PERSONAL STATEMENT

  I am a practising midwife, based at the University of Central Lancashire. The research unit I set up and which I currently direct has three streams, namely normal birth, maternal and infant nurture and nutrition, and community capacity building and childbearing. Our work is underpinned by the concept of salutogenesis, or the generation of well-being. I chair the steering group for the Royal college of Midwives Virtual Institute for Birth, and I have written regularly about the need to focusing practice, research and education in maternity services on the undervalued skills and intuitions around normal birthing. This emphasis is in recognition that very few women birth normally currently, and this has adverse personal and public health consequences for a currently unquantifiable number of women. This is in contrast to the significantly pathological emphasis in research spend, educational input and clinical practice in current maternity services.

  I co-ordinate an international elist of researchers interested in the area of normal birth research.

  I am also a member of the national multi-agency Maternity Care Working Party, and I sat on the government-initiated committee looking at the reconfiguration of maternity services which met in 2000-01 under the chairmanship of Professor William Dunlop. I have served on both the English National Board for Nursing, Midwifery and Health Visiting, and the United Kingdom Central Council for Nursing, Midwifery and Health Visiting.

  I have contributed to both the English Maternity Care Database project, and the European Peristat project.

Index

1.  Caesarean section
The impact of "normal birth" on caesarean section
Summary
2.  Maternity care databases
3.  Education and Training
4.  Organisation of care

1.  CAESAREAN SECTION

  1.1  This memo discusses the rates of caesarean and the consequences of the operation. It notes that the rise in rates of caesarean seems to be inexorable, despite a number of attempts to control it. It then goes on to note that most women giving birth in the UK today experience some kind of intervention in labour, even when the birth is coded as "normal". In response to the findings of a Canadian study looking at units with low rates of caesarean, this memo proposes that one of the key solutions in diminishing the UK rates of caesarean section is to pay attention to maximising rates of normal birth without intervention.

  1.2  Caesarean section is a major abdominal operation, which can be life-saving for mother and baby in extreme circumstances. There is no universally accepted population rate beyond which the risks of caesarean section outweigh the benefits. However, a widely quoted estimate is 10-15%[15]It is generally believed that there is likely to be very little clinical gain for populations of mothers or babies when the rate rises above 15%. It is of interest that rates of instrumental delivery vary widely across the developed world, and that those areas with the highest rates do not have the lowest levels of infant mortality[16]

  1.3  Current rates of caesarean section are up to 30% in some UK hospitals, though a series of recent reports found that these rates varied dramatically across hospitals[17], [18]Case mix and staffing levels did not appear to explain this large variation in rates. Attempts to diminish these rates through addressing single aspects of the problem have had minimal success, both in the UK and America.

  1.4  There appears to be little evidence that the sharp rise in the rates of caesarean section can be fully explained by a rise in maternal requests for the operation [19]Maternal request subsequent on a traumatic first birth experience may, however, play a small part in the rise.

  1.5  While many individual women and babies recover well from a caesarean, many others experience both short and long term adverse consequences. As discussed above, when rates are over 15%, these adverse events may not be offset by any benefits, at least at the population level.

  1.6  In the short term, these consequences are generally worse for women who experience emergency caesarean section, as opposed to when the operation is carried out electively. However, the longer term consequences of all types of caesarean section are not yet fully investigated. The long-term follow up of the Term Breech Trial may yield some information on this issue [20]

  1.7  The immediate severe but very rare risk of caesarean section is maternal death [21]This may be due to a combination of the underlying reasons for the caesarean section, anaesthetic risk, and complications of surgery. More commonly, as a recent Cochrane review has noted "The single most important risk factor for postpartum maternal infection is cesarean delivery."[22] While routine use of antibiotics during surgery have reduced this rate, it is not clear if the possible subsequent exposure to antibiotic agents through breastmilk has any impact on the neonate in the longer term. Some researchers have claimed that babies born by caesarean section are more likely to become asthmatic later in life [23]although this claim has been disputed.

