The rate of Caesarean sections and inductions are increasing for first-time mothers, a guide to national maternity services has confirmed.
Stark differences between services, policies and practices in the 21 maternity units across the country are also revealed in the revised Bump2Babe: The Consumer Guide to Maternity Services in Ireland, published by Cuidiú, the Irish Childbirth Trust.
"Both induction and Caesarean rates have risen since our last guide in 2011," reported its author Niamh Healy, an antenatal tutor with Cuidiú. "There is also still a significant range of difference between one unit and another around the country, some units having Caesarean rates 75 per cent higher than other units."
In the 2011 guide, only one hospital had a Caesarean rate for first-time mothers of over 40 per cent – St Luke’s Kilkenny. “This time around,” says Healy, “we had three units with a rate of over 40 per cent in 2016 (Midland Regional, Portiuncla and South Tipperary) and three in 2017 (St Luke’s, Kilkenny, Cavan General and Mayo University). When you add in instrumental births, that’s a very high percentage of mothers not having a straight-forward vaginal birth.”
The Midland Regional Hospital in Mullingar recorded the lowest Caesarean rate for first-time mothers in 2017 – 28.6 per cent. In 2009, it was the National Maternity Hospital which held this position with 22.1 per cent. However by 2017 its rate had risen to 29.47 per cent.
“What’s always said when the Caesarean section rates increase is that they are seeing older and more obese women, and these bring complications. But I still wouldn’t have thought the rates would be where they are,” observes Healy.
In the 2011 guide it was Dublin's Coombe Hospital which had the highest reported induction rate (though many units did not supply figures) at 36.9 per cent, and South Tipperary had the lowest at 18.7 per cent. However, in 2017 it, and five other hospitals – The Coombe, Midland Regional, University Hospital Galway, Our Lady of Lourdes Drogheda, and Cork University Maternity Hospital – had induction rates of 42 per cent and over for first time mothers. CUMH was the highest, at 44.6 per cent. St Luke's Kilkenny had the lowest rate at 25.4 per cent.
Episiotomy rates have also increased. CUMH had a rate of 38.7 per cent in first-time mothers, University Hospital Galway 37.5 per cent, and Letterkenny University Hospital 37.1 per cent. "In fact they're all quite high," observes Healy. "Last time around this was one of the most noted statistics because Holles Street was twice the rate of other units for first-time mothers (43.5 per cent). Unfortunately, this time they couldn't give me their figure. They say their episiotomy figures for spontaneous vaginal birth are included in with their second-degree tear figures, which nobody else does. However, even if we look at that figure, 36.2 per cent, and their figure for episiotomy for instrumental births 24.2 per cent, we know that it is still very high."
The guide’s statistics for Caesarean sections and inductions were extracted and collated by Healy from monthly maternity patient safety statements for 2016 and 2017 issued by each hospital and unit.
Other information in the guide was compiled using a survey of 500 questions sent in March, 2016 to the 19 maternity units and 2 midwifery-led units across the country, asking about their services and practices for care in pregnancy, labour, birth, and the post-natal period.
"While all units eventually responded – the last hospital in May 2017 – there was a vast difference in the quality and quantity of the responses received," notes Healy. "It highlights the differences in data recording and reporting abilities nationally. Hopefully, the roll-out of the new Maternal & Newborn Clinical Management System will standardise data recording in future years."
Comparing and contrasting services, policies or practices between the maternity hospitals is intended to be both informative, and to raise awareness about the inequities of the system, says Healy.
Some of the disparities, she notes, include access to anatomy/anomaly scans at 20 weeks for all mothers. They are still only routine in nine units.
Midwifery-led care, as proposed in the National MMaternity SStrategy, is also still not widely available, and there are even glaring anomalies in the most basic facilities. "With the exception of the two midwifery-led units and two maternity hospitals, very few women have access to private toilet and shower/bath facilities during labour, a situation which requires them to use communal facilities," says Healy. "No woman should have to leave a room during labour to use a public toilet block."
Many other policies and practices varied widely across the country, including restrictions on eating and drinking in labour. “Research says it is not evidence-based to restrict what a low-risk woman eats or drinks in established labour, and women need to keep their energy up, yet we hear stories back from women that they weren’t allowed eat, or drink,” says Healy. “There is quite a variation in policy from ‘mother’s choice’ to ‘light diet’ to the more restrictive ‘fluids only’. Some have relaxed their policies since our last survey in 2011.The Coombe for instance used to be ice chips only.
“So these are the sort of things we want to get the message across about, that policies differ. And just because one unit says ‘only clear fluids’ women should be able to have the confidence to say ‘thank you for informing me’, and then going ahead and eating whatever they have in their bag.”
Induction policies for being overdue also varied nationally, ranging from 40 weeks +10 days, to 40 weeks +14 days. “This might not seem a significant difference, but it actually is if you want to avoid induction,”says Healy. “It’s an improvement because some of them were Term + 7. However, you will still have some consultants who have a preference of Term + 4, 5 or 7, and their personal preference tends to supercede hospital policy for their own patients.”
