More Caesarians, fewer maternity care staff: 'were the midwives too busy ?'
Dobson reports (1) the rate of deliveries by Caesarian section in
England rose from 4% in 1970 to 19% in 1999. This could, potentially,
have created a substantially increased demand on post natal care within
maternity services, at just the time when many hospitals, especially in
Greater London, found difficulties even in maintaining numbers of midwives
at their former levels.
In two London health service trusts, a public health specialist
(P.M.) undertook a survey of maternity care which involved 477 responses
from women who had given birth in 1999. This investigated 86 different
aspects of care, with most answers in the format of tick boxes (up to six
options) in a rank order. In general, the survey revealed problems with
post natal hospital care. After submitting a detailed report on the
services provided (to the British Journal of Midwifery) the authors
decided to re-examine the data to contrast the postnatal experiences of
those women who had a Caesarian (88, 18.4%) with others, especially those
who had a 'Normal' vaginal delivery (340, 71.3%). In particular we
considered the 69 mothers who had a Caesarian without any general
anaesthetic (in case anaesthesia subsequently affected their recall of
their experiences, although these 18 mothers did report similar care to
those women with epidural anaesthesia). Trust A performed Caesarian
sections on 34 women without general anaesthesia and Trust B on 35 women.
For the non parametric statistics used (Chi2, Spearman's rank correlation
and Mann-Whitney U tests) our threshold for significance was p <0.05.
Having a Caesarian was associated with a number of unsurprising
differences in care (such as a greater length of stay or more problems
with infant feeding) compared to having a 'Normal' delivery. One of the
key questions about post natal care in both trusts was 'did you ever feel
the midwives were too busy to spend enough time with you ?', for example
patients' answers to this question were highly correlated with overall
ratings of 'your post natal care whilst in hospital' (rho > 0.5, p <
0.001). Our concerns about the rising rates of Caesarians were indeed
borne out in one of the trusts (Trust A). There the 34 women involved
were significantly more likely to feel the midwives were often too busy (U
test, p = 0.036) and less likely to report that they had known any of
these midwives before (U test, p = 0.014), compared to the 'Normal'
delivery group. However, this was not the picture in the other trust
(Trust B). The 35 women here were no more likely to report that their
midwives did not have enough time for them than the 'Normal' group, and
the service actually arranged that they were more likely to know one or
more of these midwives 'well' (U test, p = 0.005).
The services in A and B were only a few miles apart and saw a similar
range of clients. It was the organisational responses to change (like
increasing numbers of Caesarian sections) that probably underlaid the
different experiences of mothers referred to A or to B. For example an
independent consultancy reported that at the time Trust A exemplified the
special difficulties in recruiting and retaining hospital staff in London.
It was possible for the other trust to ameliorate some of the impact
of more Caesarians on their post natal care service. Nationally, a
maternity and neonatal workforce group is looking now at the organisation
of 'gold standard' care (2). The forthcoming National Service Framework
for children's and maternity services offers a fresh chance for Midwives
to develop their work in responsive and far-sighted ways.
WOODY CAAN, University College London, London WC1,
PETER MESSENT, Queen Mary, University of London, London E1.
1. Dobson R. Caesarian section rate in England and Wales hits 21%.
BMJ 2001 ; 323: 951.
2. Pearson S. Special delivery. NHS Magazine 2001 ; September: 8-11.
Copies of the Maternity Care Survey from Dr. Peter Messent, Public Health,
Barking and Havering Health Authority, The Clock House, East Street,
Barking IG11 8EY.
Both Trust A and Trust B have recently disappeared as entities in the
London Region's current re-organisation of acute care.
Declaration of competing interests: none.
Competing interests:
No competing interests
16 November 2001
Woody Caan
(Both) Public health specialist
Peter Messent
University College London, London WC1E 6BT and Queen Mary University London, London E1 2AD.
Rapid Response:
More Caesarians, fewer maternity care staff: 'were the midwives too busy ?'
Dobson reports (1) the rate of deliveries by Caesarian section in
England rose from 4% in 1970 to 19% in 1999. This could, potentially,
have created a substantially increased demand on post natal care within
maternity services, at just the time when many hospitals, especially in
Greater London, found difficulties even in maintaining numbers of midwives
at their former levels.
In two London health service trusts, a public health specialist
(P.M.) undertook a survey of maternity care which involved 477 responses
from women who had given birth in 1999. This investigated 86 different
aspects of care, with most answers in the format of tick boxes (up to six
options) in a rank order. In general, the survey revealed problems with
post natal hospital care. After submitting a detailed report on the
services provided (to the British Journal of Midwifery) the authors
decided to re-examine the data to contrast the postnatal experiences of
those women who had a Caesarian (88, 18.4%) with others, especially those
who had a 'Normal' vaginal delivery (340, 71.3%). In particular we
considered the 69 mothers who had a Caesarian without any general
anaesthetic (in case anaesthesia subsequently affected their recall of
their experiences, although these 18 mothers did report similar care to
those women with epidural anaesthesia). Trust A performed Caesarian
sections on 34 women without general anaesthesia and Trust B on 35 women.
For the non parametric statistics used (Chi2, Spearman's rank correlation
and Mann-Whitney U tests) our threshold for significance was p <0.05.
Having a Caesarian was associated with a number of unsurprising
differences in care (such as a greater length of stay or more problems
with infant feeding) compared to having a 'Normal' delivery. One of the
key questions about post natal care in both trusts was 'did you ever feel
the midwives were too busy to spend enough time with you ?', for example
patients' answers to this question were highly correlated with overall
ratings of 'your post natal care whilst in hospital' (rho > 0.5, p <
0.001). Our concerns about the rising rates of Caesarians were indeed
borne out in one of the trusts (Trust A). There the 34 women involved
were significantly more likely to feel the midwives were often too busy (U
test, p = 0.036) and less likely to report that they had known any of
these midwives before (U test, p = 0.014), compared to the 'Normal'
delivery group. However, this was not the picture in the other trust
(Trust B). The 35 women here were no more likely to report that their
midwives did not have enough time for them than the 'Normal' group, and
the service actually arranged that they were more likely to know one or
more of these midwives 'well' (U test, p = 0.005).
The services in A and B were only a few miles apart and saw a similar
range of clients. It was the organisational responses to change (like
increasing numbers of Caesarian sections) that probably underlaid the
different experiences of mothers referred to A or to B. For example an
independent consultancy reported that at the time Trust A exemplified the
special difficulties in recruiting and retaining hospital staff in London.
It was possible for the other trust to ameliorate some of the impact
of more Caesarians on their post natal care service. Nationally, a
maternity and neonatal workforce group is looking now at the organisation
of 'gold standard' care (2). The forthcoming National Service Framework
for children's and maternity services offers a fresh chance for Midwives
to develop their work in responsive and far-sighted ways.
WOODY CAAN, University College London, London WC1,
PETER MESSENT, Queen Mary, University of London, London E1.
1. Dobson R. Caesarian section rate in England and Wales hits 21%.
BMJ 2001 ; 323: 951.
2. Pearson S. Special delivery. NHS Magazine 2001 ; September: 8-11.
Copies of the Maternity Care Survey from Dr. Peter Messent, Public Health,
Barking and Havering Health Authority, The Clock House, East Street,
Barking IG11 8EY.
Both Trust A and Trust B have recently disappeared as entities in the
London Region's current re-organisation of acute care.
Declaration of competing interests: none.
Competing interests: No competing interests