Select Committee on Health Fourth Report


How have caesarean section rates changed?


  64. Just over one in five babies in England are now delivered by caesarean section. In the 1950s 3% of births in England were by caesarean section. This figure had risen to 9% by 1980 and has since increased rapidly, reaching 12% in 1990, 21% in 2000,[72] and 22.3% in 2001.[73]

  65. Caesarean section rates at individual maternity units vary widely across England. Behind the 22.3% national rate[74] local figures range from approximately 12% to approximately 30% and differences between the rates of neighbouring hospital trusts and even neighbouring maternity units, may be stark.[75]

  66. Lack of consistent data on maternity care is a problem in countries other than England and so exact international comparisons of caesarean section rates are difficult to make, although an overall increase has been recognised as a global phenomenon. Estimates for France and Germany suggest that rates in these countries are broadly in line with that in England. Caesarean section rates in Norway, Finland Sweden and Denmark (countries which produce reliable maternity care data) mirrored the position in England until the 1990s but while rates rose rapidly in England in the 1990s, in Nordic countries they remained at 12-14%. The caesarean section rate in Italy, which was comparable to that in England in 1980, had risen beyond the rate in England (to 22%) by 1995. [76]

  67. In the United States, caesarean section rates rose steeply throughout the 1970s and 1980s, from 6% in 1970 to 17% in 1980 to 24% in 1990. However, in contrast to trends in European countries, US rates in the 1990s stabilised, falling to 22% in 1995.[77] In South and Central America, caesarean section rates are considerably higher than those in the US and Western Europe. It is estimated that rates in Brazil and Chile are currently around 40%.[78]


  68. In 1985 the World Health Organization (WHO) undertook a study of caesarean section rates and maternal and perinatal mortality rates. A WHO conference on caesarean section rates concluded that no additional health benefits were associated with rates above the range 10-15%.[79] For some women and babies, caesarean section may be a life-saving procedure. However, rising caesarean section rates give cause for concern with regard to health outcomes for mothers and babies because the operation is a major surgical procedure which is associated with some immediate risks and also has some longer-term health implications.

  69. A great many of those who responded to our call for evidence on this aspect of our inquiry registered their concern about rising caesarean section rates in English maternity units, and sought to make clear to us the risks involved in the procedure. The RCN set out these risks in the starkest of terms:

    Although the [caesarean] procedure carries major benefits for some women and children, there are also associated risks, such as increased perinatal and maternal morbidity and mortality due to operative injury and complications of anaesthesia. Post-operative recovery can also be lengthy.[80]

  70. An elective caesarean section carries almost a three-fold greater chance of maternal mortality over vaginal birth, if there is no emergency present.[81] Dr Soo Downe, from the Midwifery Studies Research Unit at the University of Central Lancashire also pointed out the "immediate but very rare" risk of maternal death, owing to a combination of the underlying reasons which indicated the need for the procedure, anaesthetic risk, and complications of surgery. Martin England recounted for us how his wife delivered triplets by caesarean section after a relatively trouble-free 36-week pregnancy but subsequently died from a rare condition associated with caesarean section (Acute Colonic Pseudo-Obstruction or Ogilvie's syndrome) which was not identified until the inquest into her death.[82]

  71. Professional debate continues as to whether the mortality risks inherent in caesarean section are now so small, that the only relevant issues are morbidity differences between labour and elective caesarean section, for example, differences in recovery time, infections, and incontinence. However, there is little detailed work on morbidity and longer term outcomes. There is strong evidence that immediate serious morbidity is at least 30% higher for elective caesarean section than it is for labour, including vaginal deliveries followed by emergency caesarean sections. There is also professional consensus that caesarean section risks increase with each operation, whereas labour risks decrease with each delivery.[83]

  72. Postpartum maternal infection is also a risk associated with caesarean section. The concerns about caesareans are not only related to the immediate operation and recovery period but longer term sequelae (that include repeat caesarean, scar dehiscence and rupture, and obstetric hysterectomy), adhesions complicating further surgery, ectopic pregnancy and haemorrhage and hysterectomy following uterine evacuation. There is some evidence that women who have had a previous caesarean section are more likely to have problems with fertility.[84] Dr Downe told us of the possible implications of caesarean section for babies. She identified an increased risk of respiratory distress in babies delivered by elective caesarean section before 39 weeks gestation and also an adverse effect on successful breastfeeding and bonding.[85] It is estimated that during the procedure itself there is a 1% risk of a knife laceration to the fetus (this increases to up to 8% if the fetus is not in the cephalic, or head-first, position).[86]

  73. Increasing caesarean section rates have cost implications for the NHS. A caesarean section was costed in the mid-1990s at an estimated £760 more than a vaginal delivery. By this calculation, every 1% increase in the national rate costs the NHS £5million.[87]


  74. Since the 1920s the Department has played a key role in monitoring the risks associated with pregnancy and childbirth by commissioning studies of maternal mortality. In 1952 the Department (then the Ministry of Health) established the Confidential Enquiry into Maternal Deaths in the United Kingdom in response to concerns about deaths in childbirth. The findings of the Enquiry, a centrally-directed self-audit for health professionals involved in maternity services, are incorporated into Government health policy and obstetric practice.[88] As mentioned above in Chapter 2, CEMACH will continue the work carried out since 1992 by CESDI to collect and analyse data on deaths in late fetal life and infancy and so ultimately to reduce the number of such deaths.

  75. These projects have audited caesarean sections in relation to maternal and infant deaths, but while mortality rates have decreased, concerns about the rising national caesarean section rate and about the variation in rates between maternity units in light of the risks associated with the procedure, have intensified. Concerns about caesarean section rates pertain not only to the safety of the procedure itself but also to the perception that caesarean section might not be the most appropriate option for some of the women who undergo the operation; that it might represent an unnecessary intervention in the natural process of childbirth.

  76. In January 2000 the Department commissioned the National Sentinel Caesarean Section Audit "to accurately determine the current caesarean section rate, factors associated with variation in the rate and quality of care."[89] Data were collected from maternity units in England and Wales between 1 May and 31 July 2000. The aim of the Audit was not to judge obstetric practice but to gather the data required to inform the development of guidelines for caesarean section which the National Institute for Clinical Excellence (NICE) has been commissioned to provide.