  1.8  When performed electively before 39 weeks gestation, there is an increased risk of respiratory distress in the otherwise healthy baby [24]

  1.9  Breastfeeding can be affected[25]with potentially serious consequences for both baby and mother. There is some suggestion that bonding and parenting can be affected for some women, particularly after emergency caesarean section, although this may be a feature of mood disturbance subsequent to traumatic birth in general[26][27]Social consequences include the problems of decreased mobility especially for women with large families, and disadvantaged women without transport who often live in hard-to-access areas.

  1.10  Longer term risks are less frequently discussed with women. These include secondary infertility[28]ectopic pregnancy and possibly miscarriage[29]and need for further surgery due to adhesions and consequent chronic pelvic pain[30]These effects are likely to be present whether the operation is undertaken as an emergency or electively.

  1.11  More subtle effects have only begun to be investigated recently. These include the neuro-hormonal impact and immune response of the baby. There are some indications that babies born after elective caesarean section have a reduced stress response than those born after either normal birth or forceps[31]The effect has been measured at six weeks after the birth[32]Gut flora colonisation may be affected[33]and there appears to be fairly good evidence that some aspects of the immune response may different for babies born after different modes of birth[34]It is not clear how long this impact lasts for. It is not yet established whether these findings are related solely to mode of birth or to other factors, such as type of analgesia. It is also not clear whether lower stress responses are a benefit or a disadvantage for the neonate. However, the findings indicate that more work needs to be done on the subtle but potentially far-reaching impact of mode of birth on the baby, in both the short and the long term.

  1.12  Apart from the benefit of the operation itself in preventing death or severe injury to mother and baby, when carried out appropriately, the only other benefit found for women for cesarean section over instrumental birth, is a decrease in urinary incontinence[35]However, this benefit is restricted to women undergoing elective caesarean section, and an abdominal operation does not rule the risks out altogether.

THE IMPACT OF "NORMAL BIRTH" ON CAESAREAN SECTION

  1.13  Although the recent national caesarean section audit did not find that maternal request is a major factor in the increasing rates of caesarean section, it is clear that there is an increase in such requests. The major reason for this seems to be a previous traumatic birth experience. Anecdotally, in many cases, women making the request have had what is termed a "normal birth". However, closer analysis reveals that the use of the term "normal birth" is extremely misleading. Under current data collection systems, a woman experiencing induction or augmentation of labour with intravenous oxytocin, pethidine, an epidural, numerous vaginal examinations, numerous fetal blood tests, starvation during labour, continuous electronic fetal monitoring, and an episiotomy, but who pushes the baby out without any instruments, will have a "normal birth".

  1.14  A series of studies and popular media surveys have found that, in fact, the percentage of babies born to mothers who started labour spontaneously, had minimal analgesia, and pushed the baby out themselves without an episiotomy is very low[36][37][38]One of these studies has estimated that the rate may be around 25% overall, but closer to 16% for women having their first babies

  1.15  There are three important issues here. The first is that is that women who experience "normal" births with high rates of technical intervention may seek to avoid another such experience by requesting caesarean section. The second is that this way of managing birth be a causative factor of the increase in cesarean sections, due to the profound disruption of physiological processes. The third is that such widespread intervention in birth raises a question about the capacity of maternity care staff to believe in and understand physiological processes.[37]

  1.16  Recent research indicates that this final point may be extremely relevant[39]This small but very striking study in Canada turned the problem on its head. It examined 4 hospitals where the rates of caesarean were low, to find out what issues were in common across these sites. Twelve factors were identified. The first two were "pride in a low caesarean rate", and "belief that birth is a normal process". The other factors included effective leadership and willingness to change.

  1.17  Although a dissemination project has been set up in Canada following this project, the original study has not been tested comparatively. It is likely that some of these 12 factors are also found in units with high caesarean rates. This comparative research is needed with some urgency. However, the study provides an indication that orientation to normal birth may be one of the characteristics which holds the key to lowering the excessively high rates of caesarean in the UK, and elsewhere. The study also indicates that a single-issue clinical response to the rising rates of caesarean section is unlikely to be sufficient on its own.

