Maternal Request Caesarean - Birthrights
Transcript of Maternal Request Caesarean - Birthrights
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Materna l Request
Caesarean
August 2018
Protecting human
rights in childbirth
Foreword 3
Background 4
Summaryofresults 8
Analysis 9
Calltoaction 13
Annex1:Trustcategories 16
Annex2:Oxford 19
Annex3:ListofTrusts 20
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Contents
Foreword Transparencyaboutmaternalrequestcaesareanislongoverdue.WearepleasedtosharetheresultsofourresearchandshineaspotlightontheavailabilityofMRCSintheUK.
Sinceitsrevisionin2011,NICEGuidelineCG132hasrightlyrecognisedthatwomenshould
always be the primary decision makers in childbirth, whilst also protecting the right of
individual doctors to decline to support an individual who requests a caesarean on non-
medical grounds. Despite this guidance, Birthrights’ advice service now handles more
requestsforsupportfromwomenunabletoaccessacaesareansectionthananyotherissue.
Thepublicationof thisresearchdemonstratesthatnearlythreequartersofNHSTrustsdo
nothavewrittenguidelines that clearly commit toupholdingawoman’sautonomy in this
area.SomeTrustshaveimplementedblanketpoliciesthateffectivelybanmaternalrequest
caesareans, running contrary to NICE guidance and potentially in breach of their human
rights obligations. Our data, paired with the distressing stories we hear regularly from
pregnantwomen, demonstrates that themajority of Trusts are not consistently providing
compassionate,woman-centredcareforthoserequestingacaesarean.
The women we support have endured previously traumatic births, mental ill-health,
childhood sexual abuse, or have carefully examined the evidence available and made
informeddecisionsthatplannedcaesareanswillgivethemandtheirbabythebestchanceof
an emotionally and physically healthy birth and parenting journey. Their decision-making
processesanddesireforkindness,clarityandcontrolatatransformationalandvulnerable
timeintheirlivesarenodifferenttothoseofwomenwesupportastheytrytoaccesshome,
hospitalormidwife-ledbirths.
Positive birth experiences have repeatedly been shown to be promoted by positive
relationshipsbetweenawomanandhercareteamandafeelingofcontroloverdecisionsin
pregnancyandbirth.Birthrightsbelievesthatallwomendeserveunbiasedandpersonalised
pathwaysinmaternitycarealongsideevidence-basedinformationtoallowthemtomakethe
best decisions in their individual circumstances. It is clear that women requesting
caesareansmeet judgemental attitudes, barriers anddisrespectmoreoften than they Xind
compassionandsupport.Weareconcernedthatthislackofrespectforpatientdignitycould
haveprofoundnegativeconsequencesfortheemotionalandphysicalsafetyofwomen.
Wehopethatthisreport,andtheonlinemapthataccompaniesit,willintheshort-termgive
women information to help them choose amaternity care provider.Most importantly,we
want these results to act as a catalyst for transparency and consensus on this issue
encouraging national bodies, service-users groups, campaigners and clinicians to come
together to promote policy and guidelines onmaternal request caesarean birth that truly
meettheneedsofwomen.
RebeccaSchiller,ChiefExecutive,Birthrights
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Background Birthrights believes that human rights values have the power totransformmaternity care in theUK.Wereach thousandsofwomenandhealth care professionals through our advice and training, while ourresearch highlights the challenges and inequalities faced by women inmaternitycare.
Why did Birthrights undertake thisresearch?
Enquiriesaboutmaternalrequestcaesarean
are themostcommonreason forwomento
contacttheBirthrightsemailadviceservice.
A third of our enquiries are now on this
topic. Our advice service cases continue to
demonstrate that this groupofwomen face
considerable uncertainty about whether
their request will be listened to, and that
p ra c t i c e va r i e s b e tween Tr u s t s . 1
Furthermore, intelligence from our advice
line has highlighted a worrying trend
towards Trusts informing women on
booking into maternity care that the Trust
donotoffermaternalrequestcaesareanand
that this is causing women signiXicant
anxietyanddistress.
NICE Guideline CG132 (revised 2011) 2
states that women requesting a caesarean
with no other indication should be offered
appropriate discussion and support, but
ultimately, if they are making an informed
choice, a caesarean should be offered. The
guidelinealsostatesthatifanobstetricianis
unwilling to carry out a caesarean section
(CS) the woman should be referred to an
obstetricianwhowillcarryouttheCS.
Whilstitisnotalegalrequirementtofollow
NICEguidance,Trustsshouldbeabletogive
robust and evidence–based reasons for
divergingfromit.
The decision of the UK Supreme Court in
Montgomery v Lanarkshire Health Board
(2015) articulated the requirement for
healthcare professionals to have a twoway
dialogue with a pregnant woman that
explored all “reasonable alternatives”.
Birthrights are concerned that any
statement or policy from a Trust, that a
caesarean will only be granted on medical
grounds may be incompatible with Trusts’
obligationstohaveanopen,supportive,two-
waydiscussion that explores all reasonable
options. Ifsuchapolicy isthenappliedina
blanketway,we are further concerned that
such a policy could be incompatible with
humanrightslaw.
We therefore decided to send Freedom of
Information requests to every Clinical
CommissioningGroupinEnglandandevery
NHS Trust providing maternity services in
the UK between November 2017 and
January2018toXindout:
a) whethertheyhadawrittenguidelineon
maternalrequestcaesareansections
PleasenotethatwehavereferredtoTruststhroughoutthisreporttomeanTrustsinEnglandandNorthernIrelandand1
BoardsinScotlandandWales.
