Published: 19/02/2004, Volume II4, No. 5893 Page 27
The rise in the rate of caesarean deliveries has been a topic of puzzlement and concern for health service managers for many years. Over the last 30 years, caesarean deliveries have increased from about one in 20 to one in five, despite a desire by most professionals working in maternity services to see them reduced. Fear of litigation, the desire of doctors to intervene and the desire of patients to avoid labour pains have all been blamed.
Over the last three years Dr Foster has collected detailed data from maternity units in the UK. During this period, the caesarean rate has continued to grow, rising from 20.6 per cent to 22.4 per cent (see chart 1). There are also noticeable regional variations with, for example, a much higher rate in Northern Ireland.
One approach to trying to keep caesareans down has been the introduction of midwife-led maternity units.
These are delivery suites staffed only by midwives, where caesarean deliveries and epidural pain relief are not available. The belief is that if these facilities are harder to access more babies will be delivered without them.
Stand-alone units in cottage hospitals are often found in rural areas, particularly in Wales, Scotland and the South West. However, these units are sometimes under pressure to close. In contrast, large hospitals in urban areas have been creating new midwife-led units on the hospital site. The result has been a significant increase in the number of women giving birth in midwife-led units, rising from 1.7 per cent of births in 2001 to 2.9 per cent in 2003 (see chart 2).
Caesarean rates for maternity units vary from 15 per cent to over 30 per cent. The enormous variation in practice between maternity units supports the notion that it should be possible to reduce intervention rates.
The World Health Organization has stated that developed countries ought to be able to achieve a caesarean rate of 10-15 per cent.
There are also vast differences between hospitals in the use of instrumental deliveries with forceps or ventouse (see charts 3 and 4). In some units, forceps are virtually unused. In others they are used in over 10 per cent of deliveries. Again there are regional differences, with particularly high rates of forceps deliveries in Scotland.
There appears to be no pattern to the way in which interventions are deployed across the NHS. There is no correlation between emergency and elective caesarean rates, or between caesarean rates and instrumental deliveries using forceps or ventouse; there is not a connection between the ventouse rates and forceps rates.
As these are regarded as alternatives in many situations, one might have expected to see increased use of ventouse matched by decreased use of forceps. This is not the case.
For health service managers, the fact that a caesarean delivery is considerably more expensive than a natural delivery is an added incentive to try to reduce intervention rates. Although births in midwife-led units are still the exception, increased use of these units may, over time, help to achieve a lower rate of caesarean deliveries.
Roger Taylor is research director with health information analysts Dr Foster Ltd (www. drfoster. co. uk or phone 0207 256 4900). The figures are calculated from hospital episode statistics for the year to March 2002.
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