Thinking about how your baby is going to be born can feel overwhelming and that’s before you have considered any NHS targets.
NHS England previously had a 20 percent target for caesarean section (c-section) births but has recently made the decision to remove this goal and you’re probably wondering why this is.
What is a caesarean section?
A c-section is an operation where a cut is made, usually below your bikini line, into your tummy and womb to deliver your baby. It is major abdominal surgery that carries a number of risks. This is why it’s usually only done if it’s the safest option for you and your baby.
Your c-section may be as a planned procedure before you go into labour which is known as an elective c-section and usually done from the 39th week of your pregnancy.
Your c-section could also be an emergency one and only carried out if it’s thought to be safer than a vaginal birth for you and your baby during labour. The word ‘emergency’ makes it sound rushed. If your or your baby’s health is at risk, you may need to have a c-section more quickly.
However, the reality is that there is often time to discuss all of the benefits and risks, and make a decision together with the team. Your doctor and midwife will be able to fully explain what your options are if this happens during your labour. Sometimes this can feel rushed because of the urgency to ensure mother and baby are safe, but you should always ask questions if you are unsure of what is happening and what your options are.
Why will I need a caesarean section?
There are a number of reasons why you might have a planned c-section including:-
- you have a very low-lying placenta which covers your cervix called placenta praevia which blocks your baby’s way out
- you have other medical issues which means a c-section is the safest option for you and your baby
- your baby is in a position which makes vaginal birth more difficult such as if they’re in a breech position where your baby’s bum is first instead of their head
- You may want to have a c-section, even if there’s no medical reason
There are also some reasons why you may need to have an emergency c-section during your labour including:
- If your baby’s head is turned in the wrong position
- your labour doesn’t move on as expected
- there are signs that your baby has become distressed
- your labour hasn’t gone far enough for you to have an assisted delivery
- If you develop a serious medical illness during your labour such as very high blood pressure
- If your baby needs to be born very quickly, for example because of placental abruption where your placenta separates away from the wall of your uterus
Why do caesarean section targets exist?
A c-section can be a life-saving procedure during labour and delivery. When we look at c-section rates around the world, it becomes clear how they are either not available enough, particularly in low-income settings, or overused, particularly in middle-income and in high-income settings. For example, the c-section rate in the United States in around 33 to 35 percent compared to countries such as India and Malawi where the rate is below 10 per cent (1).
As health care professionals, we always look to the scientific evidence.
Since 1985, the international healthcare community has considered the ideal rate for c-sections to be between 10-15% (2). This is because we know that when medically necessary, a c-section can prevent against illness and death in both pregnant people and their newborn. We also know that a C-section is major abdominal surgery with associated risks such as infection, clots in your legs and lungs, damage to your bladder as well as breathing difficulties in your baby (3).
Studies have shown that when the c-section rate in a country rises towards 10% across a population, the number of deaths decreases in pregnant people and newborns. However, when the rate goes above 10%, there is no evidence that the rates of death and illness improve (4,5).
In summary, c-section targets were initially created to reach the ideal balance where enough people have a c-section to reduce illness and death, but it doesn’t become a procedure used when it is not needed. This is important because it is major abdominal surgery with associated complications.
Why did the caesarean section targets in England change?
The decision to change the targets centres around the safety of pregnant people and their babies. There was concerns that many maternity units were prioritising meeting the NHS target over the safety of pregnant people and their unborn babies.
The Okenden review (6) was launched by then-Health Secretary Jeremy Hunt in 2017 on the basis of 23 deaths of pregnant people and babies at the Shrewsbury and Telford NHS Trust. The full report was released on 30th March 2022 and looks at cases of death or harm between 1998 and 2017. This included stillbirths, neonatal baby deaths, the deaths of pregnant people, babies born with disabilities due to alleged poor care, and alleged failures which led to serious ongoing injuries. The report had multiple key findings including:-
- A culture where mistakes were not investigated
- When concerns were raised by parents they were not listened to
- The trust failing to learn from its mistakes meaning the same mistakes were repeated over
- A culture within maternity units of bullying, anxiety and fear of speaking out among staff
- Caesarean sections being discouraged in order to meet national targets
The National Institute for Health and Care Excellence (NICE), a body that provides guidance and advice to improve your healthcare, has now published new guidance which states that maternity staff should treat cases on an individual basis rather than following the aim to limit C-sections. They acknowledge that these targets can result in pregnant people not getting the most appropriate care (7).
Now the targets have been removed, am I more likely to have a caesarean in England?
It’s still important to monitor c-sections and it has been recommended this is done using a special criteria known as the Robson criteria to ensure maternity units are offering c-sections in a safe way for pregnant people (8).
If you are offered a c-section to deliver your baby, it is your choice whether to have one and it’s important that you are informed about the risks and benefits. At any point during your pregnancy, you should be able to discuss your birth preferences with your midwife or doctor that is in charge of your care so you are fully informed to make decisions about your labour and delivery.
References
- Betran AP, Ye J, Moller AB, Souza JP, Zhang J. Trends and projections of caesarean section rates: Global and regional estimates. BMJ Glob Heal. 2021;6(6).
- Betran AP, Torloni MR, Zhang JJ, Gülmezoglu AM. WHO statement on caesarean section rates. Vol. 123, BJOG: An International Journal of Obstetrics and Gynaecology. 2016.
- Field A, Haloob R. Complications of caesarean section. Obstet Gynaecol. 2016;18(4).
- Ye J, Betrán AP ila., Guerrero Vela M, Souza JP, Zhang J. Searching for the optimal rate of medically necessary cesarean delivery. Birth. 2014;41(3).
- Althabe F, Sosa C, Belizán JM, Gibbons L, Jacquerioz F, Bergel E. Cesarean section rates and maternal and neonatal mortality in low-, medium-, and high-income countries: An ecological study. Birth. 2006;33(4).
- Ockenden, D. (2022). Findings, conclusions and essential actions from the independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust. Retrieved from https://assets.publishing.service.gov.uk/gover nment/uploads/system/uploads/attachment_data/file/94301 1/Indep endent_review_of_mater nity_servi ces_at_Shrewsbury_and_Telford_Hospital_NHS_Trust.pdf
- NICE. Caesarean Section Guidelines. NICE Clin Guidel. 2021.
- World Health Organization. Robson Classification, Implementation manual. Vol. 53, Journal of Chemical Information and Modeling. 2019.