NationalInstituteofHealthandCareExcellence(NICE).2011.Caesareansectionclinicalguideline.(Availableathttps://2
www.nice.org.uk/guidance/cg132)
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b) whether this reXlected NICE guideline
CG132
c) the number of maternal request
caesareansbeingperformed.
We were interested to Xind out how far
policies on maternal request varied across
the country, and in particular whether the
practiceof informingwomenat the startof
their care that maternal request caesarean
would not be offered by the Trust was
widespread, and whether this policy was
being driven by commissioners or Trusts
themselves.
Whydowomenaskforacaesareansection?
The reasons for women requesting a
caesareanarenotalwayswellunderstood.
Our own analysis of our advice service
enquiries on this issue between November
2016 and May 2018 reveal that a third of
enquirers (33%)wantacaesareandue toa
previous traumatic birth. The second most
common reason (28%) for wanting a
caesarean birth is an underlying medical
condition such as symphysis pubis
dysfunction(SPD)-acommonproblemwith
thepelvisduringpregnancy-,vaginismusor
Xibroids. These conditions do not always
meetthethresholdofrequiringacaesarean
formedical reasonsbut the impactof these
conditions on the women affected is
signiXicant, and the thought of having their
conditionexacerbatedbyavaginalbirthcan
beacauseofhugeanxiety.
The remaining third is made up of women
whosimplybelieve it is therightoptionfor
them (16%), often after extensive research
into the evidence, or who have primary
tokophobia (8%) or who have experienced
other trauma in their lives such as sexual
assault(6%).10%didnotgivetheirreason
formakingthisrequest.
Although,thisanalysisisbasedonrelatively
small numbers (83 enquiries in total), it
paintsapictureofwomenwhoaredrivento
make this request by well thought out
reasonsorintensefears,andwhoknowthey
willoftenfaceanuphillbattletobelistened
to.
Understanding the barriers tocaesareansection
The additional physical health risks to a
womanorbabyareoftencitedasbarriersto
offering maternal request CS. Birthrights
believes that all woman should be enabled
t o m a k e i n f o r m e d a n d
individualised decisions about their
maternity care (including mode of birth).
These decisions should be based on
information that is balanced, based on the
latest available evidence and personalised.
Any signiXicant limitations of the evidence
shouldbeexplained.
We are concerned that many women we
support are not being made aware of the
quality of the evidence available, are not
presented with the full range of risks and
beneXits, and that women's own values,
needs and individual risk-factors are not
taken into consideration as part of the
decision-makingprocess.
Thisisparticularlyimportantbecause:
Thequalityofevidencearoundthisissue
is low. Most studies have used mixed
caesarean data (i.e. data from both
emergency caesareans and planned
caesareans) toreportonoutcomes.Reports
from women to our advice service suggest
thatmidwivesanddoctorscanappearover-
conXident in the outcomes drawn from this
data, and do not always explain the
limitationsoftheevidence.
Theavailableevidenceonoutcomesfrom
caesareanvsplannedvaginalbirthisnot
clear cut. A recent large scale systematic
reviewandmeta-analysisof“longtermrisks
and beneXits associated with cesarean,”
published in January2018quotedevidence
fromNICE to conclude that “the short-term
adverse associations of caesarean delivery
for the mother, such as infect ion ,
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hemorrhage, visceral injury, and venous
thromboembolism, have beenminimised to
the point that cesarean delivery is
considered as safe as vaginal delivery in
high-income countries”. Women need3
access to this information as well as the
legitimate concerns about the long-term
outcomesofcaesareanbirth for themother
andthebaby.Womenreporta tendency for
the known risks of caesarean to be
emphasised or exaggerated. The small but
signiXicant number of women who end up
with more serious injuries following a
vaginal birth often feel that they were not
in formed about those r i sks . More
transparency and unbiased presentation of
theevidenceanditslimitsisneeded.
TherisksandbeneFitsofvaginalbirthvs
caesareanbirthneedtobepersonalised.
ArecentstudybyRahmanouetalofSydney
University showed that the risk of pelvic
Xloordamagefromavaginalbirthincreased
byover6%witheachyearofmaternal age
at time of Xirst birth. If women are not4
planning to have any further children then
therisksofcaesareanforfuturepregnancies
are not relevant. Therefore a 42 year old
Xirst timemumpregnantwith her Xirst and
onlyexpectedchildmay faceadifferent set
ofrisksandbeneXits toa23yearold inher
Xirst pregnancy who hopes to have a large
family.
A woman brings her own values and
needs to this decision and may be
broader that purely clinical factors. And
an individual who has faced trauma in her
past may never disclose the reason for
wishingtohaveacaesareansection.
Women with complex social needs may
facemoresigniFicantbarrierswithin the
currentsystem.Womenwhofeeltheyneed
to comply (for a range of reasons such as
social services involvement), or who are
unable to advocate for themselves (for
examplewomenwhodon’tspeakEnglishas
aXirstlanguage,orhavelearningdifXiculties)
maybemorelikelytoagreetoproceedwith
a vaginal birth that feels unsafe to them,
eveniftheyarenotreconciledtoit.
Whatabouttherightsofhealthcareprofessionals?
One in four babies in the UK is born by
caesarean and obstetricians perform
caesareans on a daily basis. Nevertheless,
the NICE guideline is clear that any
individual obstetrician can decline to
undertake a maternal request caesarean
they do not feel comfortable with. It is
importantthatdoctorsareabletodeclineto
undertake maternal request caesareans
which they believe run contrary to their
Hippocraticoathto“donoharm”.
