Why are Maternal Requests for Caesarean Sections not always granted?
23 August 2018
Greentop guidance CG132 issued by the Royal College of Gynaecologists and Obstetricians (RCOG) in 2011 and adopted by the National Institute for Health and Care Excellence (NICE) set out that a maternal request for a caesarean section should be granted if an informed request is made. Caesarean section is significant surgery and risk understanding is needed.
Official NICE guidelines states: ‘For women requesting a caesarean section, if after discussion and offer of support… a vaginal birth is still not an acceptable option (Trusts should) offer a planned caesarean section.’
This means that a mother to be, requesting a caesarean section, who has no absolute medical need for caesarean section, should be booked in for an elective caesarean section in their 39th week of pregnancy if after discussion and if appropriate counselling, she still wants to go ahead with a caesarean section. The guidance makes it clear that it is absolutely inappropriate to refuse to provide a caesarean section if that is the maternal request.
Seems straight forward, so why is this not routine throughout the country almost 7 years after its introduction?
Pregnant women in some regions who ask about the procedure are simply told to go elsewhere. Statistics show that 15% of Trusts have policies or processes that explicitly do not support maternal request caesarean, while 47% of Trusts have policies or processes that are problematic or inconsistent. Only 26% of Trusts offer caesareans in line with NICE best-practice guidance.
Our most local hospital East Lancashire Hospitals NHS Trust (ELHT) was found by the charity Birthrights to be one of the Trusts that had problematic or inconsistent policies which restricted the access to such maternal request. In the period April 2016 – April 2017 28 women in ELHT’s care had maternal request listed as the only indicator for caesarean section. Pleasingly ELHT do not refuse maternal request, but they accept their policy could be clearer.
Elsewhere the policy is even less clear. Almost one in six Trusts were found not to offer women caesarean sections on maternal request. Naming them and shaming them they are:
• Barking Havering and Redbridge University Hospitals NHS Trust
• Royal Free London NHS Foundation Trust
• Buckinghamshire Healthcare NHS Trust
• Burton Hospitals NHS Foundation 2018 Trust
• Derby Hospitals NHS Foundation Trust
• George Eliot Hospital NHS Trust
• Great Western Hospitals NHS Foundation Trust
• Guy’s And St Thomas’ NHS Foundation Trust
• Harrogate And District NHS Foundation Trust
• Hull And East Yorkshire Hospitals NHS Trust
• Lewisham and Greenwich NHS Trust
• North West London Hospitals NHS Trust
• Oxford University Hospitals NHS Trust
• Poole Hospital NHS Foundation Trust
• Portsmouth Hospitals NHS Trust
• Royal Berkshire NHS Foundation Trust
• Salisbury NHS Foundation Trust
• Sandwell And West Birmingham Hospitals NHS Trust
• Southend University Hospital NHS Foundation Trust
• University Hospitals Of Leicester NHS Trust
• West Hertfordshire Hospitals NHS Trust
• York Teaching Hospital NHS Foundation Trust
Chief Executive of Birthrights, Rebecca Schiller said: “Maternal request caesareans are the the number one reason women contact the Birthrights advice service. The women we support have endured previously traumatic births, mental ill-health, childhood sexual abuse or have carefully examined the evidence available and made informed decisions that planned caesareans will give them and their baby the best chance of an emotionally and physically healthy start. It is clear that women requesting caesareans meet judgement, barriers and disrespect more often than they find compassion and support. We are concerned that this lack of respect for patient dignity could have profound negative consequences for the emotional and physical safety of women.”
Patient autonomy is one thing, but only with real patient stories does the importance come across. I am currently acting for a mother and son, M and D in a claim against a prominent London Trust. She asked repeatedly for a caesarean section and was talked out of this request. She should have delivered at 39 weeks by elective caesarean section. She did not. She was required to go beyond term, her unborn child got into foetal distress and 2½ years after he was born (ironically by emergency caesarean section) he was diagnosed with hemiplegia. That same Trust states that it permits maternal request when there are mental health concerns, they did not in this case as the primary reason for request was a previous traumatic birth at another hospital, yet this previous trauma was ignored. Our client would have been born healthy if maternal request had been granted.
At Curtislaw we are in entire agreement with Birthrights publication and commend their efforts. There is no need for any more patients to suffer unnecessarily in these circumstances and it probably is incompatible with Human Rights Law to simply refuse a maternal request without dialogue. Full links to the Birthrights research is set out below.
http://www.birthrights.org.uk/library/factsheets/Right-to-C-Section.pdf http://www.birthrights.org.uk/2018/08/maternal-request-caesarean-research-highlights-postcode-lottery/ http://www.lancashiretelegraph.co.uk/news/16590705.women-requesting-caesarean-section-face-multiple-barriers/
Jerard Knott, Head of Medical Negligence & Serious Injury Tel: 01254 297130; email: ClinNeg@curtislaw.co.uk; twitter: @CurtisLaw & @jerardknott