  77. NICE guidelines on caesarean section are expected in December 2003. In the mean time, the Department has commissioned NICE guidelines on two other forms of intervention in labour which might increase the likelihood of a decision to perform a caesarean section: the use of electronic fetal monitoring (EFM)[90] and the induction of labour. After repeat caesarean sections which contribute 29% to the overall caesarean section rate, the most common reason for performing the procedure is presumed fetal distress, diagnosed by EFM, which contributes 22% to the overall rate.[91] The guidelines on EFM and induction of labour are intended to support maternity unit staff in making decisions about interventions, to reduce variations in clinical practice and with particular regard to EFM, to reduce "unnecessary caesarean sections and instrumental deliveries."[92]


  78. In the evidence it provided for this part of our inquiry, the Department drew on the results of the National Sentinel Caesarean Section Audit. During the Audit over 70% of caesareans carried out were attributed to one of four factors:

  79. The National Caesarean Section Audit noted failures to use good practice guidelines dealing with these four indications in a substantial proportion of cases: Syntocinon was not used in dystocia or 'failure to progress' (in cases accounting for 2.6% of the overall caesarean section rate), fetal blood sampling which can halve the caesarean section rate for 'fetal distress' was not used (in cases making up 4.6% of the overall rate), external cephalic version, which turns approximately half of breech babies to head-first, was not offered (to 67% of women having elective caesarean section for breech presentation) and on the discussion of labour with women who had one previous caesarean section was highly variable across units (suggested by the wide range of vaginal birth achieved after caesarean section in 6-66% of women). Thus there is strong evidence that simply adhering to present standards should reduce unnecessary caesareans by at least 5%.

  80. Around 63% of caesarean sections carried out were identified as emergency procedures, while 37% were identified as elective. The Department noted that, in the Audit, 7% of caesareans were attributed to maternal request. However, the Audit Report itself indicated that such classifications might be misleading:

  81. With regard to the 'maternal request' category identified by the Department, the Centre for Family Research at the University of Cambridge found that individual obstetricians used different definitions of a maternal request, with some recording this as a reason for undertaking caesarean section even if it had been recommended by clinical staff as the best course of action. [94]

  82. We recommend that in undertaking caesarean section audits, all hospitals should classify the degree of urgency of a caesarean section in the same way. We further recommend that the classification scheme used by the National Sentinel Caesarean Section Audit be considered as a standard scheme and that the data items needed to construct it should be included in the Maternity Care Data Dictionary.

  83. The Department told us that the reasons for the rise in caesarean rates were "complex and not well understood" but suggested the following as contributory factors:

  • Technical advances have enabled obstetricians to identify complications at earlier stages [for example, through EFM], so that intervention may constitute a more appropriate option than it once did
  • Increased safety of the procedure
  • Changes in the age profile of the obstetric population [women over 35 years old form a larger proportion of all maternities than they did twenty years ago, and the caesarean section rate increases with maternal age][95]
  • Women's choice[96]

  84. Perhaps the most contentious and least understood of these factors is women's choice. The British Association of Perinatal Medicine (BAPM) told us that "greater consumer choice in choosing when and how to deliver", is a factor which contributed to rising caesarean section rates.[97] However, several others detected a perception, fuelled by media coverage of private practice, that the rise in caesarean rates is largely a consequence of maternal request for the procedure. Dr Soo Downe of the Midwifery Studies Research Unit, University of Central Lancashire, told us that:

    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. Maternal request subsequent on a traumatic first birth experience may, however, play a small part in the rise.[98]

  85. Caesarean section rates in private hospitals are often higher than in the NHS (the Portland Hospital in London has a caesarean section rate of some 44%). As we have noted, while these rates have little impact on national statistics, the levels of public awareness of celebrities who deliver their babies by caesarean section in private hospital may have a disproportionate influence on culture and perceptions.[99]

  86. According to the Centre for Family Research at the University of Cambridge, the RCOG and many others who provided written evidence for our inquiry, pregnant women want more information on the risks and benefits of caesarean section and wish to be involved in the decision-making process.[100] A survey carried out between 1999 and 2002 by the Centre for Family Research at the University found that that maternal requests for caesareans were made mainly because of fears about the health of mother or baby.[101] In their most extreme form, these fears constituted a phobia of giving birth (tokophobia), and a small number of seriously traumatised women may need surgery in order to avoid severe psychological problems.[102]

  87. Another contentious issue afforded a great deal of attention in the press, is that of litigation related to maternity care. The NHS Litigation Authority (NHSLA) had potential liabilities for clinical negligence of £5.2 billion at 31 March 2002 and as the NHSLA attests: "obstetrics is responsible for a disproportionate number and cost of clinical negligence claims with damages awarded often exceeding £3million."[103] Dr Luk Yun Chang from Mayday Hospital, Croydon, told us that the rise in caesarean section rates reflected concerns regarding the risks of litigation if a vaginal delivery is seen to be difficult or might be considered in hindsight to have been managed inappropriately.[104] The BAPM identified "an increasing tendency to practise defensive medicine."[105] This view was supported by evidence submitted by the Centre for Family Research at the University of Cambridge.[106]

  88. The RCOG emphasised the finding of the National Sentinel Caesarean Audit that lower caesarean section rates could be associated with aspects of staffing policy, such as continuous support for women in labour, and dedicated consultant time on labour wards.[107] The BAPM also argued that the staffing structure of labour wards had a bearing on caesarean section rates, stating that if less experienced staff were responsible for decisions about the mode of delivery, rates tended to rise. [108]

  89. We were keen to hear at first hand the views of health professionals and user representatives on these issues, to explore their perceptions of caesarean rates, nationally and at their own units, and in particular to try to find out why caesarean rates varied so much among maternity units in England.

What is the experience in maternity units?


The woman's role in the decision to undertake a caesarean section

  90. We put the various possible reasons for the increases in caesarean section rates to obstetricians, midwives and user representatives from maternity units in each region of England. Our witnesses addressed the well-publicised aspects of the maternal choice controversy but also helped us to explore in greater depth women's perceptions of the procedure and of their role in the decision to undergo it. Although caesarean sections undertaken at maternal request make up a small proportion of the total number carried out, the issues raised by discussion of these cases in respect of provision of information and support for pregnant women relate to all aspects of maternity care.

