By Jane Feinmann
There is no doubt that for most women in this country, childbirth remains a safe and happy experience. But it is also true that for too many, it is a highly risky and frankly horrific experience.
Stories abound of mothers-to-be left alone in labour, sometimes refused pain relief or surgical intervention, putting their babies’ health or even lives in danger.
The statistics make grisly reading: an average of 11 babies are stillborn every day in NHS hospitals, according to research published recently in The Lancet.
Unlike other high-income countries, it’s a figure that has remained largely unchanged over the past ten years — putting Britain on a par with Belarus and Estonia.
More than £27 million in compensation was paid in 2008 by London hospitals alone for childbirth cases.
Indeed, a shocking 60 per cent of all payments made by the NHS Litigation Authority relate to obstetrics.
In June this year, an unprecedented police investigation was launched into the deaths of five babies and two mothers at Furness General Hospital in Cumbria. And last weekend it was revealed another baby’s death at the hospital is also to be looked into. So what is going on?
Midwives point to an understaffed, overstretched system dealing with both a rising birth rate and a growing number of more complicated deliveries as a result of obesity, older mothers and multiple births.
The Royal College of Midwives warned last week that existing ‘massive midwife shortages’ will soon worsen as maternity hospitals face ‘falling budgets and pressure to cut staff further, despite a rapidly rising birth rate’.
Yet experts are far from convinced that falling budgets and staff shortages are the only reason for the obstetric scandals that have mired the reputation of UK maternity healthcare.
Take the tragic case of 26-year-old health care assistant Liza Brady, whose son Alex was delivered in September 2008 stillborn at Furness General with the umbilical cord wrapped tightly around his neck.
At 11lb 13oz, Alex was exceptionally large, yet midwives refused her request for a Caesarean — despite this having been suggested by a consultant obstetrician whom she saw during her pregnancy.
During a long and painful labour, the midwives persistently refused her plea to be seen by a doctor and delayed the delivery even though the machine monitoring the baby’s heart showed he was in distress.
‘A doctor offered to help as he came on duty, but he was shooed away by the midwives who said he wasn’t needed,’ recalls Liza.
Prabas Misra, an obstetrician and gynaecologist at the hospital, was so appalled by Liza’s care that he expressed ‘grave concerns’ about her case in a letter to hospital colleagues.
He condemned as ‘indefensible’ the midwives’ claim that the foetal heart rate had been normal, since they’d admitted being unable to pick up the heart rate because of positioning of the monitor.
Summing up, Mr Misra wrote of ‘the risk of trying to make every labour and delivery normal and natural, and not thinking laterally (about) possible complications. I am all for having a natural childbirth — but not at any cost’.
Although talking about a specific case, Mr Misra has put his finger on an issue at the root of the problems in obstetrics today: the dangerous myth, promulgated by some midwives, that natural childbirth is not only the kindest form of delivery but also invariably the safest.
For years, the prevailing view among some leading figures in midwifery was that obstetricians were little better than trouble-makers. They were seen as over medicalising the natural process of childbirth, slowing down labour with their foetal heart rate monitors, and so increasing the risk of complications.
It became something of a turf war.
‘These people need a job to do — and, too often, it’s taking over from the midwives and reducing their autonomy,’ said Professor Caroline Flint, a former president of the Royal College of Midwives as she opened a new midwife-led unit in 1997.
Yet while public attitudes might have changed — as seen in the rise in the numbers of women asking for Caesareans — this view that natural delivery is the only way is still influential in the midwifery world.
The NHS Institute for Innovation & Improvement’s guidance for midwives, for instance, instructs them to ‘focus on normal birth and reduce the Caesarean rate’.
Doctors, it says, should ‘only enter the room of a labouring woman when asked to review (the patient) by a midwife’.
And despite objections from obstetricians, the RCM’s high-profile Campaign For Normal Birth has the slogan: ‘Intervention and Caesarean shouldn’t be the first choice — they should be the last.’