  1.18  Other schemes designed to address the issue in a multifactorial manner include a successful local initiate to humanise birth in Brazil, a country with very high cesearean section rates[40]This project has illustrated that getting birth right may impact positively on the local community as well as on the mother and baby. One of the few global developments in this area is the "Mother Friendly Initiative"[41]This approach uses techniques similar to the "Baby Friendly Initiative" which has been successful in raising rates of breastfeeding world wide. In the UK, the Royal College of Midwives is setting up a multi-faceted initiative to promote optimal birth[42]This includes the use of new technologies to promote on the ground change, and the setting up of a scheme to recognise and promote sites in which physiological birth is maximised.

SUMMARY

  1.19  The risk benefit ratio of caesarean section may be adverse when population rates rise above 15%. Despite the recognition world wide that rates are probably rising too high, schemes to reverse the trend have been only marginally successful. It is possible that lessons can usefully be learned from sites where the rates are low. Recent research in such sites suggests that an orientation to normal birth may be one of the factors which begins to bring the risk/benefit ration into balance. This possibility needs to be explored by the maternity sub-committee.

1.  MATERNITY CARE DATABASES

  2.1  There has been a great deal of concern about the completeness of returns from maternity care systems. I assume the committee will receive a number of representations on this issue, and so I will not address it further here.

  2.2  A separate issue is the inability of current minimum data sets to discriminate between straightforward births, and those which involve significant interventions and possible morbidity for women and babies. This has implications for our understanding of the nature of birth today, and of the possible impacts this may have on women and babies and on public health.

  2.3  Under our current data collection systems, a woman and her fetus experiencing induction or augmentation of labour with intravenous oxytocin, pethidine, an epidural, numerous vaginal examinations, numerous fetal blood tests, starvation during labour, continuous electronic fetal monitoring, and an episiotomy, but who pushes the baby out without any instruments, will be recorded as having a "normal spontaneous delivery".

  2.4  A woman who enters labour spontaneously, labours with no drugs, has no tears or episiotomy, and who pushes her baby out by herself, will also be coded to a normal spontaneous delivery.

  2.5  The public health consequences of each of these scenarios will differ significantly.

  2.6  In the absence of the ability to collect data on straightforward births, the debate has become focused on caesarean section, and on maternal and fetal/neonatal pathology. This is problematic, since it does not allow for a full exposition of the issues in birth today. This issue has been noted by contributors to a number of current initiatives, including the English Maternity Care Database project, and the European Peristat project.

  2.7  Changing data collection systems to capture information about normality as well as about pathology may be catalytic in changing the focus of debate in maternity care. This is an issue the committee may wish to consider, with an awareness of the UK and European projects which are also underway in this area.

3.  EDUCATION AND TRAINING

  3.1  If the main emphasis of this paper on the importance of fostering physiological processes is supported, the education, training, and on-going skills development of staff needs to be re-focused. It appears that maternity care staff, and midwives in particular, have lost skills in maintaining normality, despite being taught this within the curriculum of most midwifery departments. This has an impact on the developing skills and attitudes of students. Anecdotally there are students towards the end of their training who have never witnessed a physiological birth.

  3.2  Part of the problem is the assignation of higher status to technical skills in the context of pathology than to the complex skills necessary in supporting women in accomplishing physiological birth.

  3.3  This is illustrated by two common approaches. Firstly, it is usual for community midwives to be brought in to the technology-intensive labour ward of the hospital to update, but not for the process to go the other way. This indicates that the skills used at home births and in birth centres are not seen as being valuable, whereas the highly technical skills used in hospitals are. Secondly, there is a common ruling that newly qualified midwives should undertake one or two years in a hospital context before they are eligible to be appointed to birth centre or community posts. This implies that the technical skills necessary in a hospital setting are those which are fundamental for all births. This may be one of the reasons why midwives lose faith in physiological processes.