  91. Some maternity care staff told us they had noticed a change in women's attitudes to caesarean section and to childbirth in general. Siobhan Hargreaves, a user representative from University Hospital, Nottingham said that "until the last couple of years" she had never known women to talk about undergoing a caesarean section "because of the convenience of arranging childcare and getting back to work." Mrs Hargreaves registered her concern for these women, asking "are they fully aware of the implications of major abdominal surgery?"[109]

  92. We heard from maternity care staff who felt that the portrayal of maternity care in the media had had an effect on women's aspirations and expectations with regard to childbirth. Marie Pearce, a Community Midwife working for West Hertfordshire NHS Trust told us:

    People in the press make it sound so easy, you can have your section at nine o'clock on a Tuesday morning and have your visitors at three. You have your champagne afterwards and it looks so nice. Some women see it in the press and think that if they can do it and get their figures back in three days then why shouldn't they? … The popular press is making it worse.[110]

  93. This image of birth does not refer at all to the health of the mother or the baby but a positive outcome is assumed. In turn, then, the portrayal of this scenario can play not only on women's lifestyle aspirations but also on their deepest concerns about childbirth. As Elaine Parker, another user representative from University Hospital, Nottingham, told us:

    Women want a perfect birth. They want a perfect outcome, and if there is any slight risk they see caesarean section as an easy option to get that birth, without always understanding the consequences of aftercare and subsequent pregnancies.[111]

  94. Several witnesses told us about the kind of fears associated with childbirth which, while they might not constitute tokophobia, could still influence women's attitude to caesarean section. Elaine Parker told us that many women were so anxious about the prospect of a forceps delivery that they would rather have a caesarean section.[112] Livia Mitson, representing women who received maternity care at the Rosie Hospital, Cambridge, summed up:

    childbirth can actually be really quite scary, whereas a caesarean section is seen as an operation and it is planned and under control. You do read about caesarean section in the media and you are aware of them whereas you are not so aware of encouragement for home births.[113]

  95. It was clear to us that women's perceptions about caesarean section and their fears with regard to childbirth were of considerable concern to maternity care staff, who felt a sense of obligation to respect a woman's choice but also to protect her from the risks associated with surgery if at all possible. Many maternity care team members and user representatives argued that providing women with adequate information about caesarean section represented the best way forward. As Ann Geddes, Head of Midwifery at St James's University Hospital Leeds told us:

    some women will require caesarean sections for some very good reasons—others perhaps not so good. I feel our role is to give the information that is required in a non-judgmental way and help them to make that decision.[114]

Sheena Appleby, Head of Midwifery Services at Derby City General Hospital also felt that women "need the information on which to make the choice … they need the support", particularly as "a lot of women's experiences have been so poor in the last ten years that they are scared."[115]

  96. Several witnesses acknowledged that work was required in this area, in the first place to establish what kind of information and advice women received on caesarean section, and then to ascertain how best to provide this. Siobhan Hargreaves, as a user representative, argued that "women should be made fully aware":

    I am sure they are told about the risk to subsequent pregnancies or what-have-you, but it is not something that can be lightly undertaken because at the end of the day it is major surgery.[116]

  97. Jennifer Fake, Head of Midwifery at Watford General Hospital, felt that women sometimes received conflicting advice and information, and that maternity care staff might be selective in imparting information. Although staff could not go through every risk with a woman, she said "I think we need to look at that again, the type of information we give them … I think that is something we should do, look at more patient evaluation to see what their feelings are after the birth."[117]

  98. The issue of women's choice in undergoing caesarean section when there is no clinical need is a fraught one. The NHS does not generally provide other major operations for patients when there is no clinical need, nor does the NHS tend to offer choices of treatment to patients when one costs on average £760 more per patient than the alternative, since it is obliged to make the best use of NHS resources. It remains to be seen whether the National Institute for Clinical Excellence will allow choice for caesareans when in other areas of the NHS patients do not have comparable freedom. We would like to see a distinct shift in emphasis to ensure that elective caesareans as a 'lifestyle choice' are not supported by the NHS and that caesarean section should be a procedure undertaken only when medically or psychologically necessary and after appropriate support and counselling.

  99. We look forward to the publication of NICE guidelines on caesarean section and recommend that these should serve to support maternity care staff not just in assessing the medical indications for caesarean, but also in giving consistent advice and information to women considering the procedure.

  100. We share the concerns of maternity care staff who wish to protect women from the risks associated with caesarean section. We are particularly concerned for those women who choose caesarean section because they are anxious about delivering their babies. While their fears about childbirth should not be compounded by new anxieties about the risks of caesarean section, these women should be made aware of the implications of surgery for women and babies and of services which help to reduce anxiety. We recommend that maternity units examine how women who request caesarean section are cared for, what kind of information and advice they receive, and how the women themselves feel about their discussion of caesarean section with midwives and consultants.

  101. Just as some women have a preference for caesarean section, so other women wish to avoid the procedure. Several of the user representatives we heard from were concerned that women did not receive sufficient information about the other interventions in labour which might render more likely the decision, not by a woman but by her obstetrician, that caesarean section was the appropriate method of delivery. Catherine Eccles, Chair of the Maternity Services Liaison Committee at St Mary's Hospital, Paddington told us that women should be advised in more detail about EFM, induction and epidural. These, she told us were all:

    … very positive steps towards having a caesarean section. That information really needs to be put across more forcibly than it is at the moment. I think at the moment women see having an epidural as having pain relief and therefore having an easier time. What they do not understand is that they have a far higher chance of an instrumental delivery or a Caesarean.[118]

Katy Waters, a user representative from West Hertfordshire NHS Trust agreed that "there is quite a lot of misunderstanding about how intervention starts at quite a seemingly low level with an epidural."[119]

  102. Induction and epidural, like caesarean section, are both associated with very rare, but potentially very serious risks to mother and baby. Some methods of inducing labour, such as use of synthetic versions of the hormone oxytocin to encourage contractions, may cause the uterus to contract too much. This may affect the pattern of the baby's heartbeat.[120] Women who receive oxytocin-type drugs in labour are more likely to have an epidural.[121] Epidural is associated with a small risk of a drop in blood pressure, bleeding, and an intense headache. Permanent paralysis resulting from epidural analgesia during labour is so rare that clear figures on its incidence are not available, but anaesthetists regard blood clots which could cause injury to the spinal cord, and damage to the spinal cord as a result of infection, as very rare but very serious complications of epidural.[122]

