Comparing caesarean birth rates: An institutionalized habit that is hard to break

Commissioned by the UK government's Secretary of State for Health and Social Care in 2017, the Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust (SaTH) uncovered prolonged systemic failings, ¹ and led to an unprecedented police investigation into hundreds of deaths. ² Critically, the review culminated in two reports (December 2020 ³ and March 2022 ¹ ) outlining 22 Immediate and Essential Actions (IEAs) to improve the safety of maternity services, that must be implemented at all trusts in England. The argument presented here is that the scope of these actions fell short, and this will have significant repercussions. Specifically, the IEAs ignored one of the review's most glaring findings: evidence of harmful attitudes and actions around monitoring and comparing caesarean births, while perceiving a low rate as ‘the essence of good maternity care’. ¹

Responding to the final report, the President of the Royal College of Obstetricians and Gynaecologists (RCOG), Dr Edward Morris, assured the public this was ‘a watershed moment for maternity care’. ⁴ He promised the college was ‘committed to enacting change,’ ⁴ and owed it to families ‘to act on the recommendations’. ⁵ In the same vein, Richard Stanton and Rhiannon Davies, whose newborn daughter Kate's death in 2009 was the primary catalyst for the SaTH review, described how various bodies responsible for ensuring safety had failed in their duties; they insisted their experience ‘should never be allowed to happen again’. ⁶

However, even accounting for the slow pace of change in the National Health Service (NHS),^7,8 there are already signs that a cultural and structural inattentional blindness ⁹ to bias against caesarean birth persists, and in the absence of clear, complete and consistent instructions for trusts, lessons have not been learned.

‘More intelligent’ monitoring

Throughout the investigation at SaTH, ‘a reluctance to perform caesarean[s]’ ¹⁰ was irrefutable. The review's chair, senior midwife Donna Ockenden, recalled how hundreds of women felt pressured to have ‘a normal birth’, ¹¹ and staff who would ‘definitely try to avoid a caesarean’. ¹ There were cases when surgery ‘would have been the safest’ or was ‘denied’, ¹² and a ‘typical quote during interviews was that “they didn't like to do caesarean[s]”.’ ² Indeed, the cross-party Health and Social Care Committee (HSCC)'s inquiry into maternity services safety found this issue so ‘deeply concerning’ that in July 2021, it recommended ‘an immediate end’ to using caesarean birth percentages as a metric for maternity services. ¹³

Unfortunately, the committee instructed NHS England and Improvement (NHSE&I) to tell maternity units to measure caesareans ‘more intelligently’ ¹³ using the Robson classification, which the World Health Organization's Implementation Manual describes as helping to assess strategies or interventions targeted at optimizing caesarean use, to compare more desirable results, and consider changes in practice. ¹⁴ By the time the HSCC's directive was communicated to trusts in February 2022, its message was even further diluted. Reiterating the RCOG's position that caesarean targets are not appropriate in individual circumstances, ⁵ the NHSE&I's letter warned that they may be clinically inappropriate and unsafe in individual cases, but it still encouraged data comparisons ‘at trust level’, including mode of birth, to identify whether maternity services are an outlier and need to implement clinical quality improvement work. ¹⁵

Where there's no will, there's no way

Differing interpretations of this inadvertent doublespeak were inevitable, though these did not fall neatly on either side of an oft-imagined midwifery and obstetric specialism line. Rather, they accorded with oral evidence given during the HSCC's inquiry, when Donna Ockenden relayed SaTH's ‘multi-professional, not just midwifery-led, focus on normal birth at pretty much any cost’, with obstetricians ‘very much leading the way’. ¹¹ Nor was the letter an isolated case of ambiguous public messaging over the same period. In a virtual panel discussion alongside Donna Ockenden in August 2021, the RCOG's Dr Morris disagreed with any suggestion of birth mode ideology as a problem ingrained in maternity services, arguing, ‘We promote vaginal birth, but no woman should be made to feel that her birth is abnormal.’ ¹² Seven months later, in a written statement, Dr Morris said the college ‘does not promote one choice of birth over another” and furthermore, “This is a position we have held for over a decade.’ ⁵

In his article, Breaking Institutional Habits: A Critical Paradigm for Social Change Agents in Psychology, ¹⁶ Dr Chad Olle explored how Dr Sara Ahmed's theoretical work, On Being Included (2012), ¹⁷ conceptualized systems [envisaged here as maternity services] as social bodies; ‘frame[s] in which things happen (or don't happen)’, and more importantly, ‘as habitual bodies’. ¹⁷ He explained, these habits ‘may be based in past decisions and commitments. In turn, the habitual body prefigures the habitual action as that which is already behind it, already committed. In this way, a habit is how a body “keeps willing something without having to make something the object of will”.’^16,17 In maternity services, the habitual reliance on caesarean birth rates as a metric is so deeply conditioned, that despite the HSCC's intrinsic call to action, prophylactic and intrapartum failure to intervene is still being institutionally repeated, rewarded, and recompensed.

Ockenden's Achilles heel

Six weeks after the NHSE&I letter was sent to trusts, and the long-awaited final Ockenden report ¹ was published, the issue of caesarean birth rates, targets and comparisons was conspicuously absent from its compulsory IEAs for trusts, and the RCOG's accompanying public statement. ⁴ This critical omission exacerbated decades of unfathomable oversight by the NHSE&I, Care Quality Commission (CQC) and others (including other professional colleges), and may prove Ockenden's Achilles heel. The very next month, for example, having imposed sanctions on Sheffield Teaching Hospitals NHS Foundation Trust (STH) in 2021, ¹⁸ the CQC doubled down on its criticism of STH's ‘inadequate’ ¹⁹ maternity safety, and the news media reported numerous parallels with Ockenden.^20,21

Except one.

