What does a good maternal request caesarean policy look like?

One of the primary objectives of our campaign on maternal request caesarean is to highlight examples of best practice and celebrate the Trusts taking a woman-centred approach. One of the guidelines that really stood out to us was that of Birmingham Women’s Hospital (BWH).

BWH’s guideline on maternal request caesarean explicitly recognises that the evidence base around this decision is of very low quality. It uses language that recognises the woman as the lead decision maker such as, “If a woman has decided on CS” and, “at every appointment re-confirm (not challenge) decision”.

It came as no surprise to learn that BWH co-produced the guideline with service users who had faced this decision and had direct experience of the process. We spoke to Sara Kenyon, Professor of Evidence Based Maternity Care at the University of Birmingham, and the lead researcher on the project to revise the maternal request caesarean, about her experience of leading this project.

How did the idea to co-produce the maternal request guideline working with service user representatives come about?

It came from the clinicians who wanted to improve the care they offered.

How did you go about co-designing a new guideline?

We used a recognised process called ‘experienced based co-design’, which was developed by the King’s Fund. It uses the experiences of women (in this case) and clinical staff to re-design services taking account of the views of all those involved.

We talked to both of these groups separately and then shared our findings to check with both groups we had heard their concerns correctly. A workshop was then held with both groups to discuss findings and agree key areas for service improvement. A final workshop agreed changes to the pathway.

What were the main concerns raised by women and healthcare professionals?

Interestingly, similar key issues for service improvement were identified by both women and clinical staff. These were women having to discuss the request a number of times, delay in the decision for caesarean, women feeling judged, and that information for women needed improving.

You describe the co-design process as challenging and rewarding – tell us more…?

It was rewarding to see how keen everyone was to get involved to improve care.

It was challenging to keep the momentum going and finding time to get everyone together- clinicians and new mothers have competing priorities.

Was there anything that surprised you as you went through the co-design process?

The willingness of all those involved to engage in the project and the fact that both groups identified the same key areas for service improvement.

You talk about tension between the midwifery model of care and the medical model of care over this particular decision; can you tell us a bit more about that?

In this context, an added challenge was the professional tensions between the midwifery model of care and the medical model. Midwives are trained in a ‘culture of normality’ in which normal birth is promoted and valued and a women choosing an elective caesarean birth can feel like a failure to midwives although many would also feel that their role is to support a woman in whatever decision she makes.

The current Maternity Transformation Programme, with its focus on increasing choice and personalisation, may act as a tool to promote change.

Do you think the results would differ if carried out by other Trusts in other areas?

I would have thought that the same concerns would be raised by women and healthcare professionals depending on the current pathway. Having the support of a research team that understands maternity care was really helpful but in principle this sort of process could be carried out by any Trust working with service users.   

Some Trust policies are a result of local commissioning pressures and it would be important that commissioners were involved in the co-design process too.

What advice would you have for other Trusts looking to review their maternal request caesarean policy?

It does take time and commitment so it would be important to get buy in to the project, make a clear plan and keep going to the end.  But the resulting policy will be worth it.

What advice would you have for other Trusts looking to use co-design to revise any maternity guideline or policy?

It is the best way and Better Births, the national maternity review which is now being implemented, says that “Local Maternity Systems should be responsible for… ensuring that they co-design services with service users and local communities”.

The mechanism for doing this is through Maternity Voices Partnerships. You can find more information here. Co-design ensures the views of all parties are considered and included and enhances understanding of the issues involved.

Read more about this project here.

Maternal request caesarean research highlights postcode lottery

Birthrights has published research today concerning the treatment of women who request a caesarean section. Results of a nationwide Freedom of Information Act request show that the majority of Trusts in the UK make the process of requesting a caesarean lengthy, difficult or inconsistent adding anxiety and distress to women at a vulnerable time. And lawyers acting for the charity are concerned that at least one Trust may be acting unlawfully.

Official NICE guidelines states: ‘For women requesting a caesarean section, if after discussion and offer of support… a vaginal birth is still not an acceptable option (Trusts should) offer a planned cesarean section.’ But pregnant women in some regions who ask about the procedure are simply told to go elsewhere. Statistics show that 15% of Trusts have policies or processes that explicitly do not support maternal request caesarean, while 47% of Trusts have policies or processes that are problematic or inconsistent. Only 26% of Trusts offer caesareans in line with NICE best-practice guidance.

Commenting on these results, Chief Executive of Birthrights, Rebecca Schiller said: “Maternal request caesareans are the the number one reason women contact the Birthrights advice service. The women we support have endured previously traumatic births, mental ill-health, childhood sexual abuse or have carefully examined the evidence available and made informed decisions that planned caesareans will give them and their baby the best chance of an emotionally and physically healthy start. It is clear that women requesting caesareans meet judgement, barriers and disrespect more often than they find compassion and support. We are concerned that this lack of respect for patient dignity could have profound negative consequences for the emotional and physical safety of women.”