  103. We heard it argued that information and advice about caesarean sections and other interventions should not only enable women to assess for themselves the risks of the procedure in considering a request but also empower them to question a recommendation by maternity care staff. Thus Rosemary Connor, Head of Midwifery and Service Manager at Trafford General Hospital asserted:

    I think we have to make sure that they are educated enough to know that it is not a norm, that it should only happen in exceptional circumstances; and if it is looking as though it is going to happen, that they should be challenging it, not just going along with it because it is the route of least resistance.[123]

    Katy Waters put this case in even stronger terms, in telling us that some "women have a battle against intervention."[124]

  104. We understand that in some cases interventions in labour are necessary to protect the health of mother and baby. However, women should be made aware that interventions such as EFM, epidural and induction may increase the likelihood of a caesarean delivery. Raising a woman's awareness in these areas should not entail merely the transmission of clinical information but rather it should involve discussion with a health professional in the context of the individual woman's background and concerns.

Maternity care staff and the decision to undertake caesarean sections

  105. We asked obstetricians how they arrived at the conclusion that caesarean section was the best course of action for a woman and her baby, and how they explained rising caesarean section rates. We heard from several obstetricians who attributed part of the increase in caesarean section rates to the advances in clinical facilities and practice which had made caesarean section a safer procedure. Professor Walker from St James's, Leeds explained how this had altered the decision-making process:

    The operation itself is now safer than it was twenty years ago, and I certainly know from my own practice that twenty years ago we strove far more not to carry out caesarean sections because of the risks to the mother. The risk to the mother is now less, therefore your threshold changes purely because the balance of risks and benefits has changed. Litigation must come into that equation.[125]

  106. Professor Walker was among several witnesses who told us of the value of experience in weighing the balance of risks and benefits of caesarean section to women and babies. Whilst we were assured by Professor Walker and others that the prospect of litigation did not outweigh clinicians' determination to provide the best possible care and the best possible outcome for mothers and babies, there was considerable concern that for less experienced doctors, anxiety about litigation might have some effect. Professor David James from University Hospital, Nottingham identified the threat of litigation as an influence on less experienced doctors, and in turn as a factor which may contribute to rising caesarean section rates:

    Nobody is going to sue you for doing an emergency caesarean section when one was justified necessarily, but they will sue you if you fail to do a caesarean section when one was justified. Experience counts for a lot in doing an operation.[126]

  107. All of our witnesses insisted on the importance of experience in coming to a decision on caesarean section and some worried that without an experienced consultant on-site in the maternity unit, women who might otherwise deliver their babies vaginally would undergo caesarean section. These worries, we were told, had been intensified by changes in staffing levels, training and working hours. Cathy Rogers from Barnet and Chase Farm Hospital said that changes in specialist training made it important for decisions about caesarean sections to be made in the presence of a consultant rather than "just being seen by somebody who talks to the consultant on call in terms of confirming the decision or not."[127]

  108. Maternity care staff at all of the units we heard from took part in audit processes to review caesarean sections and the validity of the decisions which led to the procedure being undertaken. Christoph Lees from the Rosie Hospital, Cambridge described how decisions were "put under the microscope at risk management meetings and at our junior doctor meetings" and Antony Nysenbaum from Trafford General Hospital outlined a multi-faceted and multi-disciplinary caesarean section audit:

    We audit in two different ways. We have had for probably a few years a regular meeting when we look at the emergency caesarean sections of the previous week, where one of the obstetricians - the labour ward lead will go through them with the middle-grade junior doctors and midwives, and discuss how appropriate they are. We do formal audits where we pull fifty out of one hundred notes, and break down the reasons and look at them very carefully. [128]

  109. These audit processes resulted in development of guidelines for good practice as Professor Walker from Leeds explained:

    we have a regular audit programme and there is a consultant in charge of the obstetric audit who will make decisions on what audit is done at any given time. Then people, usually junior members of staff, are involved in getting that audit together and putting it together. We then sit and listen to the audit, and policy decisions made as a result of that audit are then decided by the consultant body.[129]

  110. Junior doctors played an important role in audits at the maternity units and consultants saw this as an important form of training for junior staff. However, we heard evidence that staffing issues such as the limits imposed on working hours by the European Working Time Directive, could restrict the role played by junior doctors and in turn jeopardise the audit process. We look below in Chapter Four at the implications of the Directive. Rick Porter, Clinical Director of Maternity Services at Royal United Hospital, Bath explained how routine audit at Bath, which he viewed as "a very important part not only of good housekeeping but actually of training the junior staff as well" had stalled:

    Our ongoing running audit is in abeyance at the moment largely because of junior staff issues. Normally, what we have been doing is having a weekly run-through of every single section that goes through the unit where we actually critically analyse the decision-making process.[130]

  111. One of the most significant aspects of the audit process seemed to be the spirit in which it was undertaken. According to Professor Walker, this could be the factor which determined whether or not the audit yielded useful results:

    I think the importance of this form of audit is that it is done in a non-judgemental, informative way. One of the problems in a lot of hospitals is that review of practice is done in a judgmental way, of blame. As soon as blame comes into it - 'you should not have done this' or 'this was wrong' - then people stop buying in to the audit. It needs to be done in a regular, no-blame way so that the information can be fed back to people so that they can learn from the information that is collected.[131]

Undertaken in this way, audit might represent not just an attempt to review cases where caesarean sections might have been avoided, but to "share good practice, so that we do not reinvent the wheel all the time."[132]

  112. We were disappointed to hear that so few caesarean section audits involved the views of users. The woman's experience is an important facet of the analysis of caesarean section rates and we recommend that maternity units consider this aspect of the audit process, even if women's views can only be sought through questionnaires.