Weare conXident that the current guidance
protects doctors and have yet to be
contacted by any healthcare professionals
who feel pressured into performing a
maternal request caesarean.All thewritten
guidance we have been able to access
creates the impression that individual
obstetriciansarestronglysupportedintheir
righttodecline.
However,Birthrightshasbeencontactedby
healthcareprofessionalswhoareprevented
by their Trust from offering women the
personalised care they feel they should be
offering and are required to refer women
requesting a caesarean without a medical
reasonelsewhere.
In addition, we also know of obstetricians
who will support maternal request
caesarean even if their Trust policy is not
supportive. However we also know that in
thesecases it issometimesamatterof luck
KeagOE,NormanJE,StockSJ.2018.‘Long-termrisksandbeneXitsassociatedwithcesareandeliveryformother,baby,and3
subsequentpregnancies:Systematicreviewandmeta-analysis’.PLOSMedicine15(1):e1002494.(Availableat:http://
journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002494#pmed.1002494.ref004)
Rahmanou,P,Caudwell-Hall,J,KamisanAtan,I&Dietz,HP.2016.‘TheassociationbetweenmaternalageatXirstdeliveryand4
riskofobstetrictrauma’.AmericanJournalofObstetrics&Gynecology,215,451.e1-451.e7.(Availableathttps://www.ajog.org/
article/S0002-9378(16)30117-X/fulltext)
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as to whether women wanting a maternal
request caesarean are matched with
consultants who are prepared to support
thatrequest.
Whataboutthecost?
Theincreasedcostsofcaesareanstothe
NHSisfrequentlycitedasabarrierto
maternalrequestcaesarean.Howeverthe
economicmodellingsetoutinthefull
versionofthe2011updateoftheNICE
guidelineoncaesareansection foundthat,5
withouttakinganylongertermimpactsinto
account,acaesareancostaround£700more
thanavaginalbirth.Ifthecostsoftreating
urinaryincontinence(disregardingother
formsofdamagecausedbyvaginalbirth)
weretakenintoaccount,thecostdifference
wouldfallto£84perbirth.NICEjudgedthat
thiswasnotsigniXicantenoughtoinXluence
thedecision-makingprocess.
NationalCollaboratingCentreforWomen’sandChildren’sHealth.2011.CaesareansectionNovember2011NICEClinical5
Guideline.(Availableat:https://caesareanbirth.Xiles.wordpress.com/2017/01/2011-cg132-nice-caesarean-section-update-
full-version-guideline.pdf)
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How do MRCS policies make women feel?
“IdonotwantaLight,Iamsimplyananxiouswomanrequestingacaesareansectionandrequestingsomecertaintyaroundmysituation.”
“It is still so very sad that I cannot havemybabyatmy local hospital near tomyfamilyandsupportnetwork.IamalsoveryscaredaboutthejourneyandwhatwouldhappenshouldIgointoearlylabour."
"AtmyLirstscan,whichshouldhavebeenahappyoccasion, IwasLilledwithdreadwhenthetechniciansaidthebabywasgrowingwellasall IcouldthinkaboutwashowIwouldgivebirthtothisbabyandhowitwasgettinglargerwitheachdaythatpassedwithoutmyhavingsecuredthecaesarean"
“Ac-sectionisnotmyideaofanidealbirth;it’stheoptionthatILindleastterrifying,thelesseroftwoevils.”
"Ifeelthatmyconcernswerenotlistenedto,myknowledgeofSPDwithmyownbodyand theprevious traumamybodyhad sufferedalongwith the recovery timewereignored.Iwasmadetofeellikeanumberratherthanseenasanindividual."
Summary of
results
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What did our research tell us?
Wewroteto206CCGsandwereceived187responses–aresponserateof91%.
Wewroteto153Trustsprovidingmaternitycareandreceived148responses–a97%responserate. ThissurveythereforerepresentsacomprehensivesnapshotofTrustpoliciesonmaternalrequestcaesareansection.
26%
47%
15%
Trusts that offering MRCS in line with NICE guidance
TrustspartiallyofferingorofferingMRCSwithconcerns
Trusts that do not offer MRCS
11% Trusts that did not provide enough information to be
categorised
Visitbirthrights.org.uktoseeamapshowingtheratingforeveryTrust.
Pleasenotethatduetoroundingthesepercentagesaddupto99ratherthan
100%
Analysis Trusts
We asked every Trust offering maternity
servicesintheUKtotellus:
• h ow m a ny m a t e r n a l r e q u e s t
caesareans they carried out between
April 2016 and April 2017 with no
other signiXicant medical, obstetric or
psychologicalindication;
• toprovideuswithanyTrustguidelines,
staff guidelines or patient information
leaXletsonMRCS;
• to explain how they complied with
NICECG1321.2.9.5.
Outofthe147responseswereceivedwe
concludedthat39Trusts(26%)offer
MRCS.
TheseTrustsarecommittedtothespiritof
theNICEguidance(atleastonpaper).They
hadawrittenpolicythatmadeclearthat,if
appropriatesupporthasbeenofferedanda
womanismakinganinformeddecision,
basedonanunderstandingoftherisksand
beneXitsofalloptions,thattheywilloffer
maternalrequestcaesarean.Ifanindividual
obstetricianisnotcomfortablewithcarrying
outthesurgerytheywillrefertoacolleague
who“will”carryoutthecaesareansection
withintheirownTrust(orinonecase
“seekinginput”fromoutsidetheTrust).
Truststhatlookedafterover2,000women
thathadcarriedoutnoMRCSintheyear
datawasrequestedfor,wereexcludedfrom
thiscategoryeveniftheirpolicyappearedto
supportit.
