff, its a recipe for disaster. Not only do you have fewer staff to spot problems but you also are potentially making the environment more stressful for both women and staff. Which in theory, based on the evidence about anxiety levels and hormones, means you are much more likely to produce more difficult results as a direct result. Its exactly the opposite thing to do, if you know that anxiety inhibits the natural birthing process and is more likely to cause adverse outcomes. If you have women coming to you saying that they are too afraid to give birth, you don't increase that anxiety with beaucracy and hoop jumping. You work with them to decrease that anxiety in whatever way works best for them. Which requires contact time.

This isn't rocket science.

Its another one of these where austerity crosses over with feminism and produces actual harm. You CAN NOT reduce costs in maternity without there being the potential for HUGE adverse consequences - which are both health related and cost related. It is not cost effective to reduce staffing nor to aggressively try to reduce CS rates by gatekeeping alone. Especially when you consider the percentage of NHS negligance claims that originate from maternity departments. (And don't get me started on how maternity department with a poor record, end up with higher insurance premiums which mean they have less money to invest in actually improving care).

If you want to reduce CS rates you have to invest in staffing and the enviroment women are giving birth. You have to work on HCP relationships an trust.

Again we have this narrative appearing about women being too scared to give birth because of social media. Its been in the press this week a huge amount this week. It sets women up as infantile and pathetic sharing horror stories rather than women talking to each other and building up a picture of institutional failures and the consquences of austerity. Women are not allowed to talk.

Its interesting that tokophobia has appeared at the exact same time as austerity - its not just occurred at the same time as social media. The whole media narrative that seems to have developed this week is an exercise in correlation being used in a way that suggests causation rather than considering whether that the correlation is a sympton of another problem (austerity and ideological preferences) at root cause. Because people in power don't want to delve deeper into this - because it would require them to take action.

The role of science has gone out the window. Data is being used in a misleading way without questions being asked when they perhaps should be. Often against women to try and silence them. And women are not being listened to and are being shut out of the picture, which is leading to harm being done to them. Not only that, but women who are most able to advocate for themselves (or have someone who is able to advocate for them) and navigate through the system in a way that is good for them and prevents harm, tend to be middle class older, educated women. (Which has in part led to the term 'too posh to push' - ironically in every other area of healthcare this group are known to have better health outcomes and this is seen as a positive thing. In the case of child birth, because it harms the narrative of cs = bad, these women are being smeared by other highly motived and able activists) Younger, working class or ethnic minorities tend to have greater problems getting their concerns listened to and strangely enough have worse outcomes.

And yes, I do think the CQC has some questions to answer. MN did a thing a couple of years ago on post-natal care and I trawelled through a whole bunch of CQC reports. What jumped out at me, was how inconsistent they were, how there seemed to be things that were omitted and how as long as you ticked the right boxes the CQC would say 'yes', when there were other niggling things in the details, that made me go hmmmm in a big way. So I am very interested in what the CQC have to say over Shrewsbury and Telford and I'm very interested to see how this pans out.

Its funny how this pattern of power of groups, ideology over science, the role of the media, failure of institutions to do what they are supposed to and money that is present in trans politics and is present in wider populist politics is very much being replicated in maternity care.

And no I don't believe its a coincedence.

People do not want to see a problem and they do what they can to deny its existance, because acknowledging a problem properly means admitting failure and taking difficult (and often expensive) measures to rectify that problem. And politicially women are not deemed worth that.

The all natural Earth Mother movement is a middle class movement. I've always been suspicious of it because the outcome is so much like the puritanical Biblical idea that women should suffer in labour.

Thanks very much for bringing this up, RedToothBrush. The problem can be simply summarised as prioritising process over outcome. You shouldn't set targets that measure the number of caesareans you have; you should set targets for the number of mothers and babies who are alive and well after childbirth. Sometimes a caesarean section is the only intervention that will save a baby's life or prevent it from long-term disability. Every single case is different and must be assessed on its own merits.

Such an interesting thread. The evidence is clear that those figures are shockingly below the national average and that there is a clear correlation to horrendous medical sequelae.

Common sense seems to be overtaken by candles, mood music, water baths, doulas and hypnotherapy.

You shouldn't set targets that measure the number of caesareans you have; you should set targets for the number of mothers and babies who are alive and well after childbirth

Strongly agree, but this also means having honest criteria for what constitutes “well”. My understanding is that many women whose vaginal births have resulted in life-limiting injuries such as serious sexual dysfunction or incontinence are often recorded as having had successful births, merely because they didn’t die. It’s a disgrace.

Because for so long certain groups, often women's groups , have been banging on about natural births ; midwife led births; midwife only units ; the need to demedicalise birth; articles about "failed birth experience" because there was intervention; talking up how awful c-sections are; denigration of women who choose c-sections

Yes lass, you are right. It is always really interesting to me the extent to which this sneering about sections/evangelism regarding painkiller-free birth etc is led by women. I honestly think most men would be happier if c-sections were the default - less likely to mess up their sex lives. Some women do really seem to want other women to suffer, whether it’s necessary or not - and take great pride in having gone through avoidable/reducible suffering themselves.

Note that my post above is talking on an individual level - women I personally know or have seen talking about their natural birth experiences online. At an institutional level, I of course don’t lay the blame for these kinds of shameful situations at the door of women in particular, but at the door of the systems which paternalistically ignore women’s needs and self-knowledge in order to make some kind of scanty (and false) savings.

Strongly agree, but this also means having honest criteria for what constitutes “well”. My understanding is that many women whose vaginal births have resulted in life-limiting injuries such as serious sexual dysfunction or incontinence are often recorded as having had successful births, merely because they didn’t die. It’s a disgrace.

This is why I was pleasantly surpised when the RCOG produced the data set in 2016 that those figures above came from.

It covered a lot of things that have not previously been covered in other publically available data - things that should be, as they cover a number of different definitions of 'harm', that I'd argue are more in line with women's concerns.

• All data split down into first time mothers and mothers who have previously had children (which is particularly useful)
• Data regarding 3rd and 4th degree tears.
• Data split into EMCS and pre-labour CS
• Data regarding induction
• Data regarding VBAC
• Data regarding instruments
• Data regarding episiotomy
• Data regarding unplanned readmission to hospital

RCOG had an interactive tool about it all, but they removed it! Its incredibly frustrating (especially since I can't find the raw data it used). It wasn't perfect but it did raise questions, which needed following up.

I started a thread at the time, and listed some of the 'outliers' - figures that suggest the possible of an unusal demographic (thus a particular reason for unusual figures), really good practice which others should be encouraged to follow or the possibility of really bad practice.

www.mumsnet.com/Talk/childbirth/2598442-New-Data-Comparing-Hospitals-and-Outcomes-in-Childbirth

CS can lead to complications such as loss of bladder and bowel control, adhesions, uterine prolapse. It's an added complication in childbirth that always requires antibiotics as well even if elective.

Personally, I would rather a CS than a high forceps delivery.