Another area demonstrating differences between units were policies on the length of first and second stage of labour. “For the second stage of labour for first-time mothers not using epidural, the units’ policies vary from one hour to one to two hours, and three referring to NICE guidelines from the UK – up to 3 hours after the descent of the baby – which could be up to four hours.”
Healy says she was also disappointed with some of the figures they received regarding vaginal births after Caesarean. “However, I would hope that these would have changed in the meantime. Promoting VBACs is an effective way of reducing the overall Caesarean rate as repeat Caesareans account for a significant portion of the overall rate.”
Typically, 60-75 per cent of women attempting VBAC have a vaginal birth. However, Healy says the most telling statistics for VBACs, are for the “attempted” VBACs, rather than the rates of success. “One very interesting figure is the percentage of women with one prior Caesarean who attempted a VBAC – in other words who laboured (either spontaneously or by induction of labour) or had what’s known as a ‘trial of labour’. In some units, this is significantly lower than in others, with rates ranging from 29 per cent to 57 per cent. In units with attempt rates of only 30 per cent we have to ask, are women being given the information, support and encouragement they need from their caregivers to have the confidence to attempt a VBAC? And should we applaud VBAC success rates of 70 per cent in units where the attempt rate is only 30 per cent?”
Another concern, says Healy, are delays in how units implement best practice, and comply with national clinical guidelines. This include the provision of routine antenatal anti-D prophylaxis injections for Rhesus negative women at 28 weeks. “This is best for protecting the mother, the baby and future pregnancies, but though that guideline came out in 2012, four units between 2016 and 2017 were still not providing this service and a further two units did not answer the question,”notes Healy. “Some of these might now be providing the service, but they weren’t four years after the guideline was in place.”
Also, despite national clinical guidelines four years previously, many units reported they were still using routine CTG Admission Traces, which are deemed inappropriate for low-risk mothers and babies. “Intermittent monitoring has been shown to be safest and yet a lot of women still end up with an admissions trace and continuous monitoring,” notes Healy.
Almost half of the units had also failed to follow guidelines for the third stage of labour – the delivery of the placenta.”Even though women should be educated about the option of having a physiological third stage, 99 per cent are still having the managed third stage, said Healy. “ Again, the national clinical guidelines in 2012 recommended that the substance to use is syntocinon, a better choice for a woman who wants to breastfeed, yet nine units were routinely still using syntometrin, the older substance, which can have some side effects.”
The widespread introduction of foetal blood sampling to monitor babies is one very positive change Healy has noted. “Almost all of the units now have the ability to do foetal blood sampling during labour, which gives a much better indication if a baby needs the assistance of something like a Caesarean and it’s a very quick test, so that’s good.”
Other positive changes she has observed include growing access to “gentle Caesarean” practices – such as lowered or see-through drapes, slow emergence of the baby, optimal cord clamping, and parents discovering the baby’s sex – and the widespread introduction of ‘skin-to-skin’ policies for newborns. “Most units stated that the baby is only cleaned and wrapped if skin-to-skin is not possible or appropriate, eg because of infection, during the first hour after birth.”
Acceptance of additional support and complementary birth aids has also increased. “19 out of 21 units stated that doulas are welcome to support women. This has increased significantly since our last survey. Seventeen units also specified that they facilitate the use of hypnobirthing or GentleBirth by women who have been practicing during pregnancy. There seems to be a greater openness to its use. Some units provide hypnobirthing classes and others have midwives undergoing training.” Eleven units also supported the use of acupuncture/acupressure with several stating that they facilitate a practitioner accompanying the woman in labour.
One development she is not seeing, however, are mobile epidurals. “I think that’s a pity because in the UK it seems to be quite popular,”says Healy. “Only Mayo say that they have it, while Wexford said they had it, but because of a deficit of midwives to mothers it wasn’t utilised.”
Healy says she hopes expectant parents will use the guide to explore policies and practices around the country.
“It’s all about informed decision making. Sometimes, when caregivers make a recommendation about the way care is going to go, or a possible intervention, women often assume that’s that, that this must be international best practice, that this is what must happen for the benefit of them and their baby, and they often comply immediately. What I would hope is when women see what is offered routinely in other units they understand that actually what they are being offered by their caregiver may only be one option. It’s not the only option. Knowing this they can ask, ‘well what can we do instead’? We tell women in antenatal classes that they are the experts of their own bodies and all the decisions should be made in consultation with their caregiver.”
Cuidiú, she concludes, remains concerned that the rights of pregnant women to give informed refusal, eg to withhold consent for a procedure or intervention, are currently not being protected. “Practices and procedure in units seemed solely directed towards securing consent for interventions,” she says.
“Parents need to understand that they have options and that it is ultimately up to them to decide to give consent or not. There seems to be no acceptance that informed refusal – even as laid out in the maternity strategy – is a reasonable thing.”