70 Trusts (47%) partially offer or offer
MRCS with concerns
ThiscategoryincludesTrustswherewe
couldnotbesurewhetherawomanwould
ultimatelybeofferedacaesareansectionif
shewantedone.WedeXinedthistoinclude:
• Trusts that said they offerMRCS but had
nowrittenguideline.Werecognisethereis
no requirement to have a written
guideline but feel this indicates a
thoughtfulandconsistentapproachtothe
issue
• TrustswhosaidtheyofferedMRCSbut
hadcarriedoutnonebetweenApril2016
andApril2017(iftheTrusthadover2000
birthsperyear)
• Truststhathadapolicytorequesta
secondopinionbutitwasunclearwhat
wouldhappenifthesecondopinionwasa
“no”
• Truststhatalwaysrequiredthe
permissionoftwoconsultants(10Trusts
intotal)
• Truststhatmentionedreferringwomento
anotherhospitalaspartoftheirprocess
• Truststhatseemedtohaveanincomplete
guideline(forexamplewherethe
guidelineonlydealtwithmaternalrequest
caesareansectionstemmingfromamental
healthissue),
• Truststhatsuggestedthatacompulsory
mentalhealthappointmentwasrequired
fortheCStobeoffered,
• Trustswherethepolicywasnottomakea
decisionuntilafter36weeks,
• TrustswheretheCSwouldnotbe
scheduleduntilafter40weeks
• Trustswherewehadanyotherconcern
aboutthepolicy/processdescribed.
AnumberofTrustsinthiscategorygavea
combinationofthereasonsabove.This
categorycoversalargerangeofTrustsfrom
thosewhichseemedtohaveavery
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supportiveprocessbutnowrittenpolicy,to
thosewhowereveryclosetobeing
categorisedasnotofferingmaternalrequest
caesarean.
22 Trusts (15%) do not offer MRCS
ThisincludesallTruststhathadanexplicitly
statedpolicynottoofferMRCS.Someof
theseTrustsdidgoontoexplainthatthey
mightbeofferedinexceptionalcases.This
categoryalsoincludesTrusts(overseeing
morethan2000birthsayear)whodidnot
clearlystatewhethertheyoffermaternal
requestCSbutwherethenumberofMRCSs
carriedoutwaszero.Wehaveincluded
Trustsinthiscategorythattoldustheydid
offermaternalrequestCSwhilealsosending
usinformationtheygavetowomenwhich
directlycontradictedthis.
17 Trusts (11%) unknown
ThiscategorycoversthoseTruststhatdid
notprovideenoughinformationtobe
categorised.
WewrotetoallClinicalCommissioning
GroupsinEnglandandaskedthemto:
• advise how many maternal request
caesarean sections with no obstetric,
medical or signiXicant psychological
reason were paid for by the CCG
betweenApril2016andApril2017.
• advise how many maternal request
caesarean sections carried out
primarily for a psychological reason
werepaidforbytheCCGbetweenApril
2016andApril2017
• advise on any guidance, policies or
contractualagreementstheCCGhadin
place with Trusts setting out in what
circumstances the CCG would pay for
maternalrequestcaesareans.
Pressurefromcommissioners(Clinical
CommissioningGroups(CCGs))seemsto
haveaninXluenceonTrustpoliciesinsome
areasalthoughthisfactoralonedoesnot
explaintheresults.
Wefound26CCGsoutof206(13%)in
EnglandwhoweidentiXiedasnotbeing
supportiveofmaternalrequestcaesarean.
ThesixClinicalCommissioningGroups
basedinSouthEastLondon(Bexley,
Bromley,Greenwich,Lewisham,Lambeth
andSouthwark)haveashared“Treatment
AccessPolicy”whichstatesthat:“Caesarean
sectionisonlyavailableforclinical
reasons.ElectiveCaesareansectionfor
nonclinicalreasons,includingmaternal
request,willnotbefundedontheNHS
unlesspriorapprovalhasbeenobtained.
Suchapprovalwillonlybegrantedif
suchanelectivecaesareansectionis
justiXiedusingrecentlypublishedNICE
guidelines.Applicantswillhaveto
documentcarefullyhowthecasefulXils
thoseguidelines."Acertainamountof
ambiguityovertheNICEguidelinesis
demonstratedhere,astheNICEguidelines
suggestthatmaternalrequestcaesareans
shouldbefundedbytheNHSaslongas
appropriatediscussionandsupporthave
beenoffered.TrustsinSouthEastLondon
haveallbeenclassiXiedas“red”(apartfrom
KingsCollegeHospitalNHSFoundation
Trustwhohaverecentlyupdatedtheir
policyinlightoftheLondon-wide
tokophobiatoolkit).
InadditionweareawareofaclusterofCCGs
aroundtheThamesValleywhoarenot
supportiveofmaternalrequestcaesarean.
TheClinicalCommissioningGroups,whose
mainprovideristheRoyalBerkshire
(Newbury&District,SouthReading
andWokingham),appeartosupportthe
RoyalBerkshire’spolicyofreferringany
womanmakingthisrequesttoother
providersandstatethisisinlinewithNICE
guidance.ChilternCCGalsoappears
tosupportthepolicyofitsmainprovider
(BuckinghamshireHealthcareNHSTrust)of
encouragingwomentogoelsewhereor
exploreprivateoptions.SwindonCCGstates
thatitspolicyistopromotenaturalbirth
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andstatesthatmaternalrequestcaesarean
willonlybefundedforapsychological
reasoniftwoconsultantsagree.