James Drife, a retired obstetrician and Professor of Obstetrics and Gynaecology at Leeds University, comments: ‘It’s difficult to see exactly who the RCM is campaigning against. Every woman would like a normal birth, but the real fear is of a bad outcome.
‘To prevent that happening, we need co-operation between all the professionals in the obstetric team, rather than campaigns about which treatment is best. Without such co-operation, there is a far greater risk of mistakes being made.’
Gill Edwards, a leading clinical negligence solicitor with the firm Pannone, is in no doubt why these fatal mistakes continue.
‘Too often, we see a desire for autonomy, sometimes verging on arrogance, on the part of some midwives,’ she says.
‘It leads them to ignore National Midwifery Council rules that require them to call on the skills of other health professionals whenever something happens which is outside their sphere of practice.’
Of course, the vast majority of midwives do a superb job and their professionalism is not comprised by rivalry with doctors or dogmatic views about natural birth. However, for a minority this is not always the case.
‘Some of our worst cases occur because the drive to achieve a “normal” delivery clouds the judgment of midwives about when to call in specialist help from an obstetrician, or for a paediatrician to be present at the birth to assist with resuscitation when there are signs of foetal distress during labour,’ says Ms Edwards.
Last month, NHS watchdog the Care Quality Commission highlighted the lack of ‘a joined-up approach to working together’ as a major risk factor at Furness General Hospital. The coroner who looked at Alex Brady’s death put it more simply: ‘I don’t believe the doctors integrated. The midwives ran the show.’ No matter how much a woman longs for a normal delivery, ‘things can go wrong at the last minute’
The criminal investigation into the hospital was launched after a coroner’s report on the death of ten-day-old Joshua Titcombe in July 2008 as a result of a serious lung infection.
The inquest had heard that his parents, Hoa and James, had urged midwives to treat their son for an infection for which Hoa had been given antibiotics — but were told there was no need for the baby to see a doctor.
The coroner’s report was damning, finding ‘no integration between the midwifery and paediatric teams’, alongside ‘a failure to record fully or at all many of the factors which, taken together, might have led to a greater degree of suspicion or a referral to a paediatrician’.
It wasn’t the first such case. In July 2008, Nittaya Henrickson and her newborn son, Chester, both died at the hospital after she suffered an amniotic fluid embolism, where fluid from the amniotic sac escapes into the mother’s bloodstream.
It’s a leading cause of maternal death, but the baby normally survives provided it is delivered promptly by Caesarean.
At an inquest in July 2009, Chester’s father, Carl, described how he pleaded with the midwives to get a doctor after he felt his wife die in his arms — but was told she had only fainted and that no doctors were needed to deliver the baby.
But while the scale of the problems at Furness are unprecedented, the evidence suggests the nature of the problems is far from unique.
Last month, Laura Newman, 21, told how her baby died, aged nine days, after being starved of oxygen during the birth at Sandwell Hospital in the West Midlands last December.
‘Not only was the midwife extremely rude and dismissive to Laura and her family, but when it was clear that something was wrong and the baby needed to be urgently delivered, the midwife ignored the warning signs,’ says Jenna Harris, of Irwin Mitchell solicitors, who is representing Laura.
Laura herself has urged ‘every expectant woman to make sure the midwife makes regular checks during labour. It doesn’t make any difference whether you had a healthy pregnancy or not; things can go wrong at the last minute.’
The failure by some midwives not to monitor the baby correctly is another major factor in baby injury and death. Some midwives are resistant to monitoring in the belief it is another step to over-medicalising birth.
Electronic foetal monitoring is designed to provide healthcare professionals with continuous information on the foetal heartbeat and uterine contractions. It is seen as a major defence against stillbirth or neurological damage.
Yet mistakes made in the use of the technology are a major contributing factor to babies being damaged during birth (leading to cerebral palsy and other problems) or dying, says Edwin Chandraharan, senior consultant obstetrician at St George’s Healthcare NHS Trust, London.