  113. We agree with those witnesses who told us that ideally the decision to undertake a caesarean section should be made in the physical presence of a consultant. Whilst this is not practicable within current staffing levels we believe that consultants should always be consulted over the decision to undertake a caesarean section except in the rare cases where immediate section is necessary. Although caesarean section is now a much safer procedure than it once was, we are concerned that some women undergo unnecessary sections on the recommendation of doctors who lack experience owing to the time limitations imposed by the New Deal and the European Working Time Directive on their training. This situation renders the process of auditing caesarean sections at individual maternity units all the more important as a form of training for junior staff as well as a means of ensuring that decisions made by consultants have been appropriate. We recommend that the forthcoming NICE guidelines on caesarean section should be supported by advice on audit procedures.


  114. Beyond decisions on the individual cases subject to audit, we asked doctors and midwives to comment on what they saw as the underlying reasons for comparatively high or low caesarean section rates at their units. We heard again about the inadequacies of data collection methods as many staff members took issue with the caesarean section rates recorded by the Department of Health Statistical Bulletin, by guides based on these figures, such as those produced by Birthchoice UK, or by independent guides, such as those produced by Dr Foster.[133] For example, Lynne Pacanowski, Head of Midwifery at St Mary's Hospital, Paddington told us that figures for St Mary's had been artificially high as they had included caesareans undertaken at a privately-run maternity unit within the hospital.[134] Helen Jones, Midwifery Manager at Royal United Hospital, Bath said that rates had been skewed because the configuration of services in Bath, namely seven community units and an acute unit, could not be accommodated by the system used to generate statistics from the Maternity HES.[135]

  115. Notwithstanding these discrepancies, the doctors, midwives, and user representatives we heard from were all aware that caesarean section rates at their units were higher or lower than the national average, and indeed than units in close proximity to their own. One reason given for high caesarean rates was the location and the nature of the population served by the maternity unit. Christoph Lees acknowledged the high caesarean section rate (26%) at the Rosie Hospital, Cambridge. He said that the rate was high because Addenbrookes Hospital (to which the Rosie Hospital is affiliated) was a tertiary referral centre, a centre of expertise for neonatology, obstetrics and fetal medicine and so "we have a much higher proportion of women who are delivering pre-term, who have severe pre-eclampsia,[136] who have babies with abnormalities and problems that have required help in the antenatal period."[137] Professor Lesley Regan, Consultant Obstetrician at St Mary's, Paddington, said that the 27% caesarean section rate at the unit could be explained in this way:

    We would have in-utero transfers for a variety of complications. We have a large miscarriage service, for example. We have a lot of operative deliveries that are perhaps not commonplace to all units.[138]

  116. We also heard from staff at other tertiary units who felt that this status might contribute to lower caesarean section rates. Dr Tracy Johnston, Clinical Director for Obstetrics at St Mary's Hospital for Women and Children, Manchester (which has a caesarean section rate of 18%) emphasised this:

    We have got dedicated obstetricians that run the obstetric service, and we do not do gynaecology—and that is unusual; you will only get that in tertiary units; you are not going to get that in District General Hospitals.[139]

  117. However, as Professor Walker from Leeds told us:

    if you look at [caesarean section] rates across the country you can see differences which you can relate to hard things, like age differences, health differences, and the fact that tertiary units are different to … district general hospitals … but you cannot explain all the figures for the differences that way.[140]

  118. Dr Johnston from St Mary's, Manchester went on to say that "the other reason … that we have got such a low section rate for such a busy high-risk unit is that we have a massive consultant presence on the labour ward."[141] Staffing levels at obstetric units were acknowledged as a key influence on caesarean rates, not just in terms of dedicated consultant cover on labour wards, but also in terms of the midwifery establishment. Professor Regan from St Mary's told us starkly that in her view there was a direct relationship between high vacancy rates for midwifery staff and high caesarean section rates.[142]

  119. Caesarean section rates can be influenced by individual obstetricians. Again, we heard the concerns raised by discussion of the decision-making process which led to caesarean section. Antony Nysenbaum from Trafford General Hospital compared his hospital's caesarean section rate of over 24% to that of St Mary's, Manchester:

    I think a lot of the decision-making about caesarean sections depends on the experience and confidence of the obstetrician dealing with the case. We do not have the same consultant cover that St Mary's has, and I think it is extremely difficult when you have got a crisis … if you have junior staff or inexperienced staff, or people who are not even very confident … they are much more likely to go to section in the first instance.[143]

Beyond the issues of experience and confidence, the views of individual consultants may also have an impact on caesarean section rates. Mr Nysenbaum said that the presence of "two major interventionists for some years" constituted "one of the causes" of a high caesarean section rate.[144]

  120. Rick Porter indicated that even in areas such as Bath, where normal births in community and midwifery-led settings tended to be encouraged by clinical staff and one third of deliveries took place in the community without assistance from a consultant, individual consultants might hold very different views on caesarean section and intervention in labour:

    we have one consultant who has a different view to the rest of us and certainly has a much lower threshold for caesarean sections than the rest of us. It seems to me that that is within clinical freedom. I do not agree with the position that he takes but I respect the fact that he believes deeply that he is correct.[145]

  121. We were concerned that in planning and booking their maternity care, women might not be fully aware, or indeed might not be made fully aware, of this variation in clinical practice or of the effect it could have on how their baby would be delivered. Julianna Beardsmore, representing women who used maternity services in Bath confirmed that:

    further away from Bath … one consultant will visit each unit, so you do not get a lot of choice about what different consultants have as their thresholds. You do sometimes get somebody who, if they have a query, may ask to see another consultant but it is unusual.[146]

  122. Such variations in clinical practice, while they might not compromise a woman's safety, may affect her role in making decisions on the mode of delivery for her baby if she does not have access to information on the risks and benefits of caesarean section. We are not convinced that it can be justified for women to have a significantly increased chance of a major operation because of an individual consultant's judgement of the risks of caesarean against normal birth and we hope that the NICE guidelines will create a consistency of approach across the country. Although we recognise the sensitivity of releasing individual consultant data we believe this data should be given to all users together with national and local comparisons so that women are aware of their consultant's caesarean section rate.