TheDerbyshireClinicalCommissioning
Groups(Erewash,Hardwick,North
DerbyshireandSouthDerbyshire)are
governedbyaDerbyshire-widepolicyon
proceduresoflowclinicalvaluewhich
includesmaternalrequestcaesareanasan
interventionthatwillnotberoutinely
commissioned.
ThereisafurthergroupofCCGs(Cannock
Chase,StaffordandSurrounds,SouthEast
StaffordshireandSeisdon,EastStaffordshire
andWolverhampton)whichalsosharea
policywhichlistswhencaesareanswillbe
funded.Thelistdoesnotincludematernal
requestasareasonwhichimpliesthiswould
havetobefundedviaanindividualfunding
request.
OtherCCGscategorisedas
beingunsupportivewereDartford,
GraveshamandSwanley,Hull,Kernow,
MertonandNorthWestSurrey.
TelfordCCGhasrecentlychanged
theirpolicytonotroutinelycommissioning
maternalrequestcaesarean.
AnumberofCCGswhogaveanunclear
answeraboutcaesareansneedingtobe
clinicallyappropriateinlinewithNICE
guidelineshavebeengiventhebeneXitofthe
doubtinouranalysis.Webelievethatthe
numberofunsupportiveCCGsmaywellbe
higherthan26.
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What does a good maternal request caesarean
guideline look like?
BirminghamWomen’sHospitalco-designedtheirpathwaywithwomen.Duringthisprocess they learnt thatwomen’sandhealthcareprofessionals’ concernsabout theexistingpathwaywereactuallyverysimilar.Theseconcernsincluded:womenhavingto discuss the request a number of times, a delay in the decision for caesarean,women feeling judged,andconcernsabout thequalityof informationwomenwerebeinggiven.
Researchers helped clinicians and service users to design a new pathway usingexperienced-based co-design. As a result BWH’s guideline uses language thatrecognisesthewomanastheleaddecisionmaker,suchas“Ifawomanhasdecidedon CS” and “at every appointment re-conLirm (not challenge) decision”. It isrespectfultothewoman’sdecision-makingprocessandtacklesthetopicthoroughly.The guidance is also transparent about the low quality of the evidence on thissubject.
Asaresultofthispathwaywomenwillhavemadeadecisionwiththeclinicalteamby24-28weekswhichallowsher toenjoy the restof theirpregnancyknowing shehas been listened to. We felt this document was one of the best examples of amaternalrequestcaesareanguideline.
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A healthcare professional’s perspective
SimonMehigan,aBirthrights’Trustees,andnowDirectorofMidwiferyatPennineAcuteHospitalsNHSTrust,usedtorunaclinicinalargeteachinghospitalforallwomenrequestingcaesareansfornoperceivedmedicalreason.
Overthecourseof3years,Simonsawover500women.Simonveryquickly
foundthatreassuringwomenveryearlyonthattheirrequestforacaesarean
wouldbehonouredifthat’swhattheywanted,ledtoamuchmoreopen
conversationaboutpossibleoptions.AcoupleofwomeninformedSimonthat
beingtold“no”byconsultantshadmadethemmoredeterminedtohavea
caesareansectionbecausetheywerenotpreparedtoletsomeoneelsemake
decisionsabouttheirbirth.
Ade-briefofawoman’slastbirthwasoftenhelpful,inopeningupthe
possibilitythatthingscouldbedifferentthistimeround.Howeverwomenwere
morelikelytobeopentootheroptionsearlyonintheirpregnancyandSimon
foundthatthelatertheseconversationswereheld,thelessopenwomenwere
todiscussingalternativeoptions.Simonalsofoundthatonceadecisionhad
beenmadealinehadtobedrawnaswomenfounditverystressfultohaveto
revisitthatdecisioneverytimetheysawahealthcareprofessional.
AftermeetingSimon,85%ofwomenoptedtohaveavaginalbirthoftheirown
accordand70%ofthosewomenhadavaginalbirth.Theplansofcarethat
Simonputinplaceoftenfocusedonhavinganuncomplicatedbirthwithalow
thresholdforcaesarean.Howeversomewomensimplyfeltacaesareanbirth
wasrightforthemandcouldallexplainrationallywhytheywantedtobirth
theirbabiesthatway:
“Inover20yearsasamidwifeIhaveyettomeetawomanthathasmade
irrationaldecisionsorchoices.Theyhavealwaysbeentherightchoiceforthat
womenbasedonherindividualcircumstances.”
Call to action Birthrights would like to see:
Everytrustembracingthehumanrightsprinciplethateverywomanhastherighttomakeaninformedchoiceoverwhathappenstoherbodyduringpregnancyandbirth.
ToomanyTrustshaveapolicythatdoesnot
recognisethewomenastheprimary
decisionmakerinbirth.Theroleof
healthcareprofessionalsistoensurethata
womanhasalltheinformationandsupport
sheneedstomakeaninformeddecision,and
thentosupportthatchoice.
Themostimportantprincipleunderpinning
section1.2.9ofNICEguidelineCG132isthat
awomanmustleaddecisionsabouthowshe
givesbirth.Thisprincipleshouldbe
threadedthrougheverymaternitypolicy
andguideline,includingthoseonmaternal
requestcaesarean.Theguidelineconcludes
thatmaternalrequestcaesareanitisa
reasonableoptiontoofferwomentaking
intoaccountboththebeneXitsandrisksand
thecostoftheintervention.Whilsttheright
ofindividualdoctorstodeclineisprotected,
theydonothavetherighttopreventwomen
frommakingthatdecision.Norshoulda
decision-makingprocessaddunnecessary
andlengthyperiodsofanxietytoa
pregnancy.
