The Power of User Pressure

ISSN 0256-5004 (Print)

AIMS Journal, 2009, Vol 21 No 1

MSLC Chair Michelle Barnes campaigns successfully to reduce the caesarean rate in Sheffield

In February 2008 Michelle Barnes wrote the following letter to the Chief Executive at Sheffield Teaching Hospital NHS Foundation Trust.

Dear Sir

I am writing to you as a service user, service user representative and as recently appointed Chair of Sheffield Maternity Services Liaison Committee (MSLC) because I am extremely concerned about the increasing caesarean section (CS) rate in Sheffield.

The World Health Organisation (WHO) declared that there was no health improvement for either mother or baby when caesarean sections exceed 10%, yet Jessop Wing has a CS rate of 24%. The harmful effects, on both mothers and babies, of caesarean sections has been well documented.

As Chair of the MSLC I have raised this issue and was told that the WHO conclusion was based on pregnancy care 22 years ago and what seemed an appropriate CS rate in 1985 may not be appropriate in 2007. If that is the case then do you have statistics for 1987, 1997 and 2007 so that we can see exactly how this increase in major abdominal surgery has improved outcomes? Certainly over the last ten years we have seen a huge increase in the numbers of women suffering from postnatal depression and post traumatic stress disorder. Recently three women in Sheffield killed themselves after childbirth and the lack of an effective perinatal mental health service in Sheffield is not helping matters.

Not only are caesarean sections more harmful and carry more risk to women and their babies but they are also more expensive than vaginal deliveries, based on the estimate that a caesarean costs about £1500 more than a vaginal delivery (NICE 2004), Sheffield Teaching Hospital Trust could make a huge saving if it reduced its CS rate. St. Mary's Hospital in Manchester has a CS rate of 19.1% and Nottingham City Hospitals CS rate is 18.4% and they are both teaching hospitals, like Jessop Wing, with similar birth rates.

While obstetrics is a much needed surgical speciality for woman who require help during a complicated pregnancy or birth, midwifery is the profession of expertise for supporting normal pregnancy, childbirth and postnatal care. I am really pleased with the recent increase in home births in Sheffield, however, despite women constantly asking for ’one to one’ care this is yet to happen city wide in Sheffield. The 'one to one' practices that currently run in Crookes and Sharrow are heralded as best practice by both women and midwives and should be extended across the city.

I understand that not all midwives want to carry their own case load of women and provide 'one to one' care but have you ever considered the possibility of running a primary care midwifery ser vice and directly employing either NHS or independent midwives? GPs are independent practitioners but in recent years have become much more managed by Primary Care Trusts. There is no reason why this could not happen with midwives and evidence suggests that there are many midwives who would welcome the chance to work in this way.

As Chair of the MSLC I have suggested, at MSLC meetings on the 14/9/07 and the 16/9/07, that Jessop Wing use the new NHS toolkit ‘Focus on normal birth and reducing caesarean section rates’ launched by the NHS Institute for Innovation and Improvement. The idea of the toolkit is that each maternity unit should hold workshops to self-assess their current position with a multi-disciplinary group, including users. They should then make plans for improvements on the different categories. It appears that placing a close audit or monitoring programme, such as the toolkit, on obstetric practice leading to CS can affect caesarean birth rates.

If your Trust hasn’t got a copy, they can contact or 0800 555 550, quoting ‘NHSIDQVToolkit-C-Section. The Toolkit was developed by a team comprising an obstetrician and two midwives, who visited units across the country with both high and low CS rates. They concluded that there was a general belief amongst clinicians that maternity units applying best practice to pregnancy, labour and birth, will achieve a CS rate below 20% (like Manchester and Nottingham), with aspirations to reduce this to 15%.

I know that Marcia Baxter will be looking at the CS rate at Jessop Wing, and considering ways of reducing it as part of her MSc project over the next year. However, caesarean sections are consultant led, and I hope you will agree, a reduction in the overall rate cannot be achieved without serious consideration from the Consultant Obstetricians at Jessop Wing. The NHS toolkit would be an extremely useful way for the Consultant Obstetricians to review their practice but, as far as I am aware, no Consultant Obstetricians are willing to use it and there are no other immediate plans to try and reduce the overall rate in Sheffield.

I look forward to hearing your views on this matter.

Following this letter, the Jessop Wing has been successful in their application to become an adopter site for the use of the NHS Toolkit - promoting normality and reducing the caesarean section rate. Using the national Toolkit framework, the Jessop Wing will be accessing support from the National team in achieving the ‘Keeping First Pregnancies and Labour Normal’ pathway. The Head of Midwifery recently confirmed that the letter has helped to increase the normal birth rate in Sheffield.

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