Caesarean Sections (Hansard, 14 December 1999)

§ Baroness Cumberlege
asked Her Majesty's Government:
What is their policy towards the rising rate of caesarean sections.

§ The Parliamentary Under-Secretary of State, Department of Health (Lord Hunt of Kings Heath)
My Lords, the Government are concerned about the variation in caesarean rates between hospitals and have an active programme of work in hand to address that and the reasons for the rise in caesarean rates overall. We would expect a decision about whether to perform a caesarean section to be made on the basis of clinical need.

§ Baroness Cumberlege
My Lords, I thank the Minister for that Answer. I am interested that he feels that there is an issue about the varying rates in different hospitals. First, is he aware of two hospitals which are joining to form a trust, one of which has a caesarean rate of 12 per cent and the other of 20 per cent, and that not far away another hospital has a rate of 29 per cent? Will the Minister take this matter further and tell us how that discrepancy is to be monitored? What influence will he put on those hospitals which have a very high rate of caesarean sections?
Secondly, has the Minister seen the recent research which shows that where there is continuity of care by a midwife of a woman in labour, the intervention rate is low not only in relation to caesarean sections but also in relation to medical interventions? What is the Minister going to do about the appalling haemorrhage of midwives leaving the service?

§ Lord Hunt of Kings Heath
My Lords, the noble Baroness has asked a number of questions. The variations are considerable. The Audit Commission report of 1997 found variations of between 10 per cent and 18 per cent in the trusts surveyed. I understand that a 1998–99 survey by the English National Board for Nursing, Midwifery and Health Visiting (ENB) showed even higher variations.
Of course, some variations are explainable due to local factors. It is important that in establishing the variations and the reasons for them we take into account the factors that may arise. In its own guidelines, the WHO accepts that there can be 120 variations due to issues concerned with health, nutritional status and standards of maternity care. Clearly, it is important that local trusts examine their own rates and get to the heart of whether those rates are correct in relation to clinical judgments and the kind of services that women should expect. Of course, I accept that continuity of care is important.
On the recruitment of midwives, the recruitment campaign which started at the beginning of the year is bearing fruit. Over 4,000 nurses and midwives are returning to the profession. We have every reason to believe that as we develop those campaigns more midwives will return.

§ Lord Clement-Jones
My Lords, can the Minister confirm or deny recent press reports of several cases concerning London hospitals, including the Chelsea and Westminster Hospital, where women who are about to go into labour have been turned away because of the shortage of midwives? Is it not time that the Government got to grips with the issue? Is it not time that the Government issued their long-awaited strategy on maternity services?

§ Lord Hunt of Kings Heath
My Lords, a limited number of units have been fully booked. In such a situation, women are encouraged to turn to a midwifery unit nearby. Overall, I believe that we are tackling issues in relation to midwife shortages. I have already said that the recruitment campaign which started at the beginning of the year has borne fruit. The recruitment survey for this year shows that for England as a whole we have a 2 per cent midwifery shortage on posts vacant for more than three months. Of course, one cannot be complacent. Our efforts are bearing fruit, but we should be aware of some of the alarmist reports that we have heard in this area.

§ Baroness Masham of Ilion
My Lords, does the Minister agree that if a women who is HIV positive is pregnant, it is wise to conduct a caesarean before 38 weeks to stop trauma to the baby and to prevent HIV infection?

§ Lord Hunt of Kings Heath
My Lords, I am not in a position to give clinical guidance in that area this afternoon. I believe that all actions in relation to caesarean sections should be based on the best clinical knowledge. That is one of the reasons that the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives are conducting an audit of caesarean sections under the auspices of the National Institute of Clinical Excellence. From that we shall expect to have much more effective guidelines in relation to the use of caesarean sections in the future.

§ Baroness Gardner of Parkes
My Lords, in these days of extreme litigation, is not a factor that has to be taken into account that, where there is any doubt whatsoever, the clinician may feel obliged to carry out a caesarean section? Has the Minister any evidence on that?

§ Lord Hunt of Kings Heath
My Lords, a number of factors relate to the rise in caesarean section rates. Certainly, it is a much safer option than it used to be. The change in the age profile of women having babies has also led to an increase and I believe there is anecdotal evidence of women's own choice in the matter. However, there is no doubt that there have been reports that fear of litigation has had an influence on doctors concerned. That is a matter of regret. We have looked at the practice of defensive medicine in the US and been horrified at the prospect of that in the UK. The result of the audit on which we are working with the Royal Colleges and the development of the guidelines will, I hope, help to ensure that decisions taken for fear of litigation, rather than in the best interests of the women concerned, will not occur in the future.

§ Lord Patel
My Lords, I doubt that there will ever be another occasion when I shall feel that I can answer the Question better than the Minister! However, I agree with the Minister. It is a fact that caesarean section rates are higher now than they were a decade ago. The factors that operate now are the same as a decade ago, but there are many additional factors now. I agree that the audit—

Noble Lords
Question!

§ Lord Patel
My Lords, will the Minister support the Royal College of Midwives and the Royal College Obstetricians and Gynaecologists in the audit to reduce caesarean sections and reduce the regional variations?

§ Lord Hunt of Kings Heath
My Lords, that is the kind of question to which I am always happy to agree. I believe that the noble Lord is right to refer to the audit again. It is important that when we make statements and reach conclusions about current practice, they are based on the best possible evidence. I believe that the audit is the best way to obtain the evidence.

§ Lord Ewing of Kirkford
My Lords, is the Minister aware that I am in the Chamber especially because of this Question? I cannot understand why a House made up of old-age pensioners should be involved in childbirth issues. Returning to the question of the noble Lord, Lord Clement-Jones, is my noble friend aware that women going into Labour have substantially increased in number compared to those going into the Liberal Democrat or Conservative parties week by week? Does my noble friend welcome all those women who join Labour, especially New Labour?

§ Lord Hunt of Kings Heath
My Lords, we must always welcome new recruits to the cause of Labour. As for Members of your Lordships' House, it is worth pointing out that the average age of women giving birth has now increased to 29.1 years—a substantial increase over the years.

§ Lord Jenkin of Roding
My Lords, perhaps I may return to the serious issue of the Question. I draw the 122 Minister's attention to an interesting paper which was read last night by Professor Richard Feachem under the auspices of the CSE International Lecture. He ascribed some of the increase in the number of caesarean sections to what he described as perverse financial incentives, not on the part of the doctors, but on the part of the trusts which can increase the resources that they can claim because of the number of caesarean sections that they perform. I do not know whether or not that is correct. Is the Minister prepared to look at that evidence from a distinguished source?

§ Lord Hunt of Kings Heath
My Lords, I would be concerned if any financial regime in operation in the NHS led to perverse incentives in relation to clinical actions. I would be very surprised if that were the case, but I am happy to look into the matter.