On 27th July 2018 lawyers acting for Birthrights wrote to Oxford University Hospitals NHS Trust and Oxfordshire Clinical Commissioning Group asking for further information about the policy in place at the John Radcliffe hospital not to offer maternal request caesareans.

Programmes Director Maria Booker explains, “Many women have contacted us about disrespectful treatment at the John Radcliffe hospital. We first wrote to the Trust and CCG in May 2017. Trusts are bound by human rights duties to offer individualised care. Any statement or policy from a Trust that caesarean would only be granted on medical grounds may be incompatible with Trusts’ obligations to have an open, supportive, two-way discussion that explores all reasonable options. If such a policy is then applied in a blanket way then it could be incompatible with human rights law. We have made the Trust and CCG aware that we hope to resolve this issue without litigation and we encourage Oxford University Hospitals NHS Trust and its commissioners to begin to work with us constructively to change their policy. Otherwise we will look to explore all options, including judicial review, to ensure that women living in Oxford get the respectful care they deserve and that the law obliges their caregivers to provide.”

Click here to find out more about our campaign and to see our interactive map.

Recruiting for Chief Executive Officer

Birthrights is looking for a leader to join us as our new CEO. You will lead develop a dynamic and influential young charity which is changing the conversation in maternity care and putting human rights and respectful care high on the agenda for women, healthcare professionals and policy makers.

Birthrights champions women’s rights to dignity, autonomy, humane treatment and non-discrimination. We believe that human rights principles have the power to transform maternity care in the UK and to ensure that women’s needs are met and the most vulnerable women are equally enabled to access safe, high-quality, respectful maternity services.

We reach thousands of women and health care professionals through our advice and training. Our influencing work embeds a human-rights approach in NHS Trusts and central government maternity policies. Our research and publications highlight the challenges faced by women from vulnerable backgrounds and our strategic legal interventions give pregnant women a voice in the courts.

Our successful candidate will be a dynamic and experienced leader with a strong understanding and commitment to human rights in maternity care. You will have a track record in growing organisations, developing and implementing strategies and building income streams. You will empower and inspire staff and create partnerships with a diverse range of stakeholders to influence policy. You will understand charity governance and work effectively with the Board to ensure strong financial and organisational management.

We believe strongly in flexible working. We operate an employee-led working schedule and a flexible holiday policy. Our staff work from home with regular meetings in London and the south-east. The Board is open to increasing the CEO’s working hours if funding permits.

If you believe you have the commitment, skills and experience to lead Birthrights at an exciting time in its development we would welcome your application.

For further information, please download the appointment brief: Birthrights CEO appointment brief

Leadership news

Birthrights CEO Rebecca Schiller will be stepping down from her current role at the end of September 2018 and will be re-joining the Board of Trustees to continue her work for the organisation. Birthrights will start the recruitment process for a new CEO on 6th August and will be looking to recruit a dynamic and experienced leader with a strong understanding and commitment to human rights in maternity care. A full appointment brief and application details are now available here: Birthrights CEO appointment pack.
Rebecca Schiller comments:

 

It has been a huge privilege to lead Birthrights over the past three years – delivering work to ensure that all women matter in childbirth. Thanks to the support of our staff, Board, volunteers, donors, fundraisers and the many midwives and doctors we work  with we have achieved more over the past five years than our Chair and Founder Elizabeth Prochaska and I believed possible when we set up our kitchen table organisation. 

I am proud that we now have a team of five part-time staff and will enjoy the support of the Esmee Fairbairn and Baring Foundations over the coming years. With their commitment we have been able to develop plans to focus on the human rights challenges faced by women facing severe and multiple disadvantage, disabled women and those with mental capacity issues over the next three years. We will continue to provide free advice and resources to those who need it, deliver more training to midwives and doctors and ensure local and national maternity policy is lawful and rights-based – always insisting that the diversity of women’s voices, experiences and needs guides our work.

I will be leaving my post as CEO at the end of September 2018 to focus on my writing, speaking and consulting work. It has been a difficult decision but I believe it’s now time to hand over the day-to-day running of Birthrights to energetic and experienced new leadership who will bring the skills needed to continue to develop our work, deepen our impact and ensure we build a robust and sustainable organisation to support women and those who care for them for years to come.

I will continue to work very closely with the staff team, our funders and volunteers in my new role on the Birthrights Board of Trustees. I look forward to continuing to be a Birthrights spokesperson and contributing to our work in a number of different ways. This is an exciting new chapter for Birthrights and we look forward to sharing it with our dedicated friends and supporters.”

Shropshire Midwifery Led Units re-open their doors

New Year’s Day saw the re-opening of the three Midwifery Led Units in Bridgnorth, Oswestry and Ludlow, which is great news for local women expecting a baby in 2018. A consultation expected to propose their permanent closure and replacement with community hubs is due to be published shortly. The response from Shropshire CCG to our letter of the 7th December can be found here.