  3.4  Education to graduate and post-graduate standard is important for the development of reflective and critically aware midwives. It is essential, however, that such an education does not lose sight of the practical and intuitive basis of midwifery practice. Schemes which encourage students to case-hold and follow women through and which overtly recognise the skills of expert midwives as having equal status with academic knowledge, are those best able to equip students for practice in supporting and promoting physiological birth. It is unlikely that any midwife can be knowledgeable, skilled and confident enough to commence autonomous practice on registration without at least three years' full time education. At least half of this time should be spent in clinical situations, working with skilled and knowledgeable mentors.

  3.5  Research into the nature and short and long term impacts of mode of birth on mother, baby and society, is only just beginning. Midwifery research is located in very few traditional universities. It is essential that the current White Paper on higher education does not lead to a shutting down of newly emerging research in this area. The committee may be interested in considering the longer-term implications of the White paper on the knowledge and skills base available for future maternity services.

  3.6  Trained midwives need to have regular access to skills sharing and reflective sessions, in a supportive and constructive atmosphere. While perinatal mortality meetings provide useful forums for discussion, they are focused on risk and error. Formal sharing of supportive skills and of innovative practices is more likely promote skills which will prevent at least some of the iatrogenic risk for mothers and babies consequent upon widespread routine technical intervention.

  3.7  Independent midwives are a significant resource in this respect, and their skills and expertise should be widely and formally acknowledged, and built in to training and on-going development schemes.

  3.8  Skills in emotional intelligence as well as standard clinical skills and in the skilled but conservative use of advanced emergency techniques such as those taught in ALSO courses are necessary for effective midwifery practice. The former should be built in to primary training programmes.

  3.9  The Association of Radical Midwives has proposed that skills in normal midwifery practice and in re-reorientation to normality, and in presencing, empathy, and effective use of intuition are necessary for the promotion of physiological birth[43]3.10  Education and training such as that described in this section cannot be effective if midwives are not able to practice skills in physiological birthing. It has been reported that many midwives are leaving the profession because they cannot practice the kind of midwifery they believe in[44]Any changes to programmes and models of care need to recognise that, if effective change is to happen, it needs to happen at all levels of maternity care provision.

4.  ORGANISATION OF CARE

  4.1  There has been significant debate over the last 50 years at least as to the optimum place of birth for women. Alongside this, recent debates about the organisation of care have ranged from the need for mega-units to maximise the availability of medical expertise, to the need for team midwifery, midwife led care, integrated and free-standing birth centres, and midwifery case-holding.

  4.2  It is likely that a mixed-economy approach will be optimal for women and babies and for the service. The overriding need is that, however the service is organised, the outcomes for women and babies, the satisfaction and morale of staff, and the feasibility of the model, is optimised.

  4.3  Fixed adherence to a specific design for care organisation is unlikely to be successful. However, it is necessary that whatever system(s) are introduced at local level, they need to engender trust, and clinical, emotional, psychological and emotional safety for both service users and providers.

  4.4  On this basis, mega-centres are unlikely to be successful unless they are divided into "villages". Models of care which deliver maximum continuity of carer are most likely to be effective, and may be the safest principal to adopt for the avoidance of risk due to non-disclosure of important clinical or psychosocial issues in women's lives. If resources limit the provision of such schemes in the short term, they should be targeted in the first instance on the most deprived populations.

  4.5  The chosen schemes should also maximise the possibility of staff having pride in the service they give.

  4.6  On the basis that there is no definitive evidence that hospital is the safest place for low-risk women and babies to be during labour, the option of out-of hospital birth attended by skilled midwives should be available in every Trust.

  4.7  The current lack of both medical staff and midwives may be seen to be problematic for labour-intensive models. There are also economic issues with these approaches. However, where such schemes have been set up, there is no lack of willing midwives to participate, and the economic argument may be a short term one if such schemes maximise public health benefits.

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