BirthrightsbelievesthatpublicconXirmation
fromNHSEnglandthatchoiceinmaternity
careincludestheinformedchoiceof
maternalrequestcaesareanwouldbean
importantstepforwards.
UrgentclariLicationfromNICEthatlargerNHSTrustsreferringwomentoanotherNHSTrusttoaccessMRCSarenotcomplyingwithguidelineCG132
Public clariXication from NICE around
transferring women to other Trusts is
needed.
There are a small number of Trusts who
believe they are complying with the NICE
guidelineonmaternalrequestcaesareanby
referring women to another Trust. We do
not believe this is the case. Minutes of the
Guidance ExecutiveMeeting on 11 October
2011, supplied tousbyNICE, describeBen
Doak, Guidelines Commissioning Manager,
explaining that the new guidelines meant
that “if an obstetrician was uncomfortable
with this decision, then another NHS
obstetrician within the same unit will be
asked to carry out the caesarean section”.
NICEhaveinformedusthatatasubsequent
meeting (minutes not available) that the
wording“inthesameunit”was loosenedin
response to concerns about whether this
was feasible for small Trusts, although the
intention remained the same.WhereTrusts
are really too small to genuinely offer an
option to refer to a supportive consultant
within the same Trust, pathways to
consultants in other hospitals should be
agreed,andwomennot just left tonavigate
on theirown,but for themajorityofTrusts
referral to other Trusts should not be
necessary. We are not aware of any Trust
withapolicyofreferringwomenelsewhere
thathascarriedoutaproperassessmentof
theimpactonwomenofsuchapolicy,which
weknowhasahuge impactonwomenand
their families trying to juggle jobs, other
children, interactions with other medical
specialities etc. We would welcome
clariXicationfromNICEonthisissue.
Furthermore“Maternalrequestonitsownis
notanindicationforcaesareansection”was
aphrasefoundinanumberofpolicies,often
followedbythewordinginthecurrentNICE
GuidelineCG132.Infactthisphraseistaken
from the2004guideline (CG13nowoutof
date) and is at odds with the revised
guideline (CG132), which implies that if
womenaremakinganinformedchoice,then
maternal request is on its own is an
indication forcaesarean.Again, clariXication
andraisingawarenessthatthisphraseisno
longer part of theNICE guidancewould be
helpful.
�13
Abetterunderstandingofthediversereasonswomenaskformaternalrequestcaesarean
Our Freedom of Information campaign
revealedthatmanyTrustshadapathwayin
place for dealing with anxiety and/or
tokophobia. The pan-London tokophobia
toolkit published in January 2018 is a
welcome additional resource on this
subject. However some Trust policies on6
maternal request caesarean appear to be
based on the assumption that all maternal
request caesareans aremotivated by a fear
of childbirth, as opposed to a rational
readingoftheevidenceandhowtheyapply
toanindividual’scircumstances,orconcern
as to the impactonanotherphysicalhealth
condition, for example. Some women have
told us that they are surprised and
concerned to be treated as if they have a
mental health issue, if this is not what is
drivingtheirrequest.
Furthermore, while a debrief of a previous
birth isoftenhelpful, forwomenwithpost-
traumatic stress disorder following aprevious traumatic birth, interventions that
focus on re-living the birth risks further
traumatisation.Somewomenwithahistory
of traumamay not feel able to disclose the
reason for their request, despite those
reasons being compelling. Therefore a one-
size-Xits-all pathway is not appropriate for
maternalrequestcaesarean.
The vision of individualised care set out in
"BetterBirths" ,"SaferMaternityCare" and7 8
otherpolicydocuments isessentialhere,as
is more research and debate about best-
practice.
Unbiased,evidence-basedandup-to-dateinformationforwomen
WewelcomethecommitmentfromRCOGto
review their patient information leaXlet on
maternalrequestcaesarean.
Women need balanced information that
differentiates between risks of planning a
caesarean birth to a woman and her baby
compared to a planned vaginal birth and
also explains what is known about longer
termoutcomesforbothmothersandbabies
foreachmodeofbirth.
Healthcare professionals need to be
transparent with women about the
differences in how this information applies
to different individuals and about the
limitationsoftheevidenceavailable.
Pathwaysthatareco-producedbywomenandhealthcareprofessionals,sothattheyfeelsupportivetowomenratherthanheighteninganxiety.
Trusts such as Birmingham Women’s have
already shown the way in terms of co-
designingapathwaythattakesintoaccount
the needs of both women and healthcare
professionals. Many other Trusts offer
individualisedcareplanning.Weurgeother
Truststofollowtheirexampleandtoensure
service-user involvement includes the
experiences and voices of women with
complexhealthandsocialcircumstancesvia
MaternityVoicesPartnerships.
AnagreednationwidemethodtocategoriseandrecordmaternalrequestcaesareansconsistentlyineveryNHSTrust’smaternitystatistics.
Pan-LondonPerinatalMentalHealthNetworks.2018.FearofChildbirth(Tokophobia)andTraumaticExperienceof6
Childbirth:BestPracticeToolkit.(Availableathttps://www.healthylondon.org/wp-content/uploads/2018/01/Tokophobia-
best-practice-toolkit-Jan-2018.pdf)
TheNationalMaternityReview.2016.BetterBirthsImprovingoutcomesofmaternityservicesinEnglandAFiveYearForward7
Viewformaternitycare.(Availableathttps://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-
review-report.pdf)
TheDepartmentofHealth.2017.SaferMaternityCare.TheNationalMaternitySafetyStrategy-ProgressandNextSteps.8
(Availableathttps://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/Xile/662969/
Safer_maternity_care_-_progress_and_next_steps.pdf)
�14
Without agreed deXinitions of maternal
request caesareans and no comparable
national data it is difXicult to develop an
accurate understanding of numbers and
hard to develop a better evidence-base on
theshortandlonger-termoutcomesinthese
births.Wehope thatNHSEnglandwill take
up this issue as it reviews national data
collection.
