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Great expectations: fear, fortune and failure in the maternity services

While the nation as a whole is getting healthier and lives longer, why are our births getting more and more complex and complicated?

The number of women in labour getting the label “failure to progress” and needing intervention is rising, according to NHS figures . But is it in fact the medical professionals who are failing to wait for nature to run its course when it comes to childbirth?

A few days before her due date, Caroline Green’s contractions started and then suddenly stopped. Being a first-time mum and not knowing if contractions were supposed to act this way, she called the hospital and was advised to come in for a check. She never considered bringing her neatly packed hospital bag that had been at the ready for weeks. She and her partner just hopped on a bus, expecting to be home that same afternoon.

Green went through checks and monitoring and was told that her baby was completely fine. But as she was getting ready to go home, the midwives suddenly encouraged her to stay. “It didn’t make sense to me, because they didn’t give me any real reasons”, she says. “They just tiptoed around me and handed the decision over to me. This was my first baby, so of course I didn’t want to do anything wrong, but nobody was willing to give me clear medical advice. Instead it was as if they were keeping information from me.”

Confused, Green stayed at the hospital, waiting for days in a grim ward to go into labour. She finally did, but did not progress as quickly as expected. “I had planned to have a natural water birth, and I stuck to that and waited even though the midwives kept coming up with ways to speed my labour up”, she says. However, after two days of contractions, an obstetrician finally told her that she was putting her body under a lot of stress and suggested induction via an oxytocin drip. “This was the first person who actually gave me some facts about what was happening to me, and at that point I just thought ‘yes, please, let’s get this over with!’”, says Green. Her son was born a few hours later.

Still, she and her partner are left with a feeling that the medical staff somehow wanted to cover their bases. “They were overly cautious in keeping us there”, says Green’s partner James. “They should have said: ’This is what happens, contractions come and go, just go home and wait.” Green adds: “I am sure that if I had gone home and gone on with my life, then labour would have progressed naturally and there would have been no need for intervention.”

The number of completely “natural births” (deliveries without induction, use of instruments, caesarean section or any type of anaesthetic) in England on the NHS has decreased, according to figures from the Health & Social Care Information Centre. In 2013-2014 more than one in four of all births in England were by caesarean section, 25 per cent were medically induced and 12.9 per cent were by instrumental delivery (forceps or suction).

But while the nation as a whole is getting healthier and lives longer, why are our births seemingly getting more and more complex and complicated?

Better out than in

The problem, according to Alison Ryan, an antenatal teacher with the National Childbirth Trust (NCT) is that there is a “better out than in” mentality ruling the NHS. “Obstetricians are terrified of litigation in case of stillbirths. As soon as the baby is out, it is no longer the responsibility of the maternity services, instead it is handed over to the paediatricians.”

“The problem then boils down to ‘being too busy’ and starting to ‘rattle the forceps’ too soon in an attempt to make mothers push harder,” says Ryan.

But there is good reason to avoid instrumental deliveries. According to the Birth Trauma Association, forceps deliveries can lead to trauma to the head, subsequent problems with breastfeeding and increase in the severity of jaundice. Women with ventouse (suction) deliveries report a feeling of not really having given birth, as do those with caesarean sections.

The NHS is also reporting a long-term trend of trend of fewer midwives and more doctors conducting deliveries. Last year, nine out of ten births happened in hospital under the supervision of obstetrician.

And stillbirth rates in England have not improved for the past 25 years despite the rise in medical interventions, in contrast to other developed nations that we compare ourselves to. But England also has many more deliveries of babies before 36 weeks of gestation and many more babies then needing special care, says Ryan. “Normal viability used to be 38 weeks but now it is 37. What does that show us? Better out than in.”

Payment by Results

The driving force behind the NHS mentality on births , according to Ryan, is the Payment by Results (PbR) system, which was first introduced in 2002. The original PbR meant that the hospital would receive a payment per activity or “episode” for the woman in maternity care. Put simply, the more clinical interventions happening to a pregnant and labouring woman, the more money for the hospital. Effectively, the system could have helped increase the number of caesarean sections, which is a more expensive activity. The “old” PbR was also financially bad news for more midwife-led community-based maternity care, which has fewer interventions.

The current government is phasing in a new PbR system, which promises to “remove these perverse incentives and free providers to develop the right services for their women without the prospect of losing income,” according to the government guidelines, and promises to “complement a culture based around normality”.

