Comparing caesarean birth rates: An institutionalized habit that is hard to break

Abstract

Commissioned by the UK government’s Secretary of State for Health and Social Care in 2017, the Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust (SaTH) uncovered prolonged systemic failings, and led to an unprecedented police investigation into hundreds of deaths. Critically, the review culminated in two reports (December 2020 and March 2022) outlining 22 Immediate and Essential Actions (IEAs) to improve the safety of maternity services, that must be implemented at all trusts in England. The argument presented here is that the scope of these actions fell short, and this will have significant repercussions. Specifically, the IEAs ignored one of the review’s most glaring findings: evidence of harmful attitudes and actions around monitoring and comparing caesarean births, while perceiving a low rate as ‘the essence of good maternity care’. Responding to the final report, the President of the Royal College of Obstetricians and Gynaecologists (RCOG), Dr Edward Morris, assured the public this was ‘a watershed moment for maternity care’. He promised the college was ‘committed to enacting change,’ and owed it to families ‘to act on the recommendations’. In the same vein, Richard Stanton and Rhiannon Davies, whose newborn daughter Kate’s death in 2009 was the primary catalyst for the SaTH review, described how various bodies responsible for ensuring safety had failed in their duties; they insisted their experience ‘should never be allowed to happen again’. However, even accounting for the slow pace of change in the National Health Service (NHS), there are already signs that a cultural and structural inattentional blindness to bias against caesarean birth persists, and in the absence of clear, complete and consistent instructions for trusts, lessons have not been learned.