  123. However, we also heard evidence that in a number of areas women were very much aware that there were different thresholds and beliefs over intervention in labour, and that they planned their care accordingly. These were the areas with maternity units in which individual consultants and their midwife colleagues seemed to work together according to a certain ethos which was apparent, and attractive, to women seeking low-intervention maternity care. Several units told us that they believed that such an ethos was the decisive factor in achieving comparatively low section rates. Professor Walker from St James's University Hospital, Leeds suggested that differences in caesarean rates could "relate to the attitude within the environment of the women themselves, the midwives and obstetricians … because of a philosophy that comes from within the hospital. Also, to some extent, women choose which hospital fits their philosophy."[147]

  124. Dr Tracy Johnston from St Mary's, Manchester, outlined this philosophy in terms of its direct relationship to policy on caesarean section:

    it is not so much that we will not do caesareans at any cost, but it is very much a case of promoting normality, minimising unnecessary intervention, but taking the women with us and making sure that they are involved in the decisions that are made.[148]

Professor Walker also talked in specific terms about a collective belief that unnecessary intervention should be minimised, for example through encouragement of vaginal delivery of babies in the breech position (seen by some clinicians as an indicator for caesarean section), and through involving the women themselves by "following" their feelings.[149]

  125. David Redford, a consultant obstetrician working for Royal Shrewsbury Hospitals NHS Trust, which had a caesarean section rate of under 11%, told us that once such a philosophy or culture was in place, it became self-perpetuating for two reasons. In relation to staff he stated "we have low intervention rates and once that is known we attract both midwives and obstetricians who like to practise in that way" and concerning the women cared for within the Trust, Mr Redford pointed out that:

    The caesarean section rate this year is very largely determined by what it was last year in that the largest single contributor numerical-wise to the number of caesarean sections is repeat caesarean sections from previous years.[150]

  126. While this trend is most encouraging for those units in which staff are trying to maintain a culture of low intervention, it presents a serious obstacle for staff trying to reduce caesarean section rates in those units in which rates have historically been high. As Antony Nysenbaum from Trafford told us, "we know where we are going wrong; it is the ability to change that that can be very, very difficult."[151]

What can be done to reduce caesarean section rates?


  127. For staff at maternity units where the caesarean section rate is currently "probably higher than it needs to be", a major component of the strategy to reduce caesarean section rates is a careful review of provision of care for pregnant women who have undergone a previous caesarean section.[152] For many years it was accepted clinical practice for women who had delivered their first child by caesarean section to deliver all of their children in this way. However, there is now strong evidence to suggest that at least 70% of women who have had a previous caesarean section can go on to have a successful vaginal delivery.[153] The National Sentinel Caesarean Section Audit found a direct link between low rates of vaginal birth after caesarean section and high rates of caesarean section and recommended that in the absence of complications vaginal birth should be considered by all women who had undergone a previous caesarean section.[154]

  128. The Audit also cited evidence that counselling after caesarean section and during subsequent pregnancy had an impact on the decisions a woman took in delivering her second child.[155] Christoph Lees told us that vaginal birth after a caesarean section for the first child was actively encouraged at the Rosie Hospital, Cambridge. He reported that over half of women who had one caesarean section attempted a normal delivery in their next pregnancy under the care of the unit: "we know that the risks are quite low for having a vaginal delivery after one Caesarean section and it is something we encourage and many women are very happy to do it with, of course, appropriate monitoring."[156]

  129. Professor David James from Derby General Hospital confirmed that women undergoing repeat caesarean sections constituted the largest group within the overall total number of caesarean sections undertaken at the maternity unit. He said that staff at the unit made special arrangements to meet women who had delivered a baby by caesarean section to discuss their concerns about vaginal delivery.[157]

  130. Other maternity units took similar approaches to care for pregnant women who had a caesarean section. Cathy Rogers from Barnet and Chase Farm Hospital argued that helping women to consider vaginal birth after a caesarean section depended on making contact with them at an early stage:

    People who have had previous sections are very late when it comes to making decisions about subsequent mode of delivery and if we want to reduce caesarean section rates, reduce second caesarean we really have to start after the woman has had her first section and meet with her, debrief her, really give her information very early in the pregnancy in relation to supporting and being more positive about the whole thing.[158]

Antony Nysenbaum told us that "careful discussion about mode of delivery … does take time" but that "most women" would often then "opt for aiming for a normal birth—successfully."[159]


  131. Maternity units have used caesarean section audits to develop a number of other strategies to reduce rates. One of these strategies has been to review practice with regard to electronic fetal monitoring (EFM), which is directly associated with caesarean section. While it may be a vital aspect of care for women who have had difficult pregnancies and where there are complications in labour, use of EFM does not lead to better health outcomes for women who have had low risk pregnancies and guidelines issued by the NICE in May 2001 recommended that EFM should not be used with low risk women on admission to a maternity unit.[160]

  132. This recommendation marks a shift in policy and practice relating to fetal monitoring as until recently every woman arriving in hospital in labour was routinely monitored using EFM for 20 minutes, a practice known as the 'admission trace'. A great many midwives doubted the benefit of EFM on admission to hospital as they saw that the monitoring equipment could restrict a woman's choices with regard to her position and movement, and worried that the reassurance of EFM might permit doctors and midwives in busy wards to leave women unattended in labour. As Helen Shallow, Midwife Consultant at Derby City General Hospital explained, lower levels of intervention combined with higher levels of support in labour might reduce the likelihood of caesarean section becoming necessary:

    If a woman is confined to bed for fetal monitoring for no real reason, her pain is worse. She requires an epidural because her pain is excruciating and there is nobody there to support her. If you change that model and encourage women to move around and be in a nicer environment, a more relaxed environment where somebody is supporting you, then we know that that makes a difference to how that woman labours.[161]

  133. For these reasons, NICE guidelines on EFM were welcomed by members of maternity care teams who have used them to implement and support a change in policy. Catherine Eccles, Chair of the Maternity Services Liaison Committee at St Mary's Hospital, Paddington, told us that women welcomed the change to the policy of admission trace "because it has been shown to be the first step towards intervention and therefore the first step towards possible caesarean but with no positive outcome."[162]

  134. Similar developments have taken place in respect of induction and augmentation of labour using drugs and in June 2001 NICE issued guidelines on induction in order to reduce the risk of stillbirth in ongoing pregnancy "without increasing the caesarean section rate."[163] Once again, caesarean section audits had indicated a direct relationship between high induction rates and high caesarean section rates, and a renewed focus on induction policy was seen as a way of reducing the likelihood of caesarean section. Rosemary Connor, Head of Midwifery at Trafford General Hospital, described the rationale behind her unit's review of induction policy:

    One of the big issues when we tried to tackle our caesarean section rate was that we had a very high induction rate. Once you start intervening, you are much more likely to end up with caesarean sections, so we did address it … we had clinicians who were very interventionist. We have had to address that now. We have revisited our induction policy in line with NICE, and we are seeing a falling induction rate.[164]

This policy has had a dramatic impact on the induction rate, which was approximately 28% in 2000-01 but has since fallen to 24.2%.[165]

  135. Reducing induction rates involves discussion and counselling as well as revised policy on clinical procedure. At St Mary's Hospital for Women and Children in Manchester, no woman is induced until she is ten days beyond the full term of her pregnancy (term plus ten). After that, Dr Johnston told us, the woman is given "informed choice" on how to proceed: "It is a case of sitting down and giving the options … quite a lot of women will say: 'that is fine. As long as you are monitoring it, it will be fine and I will carry on."'[166] At Bath, where labour is induced at term plus 12 days, Helen Jones, Maternity Services Manager, told us of a new initiative whereby women booked inductions with a midwife rather than a consultant. The midwife's counselling, it was thought, might help women to consider all the available options.[167]

  136. We strongly endorse innovative approaches to reducing caesarean sections which involve women in detailed discussion about their maternity care and help to raise awareness of the risks and benefits of the different kinds of intervention in labour. We believe that this involvement is key to a positive experience of childbirth and of maternity care, and that the development of strong relationships between women and well-trained, confident midwives is crucial. The information gathered from discussion of previous experiences could be vital to the development of maternity services, particularly in relation to caesarean section. We recommend that information from women on their previous caesarean section should be incorporated into audits.

  137. We are encouraged to hear that maternity care staff value NICE guidelines and evidence based on research commissioned by the Department as tools for developing strategies to reduce caesarean section rates and to increase 'normal' birth rates. We recommend that the Department continue to support research and evidence-gathering initiatives and in particular the work on caesarean section audit.


  138. The key to all of these strategies for implementing policies to reduce caesarean section rates is time spent with a pregnant woman; discussing her care and advising her of her choices. Consultant input in discussions can be particularly important, both in the initial stages where women are making choices about their care, and during labour. Alex Silverstone, a user representative at St Mary's, Manchester was certain that caesarean rates at the unit were kept lower (18%) than the national average (21.5%) on account of consultant availability:

Dr Johnston, Clinical Director at the same hospital emphasised the importance of a consultant presence on the labour ward, particularly if less experienced doctors were caring for a woman:

    I think couples find that very reassuring, that a more senior doctor has come in and is looking at the whole picture again … they turn round and say: 'I have looked at this. You are doing fine. You can do this. We do not need to intervene just now. Carry on.' A lot of them take faith in that, but if the consultant is not there and does not come in, then it is very difficult for the registrar to go back and say 'I phoned him and although I said I thought you needed a section, he said that you do not so we are not going to section you now.' It is not the same as going in and talking to them.[169]

  139. Along with all of the other consultants who spoke to us during our inquiry, Dr Johnston stated that a woman's choice with regard to caesarean section must be respected. However, she was insistent that making time to provide women with information on which to base their choices, did yield results in terms of keeping caesarean section rates under the national average rate:

    We do get a lot of women requesting elective caesarean section, and with each of these women we sit and talk to them and find out what it is they are frightened of; and the vast majority of them are scared about something with labour and delivery. With good investment antenatally, with obstetric staff and midwifery staff, I would say that over three-quarters of these women will change their minds and then go for a vaginal delivery afterwards, and be very, very satisfied with that. That requires a lot of time. That would take me two hours of clinic time sometimes to talk to somebody about that, but I see that as important - as a consultant, that is what I am there for.[170]


  140. There was consensus amongst our witnesses that continuous midwifery support, antenatal and intrapartum, was just as important, if not more important, than consultant presence on a labour ward or in a clinic. Lynne Pacanowski, Head of Midwifery at St Mary's, outlined the unit's strategy to reduce caesarean section rates by creating more community-based caseload teams.[171] Professor Regan from St Mary's Hospital, Paddington, having linked a high midwifery vacancy rate to a high caesarean section rate said that "in an ideal world we would have one-to-one care for women in labour and I would anticipate a significant reduction in caesarean section rate."[172] The proof of this, we were told, could be found in the results of an audit of a case load team of midwives working with women in the community. The caesarean section rate for women cared for in this way was 15%, as opposed to the 27% rate overall.[173] Professor Regan outlined for us the system of care which yielded such a substantial reduction in caesarean section rate:

    It is continuity of care and one-to-one care in labour. These women are cared for primarily in the community with hospital input for various screening tests and investigations and reference for any complications or queries, and then when they go into labour they are seen at home by their midwife in this caseload team and then brought into hospital. They are delivered by one, two or possibly a third midwife from that team with whom they will already have developed a relationship. That midwife will stay on duty—unless some exceptional circumstance occurs—until the baby is delivered.[174]

  141. Once again, the key to reducing caesarean section rates seems to be time spent with a pregnant woman, advising and reassuring her, supporting her from the time she makes contact with a unit to book her maternity care through to the early stages of her baby's life. Indeed this kind of support is vital to a healthy outcome, not just in terms of mode of delivery but also in terms of the development of early bonds between a new mother who is relaxed and confident in her care, and her baby. However, as we heard from all too many maternity units, this kind of support can be difficult, or even impossible, to provide if services are blighted by staffing problems.

  142. Based on evidence we heard from maternity units, we see a relationship between high rates of caesarean section and low levels of staffing. It seems to us unacceptable that a woman should undergo a surgical procedure that might have been avoided had she been better supported during pregnancy and/or during labour. It is clear from strong evidence that one of the most important means of reducing the caesarean section rate is to provide adequate support for women in labour. The level of staffing and organisation of care should enable women to be supported at all times.