The April 2022 inspection report itself revealed current caesarean birth rate targets at STH, and included criticism for rates described as higher than the expected range and worse than the national average. ²² STH assured the CQC that it continues to monitor rates, but inspectors complained, ‘There were no trust targets (thresholds) for caesarean section displayed on the maternity dashboard.’ ²² Ironically, STH implemented this dashboard ‘Following the Ockenden Review’, as was noted in its 2021 CQC report, which also criticized a caesarean rate higher than the national average, and a lack of ‘target figures to achieve’. ²³

Who monitors promised change?

Yet in 2018, in response to a review of 312 CQC inspections over the preceding 5 years (reporting references to caesarean rates at 95% of trusts, actions to reduce rates at 45%, and mode of birth targets at 56% ²⁴ ), the CQC had insisted, ‘it is absolutely not our view that trusts should be encouraged to reduce caesarean rates’; ²⁵ and we ‘don't inspect against targets’. ²⁴ At the time, an NHSE&I director acknowledged caesarean targets have ‘all sorts of unfortunate consequences’, and therefore the NHS was ‘moving away’ from using them. ²⁶ However, years later these assurances were not reflected in the Ockenden and HSCC findings, nor subsequent CQC reports. This raises important questions around communication, consistency and commitment to change in maternity services. Who is responsible for monitoring when and how promised change will happen, and who is to blame when deaths and injuries that are preventable with timely caesarean intervention keep recurring?

In 2009, the same year Kate Stanton-Davies died and SaTH tried to blame her mother, ²⁷ an inquest heard how Benjamin Steedman died at STH after a forceps skull fracture and brain damage. Another hospital trust had originally scheduled a caesarean for the twin birth, but at STH, Benjamin's mother recalled staff ‘just kept saying a C-section was not their procedure’ and arguing this followed national guidelines. ²⁸ Fast forward again to April 2022, and while the CQC criticized STH for its lack of caesarean targets on display, ²² a coroner prevention of future deaths report cited concerns about the trust ‘encouraging expectant mothers to be influenced into a natural birth when they may prefer to explore options such as caesarean section.’ ²⁹

New Ockenden review

A similar pattern of events is evident at Nottingham University Hospitals NHS Trust (NUH), where a new Ockenden review is now underway. ³⁰ For years, its CQC inspections focused on birth mode: NUH perform better than the national average for caesarean births (2020) ³¹ ; clinic success helped reduce the number of women choosing caesareans (2016) ³² ; visible fetal monitoring equipment did not follow the values of midwife-led care (2016) ³³ ; we had no concerns about 85 deliveries in a 14-month period that went beyond 42 weeks; the low caesarean rate indicates there is good practice (2014). ³⁴

Between 2014 and 2017, NUH failed to conduct formal investigations into the deaths of 35 babies, ³⁵ and in 2020, a coroner prevention of future deaths report stated Wynter Sophia Andrews ought to have been delivered by caesarean well before her birth. ³⁶ NUH litigation claims expose birth mode bias too, plus a failure to learn or change. For example, the circumstances of Harriet Hawkins’ death in 2016, at almost 41 weeks’ gestation, ³⁷ echoed those of overdue Alyssa Rose Legg in 2013. ³⁸ Both causes of death were incorrectly recorded as infection instead of failure to intervene. Going back further to 1996, newborn Charlotte died after NUH denied her mother's caesarean birth request, and lawyers described the ensuing court ruling as a ‘legal landmark’. ³⁹ Yet 20 years later, and regardless of another ‘landmark judgment [Montgomery]’, ⁴⁰ Sebastian Harrold died 7 weeks after his birth at NUH, for the same reason. ⁴¹

Hidden in plain sight, and evidenced by complaints and claims at numerous other NHS trusts in England, the connection between these failings makes the seemingly willful inattention and inaction of large, powerful organizations all the more morally distressing. By ignoring and downplaying the caesarean issue, they only increase the potential for further harm.

Conflict, challenge and courage

Dr Olle suggested that to break an institutionalized habit, conflict is unavoidable and necessary; ‘not with dispassionate structures or ideologies [pursuing one voice ¹² on safety] but with people, flesh and blood, emotions, and relational attachments [acknowledging and managing complex, unresolved disagreement around too much too soon and too little too late].’ ¹⁶ Certainly, this is a messy ¹⁶ and challenging process of system change, but the alternative bodes ill for Ockenden's IEAs: ‘actions that are restricted to ready-made institutional channels relegitimize institutional habits and reproduce the system as such.’ ¹⁶

With maternity safety at NHS trusts still a lottery for unwitting families, the courage to court caesarean controversy is long overdue. External challengers [bereaved parents, and maternity advocates] have had some success circumventing the system ‘by garnering media attention’, ¹⁶ but too many professional bodies and individuals choose to remain hidden behind a finger of blame rotating ‘beyond’ them – towards ‘the government’, ‘funding’, ‘staffing’, ‘midwives’, ‘trusts’ or ‘the NHS’. Even when they know, that to adequately address incontrovertible internal discord over caesarean birth, that finger must ultimately move from ‘Out There’ to ‘their own backyards’. ¹⁶

Only then can there be the full accountability, apology and action needed to reduce habitual risk, and ensure history is not repeated – again.