Mr Chandraharan recently pointed out: ‘A 1997 report highlighted that substandard care, especially with regard to CTG (cardiotocography or fetal monitoring) contributed to over 50 per cent of deaths during labour and birth. Unfortunately, more than decade later, (there is) a continuing problem of CTG misinterpretation.’
Last year, the Birth Trauma Association made a Freedom of Information request about obstetric cases going through the courts, and found that of 1,040 cases a large proportion related to failure to monitor the baby properly during labour.
‘While there are excellent maternity services, there are also some that are fragmented, dysfunctional and occasionally unsafe,’ says the association’s Maureen Treadwell.
‘For instance, despite evidence to the contrary, some midwives still believe using electronic monitoring on women considered to be at risk during childbirth is unhelpful because it makes medical intervention more likely. Simply having more midwives won’t change that.’
So what will? A start could be universal acknowledgement that no matter how much a woman longs for a normal delivery, ‘things can go wrong at the last minute’ — as Laura Newman put it.
And that recognition needs to start with antenatal information provided by midwives, which, according to Mrs Treadwell, is too often too rosy.
‘Women have the right to honest, objective information of what can go wrong, and what their choices are, and midwives have an ethical duty to provide that information,’ she says.
Such assessments have to be evidence-based.
‘Some midwives still suggest it’s equally safe to have a normal delivery with a breech baby, even though the evidence Caesareans are safest for breech births is overwhelming.’
The general safety of Caesareans has been a key issue. Until recently, they have been regarded as riskier than normal births.
But new draft recommendations from the National Institute for Health and Clinical Excellence, likely to be approved next month, indicate Caesareans are so safe they should be offered to any woman who asks for one, even if they suffer only from fear of childbirth.
Perhaps most important for the safety of newborn babies, say experts, is the widespread provision of multi-disciplinary training, enabling obstetric teams comprising midwives, obstetricians and anaesthetists to learn how to respond to emergencies — so that every midwife fully understands the risks of childbirth and how to deal with them effectively.
‘It’s all about creating a spirit of co-operation between different professional groups, and it really works,’ says Professor Drife, who chairs Baby Lifeline, a charity that pioneers such multi-disciplinary obstetric education.
When one such training scheme was provided at Southmead Hospital in Bristol, baby deaths and injuries fell dramatically.
There was also a 70 per cent reduction in disability caused when the baby’s shoulder becomes lodged behind the mother’s pelvis — a leading cause of cerebral palsy as well as death, but avoidable by appropriate, timely intervention.
‘Just as some obstetricians are convinced that only Caesarean births are safe, a few midwives are fanatics about natural birth — and it’s important that such midwives get the chance to train with an obstetrician dealing with high-risk cases,’ says Professor Cathy Warwick, general secretary of the Royal College of Midwives.
‘That’s the evidence-based way forward to ensure a safe response to obstetric emergencies.’
Yet the college warned last week that cuts in training budgets mean that for many midwives, training has to be self funded and largely online.
The maths of cutting courses that cost hundreds of pounds, thereby increasing the risk of obstetric mistakes that cost millions in litigation, seems not to make sense.
But with a financial squeeze on maternity services extending back decades — even all the way through the Labour years of spending more on the NHS — there are other obstetric conundrums that simply do not add up.
For instance, many smaller maternity units do not have 24-hour emergency surgical cover, even though obstetric emergencies are most likely to result in death or severe injury during the night shift.
So what can couples do to choose the safest place for the birth of their baby? Ask the right questions, says solicitor Gill Edwards.
‘So many maternity hospitals sell themselves by pointing to low rates of intervention or Caesarean sections, with the emphasis on the peace and quiet or the number of birthing pools. But the real test is the number of healthy births at the unit.’
Birth Trauma Association: birthtraumaassociation.org.uk.
(first published 04.10.11 Mail on-line)
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