NextstepsTheseFOIresultsareaclearindictmentof
thepostcodelotteryfacingwomenintheUK
who,forawiderangeofreasons,feela
caesareanbirthisrightforthem.Wehope
thattheyprovideatransparencythathas
hithertobeenmissingaroundthe
differencesinpoliciesandprocesses
betweenTrustsatthismomentintime.
Thereisstillworktodotoexplainthis
divergenceandanationaldebatetobehad
aboutthelevelofevidenceavailable,what
bestpracticelookslike,andhowtotake
forwardthecallstoactionidentiXiedinthis
report.
WearecommittedtoworkingwithNHS
England,TheRoyalCollegeofObstetricians
andGynaecologists,theRoyalCollegeof
Midwives,ClinicalCommissioningGroups,
LocalMaternitySystems,Trusts/Boards,
userrepresentativesandother
organisationswithaninterestusingall
availablelegalandpolicyoptionsavailable
tomakeprogressonthisissueandtoensure
thatallpregnantwomenwantingamaternal
requestcaesareangettherespectful
treatmenttheydeserve.
Birthrights,August2018
�15
Annex 1:
Trust
categories How did Birthrights categoriseTrusts?
When categorising Trusts we largely relied
on the response and guidelines provided.
When certain elements on the response
wereunclearwe tookaholisticviewof the
toneandwordingofalldocumentssupplied
indecidingonacategory.
However, only Trusts with a written
guideline on maternal request caesarean
havebeen classiXied as “green”.We felt that
this provided some evidence to an ongoing
service-wide consistent approach on
maternalrequestcaesarean.
For Trusts of a reasonable size (over 2000
births) who said they offered maternal
request caesarean, or weren’t clear about
whethertheyofferedthemornotbuttoldus
that they didn’t perform any betweenApril
2016 and April 2016 then the zero Xigure
providedhasbeentakenintoaccountwhen
decidingonthecategory.
AlltheinformationprovidedtousbyTrusts
hasbeenmadeavailableonourwebsitevia
our interactivemap so that individuals can
make up their own mind about the
responses, as well as being guided by our
analysis.
Whatdoesthismeaninpractice?
This means that a Trust like Liverpool
Women’s which seem to have a very good
pathwayformaternalrequestcaesareanbut
has no formal written guideline that
references its approach has been classiXied
asanamber.
SimilarlythePrincessAlexandraHospital in
Harlow,Essexwouldhavebeen categorised
“green” based on the policies supplied, but
also said that it carried out zero MRCS
between April 2016 and April 2017. It has
thereforebeencategorisedasanamber.
Gloucestershire, Ashford and St Peters and
County Durham and Darlington have all
been categorised as “green” despite using
the phrase “maternal request caesarean is
not on its ownan indication for caesarean”
because they all went on to quote the
revised NICE guideline (CG132) process in
full includinghavingawritten commitment
to ensuring women were referred to an
obstetricianwho“will”carryouttheCS.
WhydidBirthrightsnot take intoaccount the number of maternalrequest caesareansperformedbyTrusts?
Only 61% of Trusts (91) that responded
were able to provide a Xigure of howmany
materna l reques t caesareans they
performed. Many of these Trusts have said
that they are not sure their Xigure was
reliable. Trustsnot supplying a Xigureoften
said that they would need to go through
individual records manually to supply a
Xigure.
We do not believe that maternal request
caesareansarerecordedinaconsistentway
acrossTrustsandthereforewehavechosen
not to rely on these Xigures to inform our
analysiswith theexceptionofwhereTrusts
have said they perform zero maternal
requestcaesareans.
Were Trusts who said theyf o l l owed N I C E g u i d e l i n e sautomatically categorised asgreen?
No. The NICE guideline seemedmore open
to interpretation that we had anticipated.
Most Trusts said they complied with NICE,
eventhosewecategorisedasred,andwere
referring women making this request to
other Trusts. Therefore Trusts needed to
explain their understanding of NICE and
what pathway they followed, however
concisely in order for us to analyse their
response. Trusts that demonstrated an
understanding of, and commitment to, the
revisedNICE guidelinewere categorised as
green(unlesstheyhadover2000birthsand
�16
carried out zeroMRCS). Trusts that simply
said they followed NICE and nothing else
werecategorisedas“unknown”.
Why were Trusts categorised asamber?
39Trustsofthe70Trustsinthiscategory
didnotshowaclearcommitmentto
ensuringawomanwoulddeXinitelygeta
caesareanifshecontinuedtowantone.
ManyTrustsdidnotspecifywhatwould
happenbeyondasecondopinion.For
exampleBarnsley’spolicystates“inallcases
theConsultantretainstherighttodeclineto
performacaesareansectionwithnoclinical
indication.IfthisisthecasetheConsultant
Obstetricianwilleitherreferthewomantoa
Consultantcolleagueforasecondopinionor
referthewomanbacktoherGeneral
Practitionertoarrangereferraltoanother
hospitalforasecondopinion.”
10Trustsinthiscategoryrequiredthe
permissionoftwoconsultantsorhadan
otherwiseburdensome/resourceintensive
processinorderforamaternalrequest
caesareantobearranged,regardlessof
whetherthiswaswantedbythewomanor
whetheritwasappropriatetohersituation.
