news focus: The risk of litigation and the growing number of Caesarean births are combining to make childbirth a real headache for the NHS.

Published: 16/05/2002, Volume II2, No. 5805 Page 12 13

Nobody could pretend that childbirth is easy. From conception to delivery, it is a messy business.

Although most would say that there are concomitant compensations, do not expect managers to agree.

Two reports published in the past few weeks suggest that the whole process of childbirth is creating twin headaches for the health service.

First, in a National Audit Office publication, was a reminder that the NHS litigation bill is rising, due in no small part to the costs of claims arising from problems during childbirth.

Then came the finding that there are now fewer so-called natural births in the NHS in England than those involving some form of medical intervention - what the Daily Mail calls turning childbirth into a 'joyless medical procedure'.

As managers ponder the demands of cutting the medical negligence bill and reducing the numbers of interventions, it is almost too easy to find a link between the two.

Doctors are fearful of litigation, the argument goes, so are practising defensive medicine, relying on technology to make births arguably safer.

Certainly the figures seem to show that the risks of increasing the compensation bill are greatest in obstetrics and gynaecology.

Last month a report from the NAO on NHS accounts to the end of March 2001 showed that known and anticipated claims had risen to£4.4bn, a£500m increase on the previous year.

Although that figure has not yet been broken down into clinical area, an NAO report published a year ago - Handling Clinical Negligence Claims in England - showed that 80 per cent of the value of claims was down to brain damage and cerebral palsy, while a quarter of actual claims involved childbirth.

At the same time, the Department of Health's own figure published two weeks ago show that the rate of Caesareans has risen to 21.5 per cent, almost double the level 10 years ago.

Other interventions such as induction (21 per cent) and the use of instruments like forceps (11 per cent) push up the intervention rate.

Leicester Royal Infirmary consultant gynaecologist Nick Naftalin is putting the finishing touches to a report which he has compiled for the DoH, looking at how to meet its target of reducing the incidence of both negligent harm and litigation in obstetrics and gynaecology.

'I haven't been looking for a link between greater intervention and negligent harm, but data from a wide variety of sources, such as solicitors, medical defence organisations and the NHS Litigation Authority, do not suggest there is a link, ' he says. 'I put the question to colleagues whether they felt the media or lawyers were contributing to the rise in claims, and they concluded that it was a very minor factor.'

His report will, he hopes, be published later this year. 'It is not rocket science, ' he says. 'The key is getting the right people with the right skills in the right place at the right time.

'We have some difficulties around this area.We do not train people in communication, in risk management, in how to deal with bereaved parents, how to deal with things when they happen.We have to accept that things happen, but the service has maybe not been good at handling it.'

Mr Naftalin says these messages have been around for several years, but that the difficulty has been getting them implemented at trust level.He has great hopes for the National Patient Safety Agency. 'It will have some teeth and should make things happen, ' he says.

National Childbirth Trust head of policy research Mary Newburn is sure there is a link between rising litigation levels and increased intervention. 'There is little doubt that the thought of litigation affects the culture on the wards and individual clinical care, ' she says. 'Changing a culture is difficult, but there are things which can be done to make a difference. For example, we know that the practice of putting women on a foetal monitor, even for 20 minutes, increases the Caesarean rate.'

Medical Defence Union senior medical claims handler Dr Frances Szekeley says the reasons behind the rise in the numbers of interventions such as Caesareans are complex. 'Fear of litigation and the so-called blame culture are undoubtedly one factor, but there are hundreds of others, ' she says. 'There is the general medicalisation of society, There is patient pressure from women, partly because It is perceived as being what the rich and famous do - and That is hugely influential.

'Women also read that It is safer for the baby and may believe it will lessen the pain of childbirth.

There are also other factors like staffing.We know that if women have one-to-one care from a midwife there will be fewer interventions, but few hospitals have those resources available.'

In Dr Szekeley's view, the move to a more litigious society hasn't been all bad. 'It is had benefits in terms of risk management and clinical audit. Doctors' recordkeeping has improved immeasurably, ' she says. 'It used to be that if you asked a doctor about clinical audit they would tap their head wisely and say, 'It is all in here'. They do not do that now.'

For Royal College of Obstetricians and Gynaecologists spokesman Peter BowenSimpkins, the solutions to cutting negligence and interventions are staring us in the face.

'We have to employ more senior staff. Every labour ward should have a consultant there 24 hours a day, and I mean there, seeing what needs to be done, not sitting at home on call.We also need more midwives. They are overworked and demoralised. If the proper staffing is there, you'll reduce clinical negligence cases and you'll also reduce the numbers of interventions.'