Letter to Shropshire CCG about permanent closure of Midwifery Led Units in Shropshire

On 7th December, we wrote to Shropshire Clinical Commissioning Group to express our strong concern over the recent decision to permanently close three Freestanding Midwifery Led Units in Oswestry, Bridgnorth and Ludlow.

After the units were shut on a temporary basis last summer, we wrote to the CEO of Shrewsbury and Telford NHS Trust reminding him that the closure of the units ran contrary to national policy, most recently confirmed by “Better Births” to offer women the full range of choices in terms of place of birth and to increase the number of births taking place in midwifery-led settings in line with women’s wishes. We also advised them that choice of place of birth falls within the right to respect for private and family life conferred by Article 8 of the European Convention of Human Rights/Human Rights Act 1998.

In his response dated 4th August 2017, Trust CEO Simon Wright claimed that the temporary closures were caused by short and long term staff sickness. It is therefore very disappointing to hear that the CCG have come to a decision to permanently close the units.

You can read our most recent letter, dated 7th December 2017 here.

Recruiting for New Legal Professional Trustee

Birthrights are recruiting for a new trustee from the legal profession. The role offers an exciting opportunity for a lawyer to get involved in our cutting edge work on women’s reproductive rights and bring further legal experience to our board providing invaluable advice and support for the work that Birthrights does.

Download the role description here for more information. Closing date for applications is 29 November 2017.

Birthrights comments on midwives and normal birth

In response to this weekend’s news coverage of the Royal College of Midwives, Birthrights’ CEO Rebecca Schiller gave this comment to the Sunday Times:

“The RCM’s decision to change the name of its campaign to the ‘Better Births Campaign’ took place in 2014. I welcomed this and continue to value the RCM’s drive to ensure women have access to the very best births no matter their circumstances and whatever their wishes. Birthrights has worked closely with the RCM to train midwives across the country in their human rights obligations. These obligations make it very clear that – whatever the health care professional’s personal beliefs – women must always be provided with the best evidence available, pressure should never be put on them to do something they don’t want to and their decision is to be respected. Whether women want a home birth or an epidural, the RCM has demonstrated their commitment to promoting care that responds to women’s needs.

I welcome a shift away from the use of the term “normal”, as it’s a term that has caused unnecessary division and become needlessly politicised. No-one should tell a woman how she should give birth, but should listen to her and work with her to develop a plan that fits her needs and circumstances.

Intervention in childbirth can be life-saving and midwives work with obstetricians during complex pregnancies and births every day. However, the reality remains that many women want to avoid unnecessary intervention in childbirth as it comes with its own set of risks to their physical and emotional health. It is clear from the evidence base that, in our current maternity system, too many women who don’t want and need intervention end up with it – sometimes with long-lasting consequences. So it is essential that we ensure that midwives’ pivotal role in supporting physiological birth is protected, while remaining supportive of all women’s choices. We must also campaign with them for services that genuinely enable the women who want to, to access care that minimises their chances of having an intervention they didn’t need.

The current trend to use terms such as the “cult” of midwifery, pointing the finger of blame at midwives and seeking to devalue their profession, autonomy and valuable role in our maternity system is deeply concerning. The media focus on this three-year-old change of campaign name is just another example of the contemporary witchhunt of midwives that ultimately makes pregnancy birth less safe and more stressful for women at a vulnerable time in their lives.”

Do I have a right to a c-section? Update on Oxford University Hospitals

On 24th May we launched a campaign to engage with Trusts who state that they do not offer maternal request caesarean sections, thereby denying women the individual respect and consideration they are entitled to. The first Trust we wrote to was Oxford University Hospitals whose policy on offering planned caesarean sections is stated in this leaflet:

http://www.ouh.nhs.uk/patient-guide/leaflets/files/10405Pcaesarean.pdf

OUH responded to our original letter stating that their approach was in full compliance with NICE guidelines, and that they offered a “kind, friendly and professional service”. Unfortunately the reports we have received of women not being listened too, being left shaken by consultations, and being left distressed and anxious knowing that their request for a caesarean section would not be granted by OUH, are at odds with OUH’s account.  Therefore, this week, we wrote again to the Trust, their Commissioners, Healthwatch Oxfordshire and the CQC, to share some of your stories and to urge them to reconsider their approach. If you would like to tell us about your experience or requesting a maternal request caesarean section at OUH or elsewhere, please comment below…

Letter to R Schiller (Birthrights) from OUH

Second letter to OUH from Birthrights with case studies

Birthrights Administrator vacancy

Birthrights is very excited to be expanding our small team. Are you highly organised? Have experience of running a busy (virtual) office? Then you could be our new administrator! You will be the key to ensuring our organisation runs smoothly as our work continues to grow at pace. The role is part-time (22.5 hours), flexible and home-based. Closing date for applications is the 23rd June, with interviews in mid-July. Download the job description here for more details.