In other words, the new PbR aims to reduce the number of unnecessary interventions in childbirth. The philosophy is that normal deliveries are seen as having advantages for mothers and babies, but only “where they are in line with mothers’ preferences and in the absence of clinical indications to the contrary.”

However, says Ryan, “the problem is that with the new PbR, the hospital will categorise women according to risk. The higher the risk, the higher the insurance rating and the higher the insurance rating, the more money will go into the hospital.” That is, we will probably see a lot more women put into the high-risk category in the future.

Not so, says Rachel Ambler, Consultant Midwife in Public Health at Whittington Hospital in London. “If we did that, we would be penalised.” In fact, the new PbR is better from a patient point of view, she says, “because the payment is for a particular case mix,” not just for a series of activities.

Great expectations

Ambler points out that it is somewhere between the woman’s birth expectations and the reality and economy of medicine that a clash between the NCT and the NHS happens.

“The NCT do a lot of fantastic work,” she says, emphasising that the organisation has worked hard to reclaim a normal birth for women after decades of a “dark notion” that births have to take place in a hospital. “But there is a very fine line between educating women and raising their expectations unnecessarily.”

Both as a practicing midwife for 39 years and as a mother, Ambler has witnessed the argument between the medical profession and what she calls the “normality people” in the NCT. “The NCT sometimes fill women’s heads with all sorts of non-evidence based information, such as ‘you will never need a caesarean’. Some women will, that’s a fact.”

“It is important to remember that caesarean sections are used in life-death situations. If you don’t need it, you are not offered one”, says Ambler, comparing the scenario to someone asking for an amputation to remove a tattoo.

Alison Wright, Obstetrics Consultant at Royal Free Hospital in London, agrees that the one-eyed focus on reducing intervention is fruitless: “Personally I worry about the drive to reduce the caesarean rate. It may well be that sometimes caesareans are done unnecessarily but we need to manage those ones better. I believe that if we improve quality of care for women the caesarean rate will naturally fall.”

What the NCT is trying to do, says Ryan, is to get people to use their brains and be selfish. This also includes their birth partners. For the NCT, it is the mother that has the responsibility to make safe decisions for herself and her baby. “The clinicians are looking at safe care for a whole unit, not the individual. This involves time schedules, shift changes etc.,” says Ryan. “Healthcare in this country has all these financial drivers and nobody ever mentions it.”

Ambler admits that midwives are very focused on what can go wrong. “Sometimes we make things sound risky when actually they aren’t. But to me it seems reasonable to warn people that there is a one in four chance of getting a caesarean section, for example, because that is what the statistics show us.”

Ambler has seen women almost sacrificing the health of their unborn child because of their own desire for a natural birth. “I had one lady who refused to have an episiotomy (cutting the perineum during labour to allow for more space for the baby to come out). The baby’s heartbeat was getting weaker and he was obviously in distress, but the mother wouldn’t let us help him along. He was marked by it when he finally came out.”

“Sadly,” she says, “the unborn child has no rights in that situation.”

Fear

But could it be that women in general are becoming more pain averse, more stressed and less able to go into labour spontaneously? Are modern women in fact asking for more pain relief, more interventions?

“I think there are some women who are getting more risk averse but also some who are very keen to avoid intervention. I think there is always a degree of luck - no matter how motivated women are to have normal labour,” says Alison Wright.

The trouble, says Ambler, is that obstetricians tend to put fear into women. They will tell women who express the wish to have a non-interventionist home birth that there is a chance of having a stillbirth. “The problem is that they don’t give you the numbers, and in many cases the numbers are really small. We need to remember that modern women are completely capable of understanding statistics.”

Ambler has seen big changes happening within her profession during her career. “Society and the cultural mix is changing,” she says “and the more things change, the more interventions we tend to have.” She remembers a time when the discussion about gestational diabetes was not so much about who was at risk, but whether the condition existed at all. However, the more the medical profession knows, the more it tends to intervene to be on the safe side.

“Obstetrics is the biggest area of medicine with litigation”, says Ambler, and in her opinion, that is a good thing: “Hospitals have to be sued for children to be safe. We need litigation to keep hospital standards up.” But she agrees that more often than not, a lawsuit does not adequately place the blame for a stillbirth. Nature will inevitably run its course despite our best intentions and interventions.

Photo by markheybo

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