72   Ev 163 Back

73   Department of Health, Statistical Bulletin NHS Maternity Statistics, England 2001-02. 2003/09, May 2003 Back

74   IbidBack

75   Caesarean Sections, POSTnote 184, Parliamentary Office of Science and Technology, October 2002. Caesarean section rates in private hospitals are often higher than in NHS maternity units. For example, the Portland Hospital in London has a caesarean section rate of approximately 44%. However, only around 0.5% of births take place in the private sector and so this has little impact on national statistics. Back

76   Thomas, J., and Paranjothy, S. Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. National Sentinel Caesarean Section Audit Report. RCOG Press, 2001, p 2 Back

77   Ibid.  Back

78   Caesarean Sections, POSTnote 184, Parliamentary Office of Science and Technology, October 2002 Back

79   Having a Baby in Europe, World Health Organization, Copenhagen, 1985 Back

80   Ev 207 Back

81   Hall, M.H. and Bewley, S. "Maternal mortality and mode of delivery", Lancet 354 (1999), pp 776-79 Back

82   Memorandum from Martin England (MS6) (not printedBack

83   Hall, M.H. and Bewley, S, "Maternal mortality and mode of delivery", Lancet 354 (1999), pp 776-79; Hofmeyr, G.J., and Hannah, M.E. "Planned caesarean section for term breech delivery." Cochrane Library. Issue 4, 2001. Back

84   Hemminiki, E. "Impact of caesarean section on future pregnancy -a review of cohort studies." Paediatric and Perinatal Epidemiology, 10 (1996) pp 366-79 Back

85   Ev 186 Back

86   Smith, J.F., Hernandez, C, Wax, J.R., "Fetal laceration at caesarean delivery," Obstetrics and Gynaecology 90 (1997), pp 344-46 Back

87   Audit Commission, First Class Delivery: improving maternity services in England and Wales,1997  Back

88   Why Mothers Die 1997-1999: The Confidential Enquiries into Maternal Death in the United Kingdom, 2001 Back

89   Thomas, J., and Paranjothy, S. Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. National Sentinel Caesarean Section Audit Report. RCOG Press, 2001. p xvii Back

90   EFM is used to monitor a baby's heartbeat continuously during labour. Sensors are placed against the mother's abdomen and are connected to a heart rate monitor, which produces a record of the baby's heart rate. Back

91   Caesarean Sections, POSTnote 184, Parliamentary Office of Science and Technology, October 2002, p 2 Back

92   Ev 163 Back

93   Thomas, J., and Paranjothy, S. Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. National Sentinel Caesarean Section Audit Report. RCOG Press, 2001, pp 49-50 Back

94   Ev 244 Back

95   Thomas, J., and Paranjothy, S. Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. National Sentinel Caesarean Section Audit Report. RCOG Press, 2001, p 25 Back

96   Ev 162 Back

97   Ev 130 Back

98   Ev 185 Back

99   Caesarean Sections, POSTnote 184, Parliamentary Office of Science and Technology, October 2002, p 3 Back

100   Ev 242; Ev 194 Back

101   Ev 242 Back

102   Ibid. Back

103   NHS Litigation Authority, "Key facts", NHSLA website, _to_NHLSA.htm; NHSLA Review, Issue 23 2002, p 6 Back

104   Ev 209 Back

105   Ev 130 Back

106   Ev 242 Back

107   Ev 194 Back

108   Ev 130 Back

109   Q 209 Back

110   Q120 Back

111   Q 208 Back

112   Q 213 Back

113   Q 120 Back

114   Q 377 Back

115   Q 220 Back

116   Q 210 Back

117   Qq 114-19 Back

118   Q 44 Back

119   Q 115 Back

120   National Institute for Clinical Excellence, Inherited Clinical Guideline D: Induction of Labour, June 2001 Back

121   Anaesthetic is injected into the space around the spinal cord, so that the nerves are blocked below the level of the injection. Back

122   Fellows of the Royal College of Anaesthetists, Educational points on epidurals,, 2003 Back

123   Q 507 Back

124   Q 115 Back

125   Q 386 Back

126   Q 197 Back

127   Q 57 Back

128   Q 99, Q 496 Back

129   Q 397 Back

130   Qq 661-62 Back

131   Q 398 Back

132   Q 398 Back

133   Dr Foster is a commercial organisation which produces independent guides to health services in the public and private sectors. The Dr Foster Good Birth Guide was first published in 2001. Birthchoice UK is a voluntary group which maintains a website ( designed to provide women with information on what to expect from maternity care and on the options available to them. Back

134   Q 20 Back

135   Q 651 Back

136   Pre-eclampsia is a condition that can occur in the second half of pregnancy, which can cause the blood pressure to rise, causing circulation problems for the mother and preventing adequate flow of blood to the placenta. The usual treatment for pre-eclampsia is delivery of the baby as soon as it is sufficiently developed to live outside the mother's womb. If not treated in this way, pre-eclampsia can lead to eclampsia, where a seizure occurs, putting mothers at serious risk of stroke and causing fetal distress. Back

137   Q 96 Back

138   Q 26 Back

139   Q 467 Back

140   Q380 Back

141   Q 467 Back

142   Q 24 Back

143   Q 491 Back

144   Q 476 Back

145   Q 663 Back

146   Q 664 Back

147   Q 380 Back

148   Q 467 Back

149   Q 383 Back

150   Q 264 Back

151   Q 496 Back

152   Q 195 (Professor David James) Back

153   Caesarean Sections, POSTnote 184, Parliamentary Office of Science and Technology, October 2002, p 2 Back

154   Thomas, J., and Paranjothy, S. Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. National Sentinel Caesarean Section Audit Report. RCOG Press, 2001, p 46 Back

155   Thomas, J., and Paranjothy, S. Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. National Sentinel Caesarean Section Audit Report. RCOG Press, 2001 Back

156   Q102 Back

157   Q 201 Back

158   Q 44 Back

159   Q 476 Back

160   National Institute for Clinical Excellence, The use and interpretation of cardiotocography in intrapartum fetal surveillance, May 2001, p 4 Back

161   Q 204 Back

162   Q 32 Back

163   National Institute of Clinical Excellence, Induction of Labour, June 2001, p 4 Back

164   Q 501 Back

165   Ev 75 Back

166   Q 498 Back

167   Q 678 Back

168   Q 486 Back

169   Q 507 Back

170   Q 465 Back

171   Q 60 Back

172   Q 24 Back

173   Q 24 Back

174   Q 25 Back

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