ForexampleEastandNorthHertsrequirea
womantobecounselledbytwo
obstetriciansandbereviewedbythe
consultantmidwife.
2Trusts(BedfordandMiltonKeynes)would
onlyscheduleamaternalrequestcaesarean
forafter40weeks(NICEguidelinessuggest
aplannedcaesareanshouldbescheduledfor
after39weeks).
AnumberofTrustssuchasCityHospitals
Sunderland,HywelDa,Imperialand
UniversityHospitalsofBristolapproachthis
requestasbeingdrivenbyamentalhealth
issue.Itisnotclearwhathappenswhenthe
requestismadeforanotherreason.
Ipswich’spolicysuggestsamaternalrequest
caesareanwillonlybegrantedafterthe
womanhasbeenseenbyanappropriate
healthcareprofessionalsuchasa
psychologistorpsychiatrist.
OtheramberTrustssuchasBrightonand
SussexandShrewsburyandTelfordhadvery
sketchypoliciesandwereclosetobeing
categorisedasunknownorred.CCGsDid
youtellTrustshowtheyweregoingtobe
categorisedbeforepublication?
Yes,wenotiXiedallTrustsofourintentionto
publish their results and their individual
category,andgaveallTruststheopportunity
to respond. A number of Trusts were re-
categorisedasaresult.
Are all Trusts now happy withtheirresult?
We have applied our criteria consistently
across all Trusts but this does mean that
there are some edge cases that could be
regardedasanomalous.
For example, the Royal Free in London has
beencategorisedasredbecausetheyhavea
policy that states, “The RFL promotes a
philosophy of no unnecessary intervention.
It is not the policy of the RFL maternity
services to perform caesarean sections at
maternal request”.Furthermore theirpolicy
alsostatedthatwomenmustbeseenbythe
Birth Options clinic before a caesarean can
be booked. However the Royal Free clearly
doeshaveapathway formakingexceptions
to this “policy” in some cases which is not
thecase forall “red”Trusts.TheRoyalFree
London h a s d i s pu ted t h e i r “ red ”
categorisation on the basis that they have
carriedout209intheyearforwhichXigures
were requested.Howeverasalreadystated,
wedonotfeeltheXiguresprovidedbyTrusts
areconsistentenoughtobereliedupon,and
we believe our categorisation of the Royal
Free is defensible based on its own stated
policy.
The University Hospitals of Leicester NHS
Trust has also challenged its “red”
categorisationandhassaidthatitdoesoffer
this option and defended its Xigure of zero
maternal request caesareans as being
reXlective of a genuinely zero number of
requests.AstheTrusthasover11,000births
ayearwehavekept thisTrustasareddue
to the lackof clarityover itspolicyand the
zeroXigureprovided.Howeverwerecognise
�17
that this may reXlect a genuine difference
between how Trusts record a maternal
request caesarean, or genuine local
differencesinnumbersofrequests.
MedwayNHSTrustaskedustochangetheir
categorisation from green to amber on the
grounds that they sometimes refuse
requests for caesarean section, which we
havedone.
Did you take into accountintelligence from your adviceserviceinyouranalysis?
No.Wedidnotfeelthiswouldbefairaswe
donotgetarepresentativesampleofadvice
serviceenquiriesacrossallTrustsorenough
to be representative of an individual Trust.
Therefore, we have only judged Trusts on
theinformationtheyprovidedandnottaken
intoaccountotherintelligencewemayhave
about a Trust. However we are aware of
incidences from our advice service where
womenreceivingcarefromTrusts,including
“green” Trusts have not had treated in
accordance with the policy we have been
sent.Forexample,wehaverecentlywritten
toMid-Essex, to ask them to explain a case
inwhichtheir“green”policywasclearlynot
followedandhaveyettoreceivearesponse.
�18
Annex 2:
Oxford
�19
The position at Oxford University NHS Foundation Trust
and Oxfordshire CCG
On 27th July 2018 lawyers acting for Birthrights wrote to Oxford UniversityHospitals NHS Trust and Oxfordshire Clinical Commissioning Group asking forfurtherinformationaboutthepolicyinplaceattheJohnRadcliffehospitalnottooffermaternalrequestcaesareans.Asimilarpolicyisalsoadoptedbyanumberofsurrounding Trusts which leaves women around Oxford with very little choiceovertheirmodeofbirth.
AsstatedinthisreportBirthrightsisconcernedthatanystatementorpolicyfroma Trust, that caesarean would only be granted on medical grounds may beincompatible with Trusts’ obligations to have an open, supportive, two-waydiscussionthatexploresallreasonableoptions.Andifsuchapolicyisthenappliedin a blanket way, we are further concerned that such a policy could beincompatible with human rights law. Following signiXicant numbers of adviceservice enquiries concerning MRCS in the Oxford area, and a chain ofcorrespondencewiththeTrustandCCG(allpublishedlettersareavailableontheBirthrightswebsite)wehavetakenlegaladvicewhichindicatesthatourconcernsmaybewellfounded.
Local MP Anneliese Dodds has also written to both the Trust and the CCGexpressingconcernaboutthispolicyandtheimpactitishavingonwomen.
Asof17thAugustweawait theTrust’s replyhaving receivedaholding replyon14th August alerting us that the Trust will respond “in the immediate future”havingmissed their reply deadline of 10th August. In a letter dated 8th August2018,lawyersactingfortheOxfordshireClinicalCommissioningGroupconXirmedthattheirclient“hasnopolicyorrecommendationnottofundwomenrequestingaCaesareanSectiononnon-clinicalgrounds.”BirthrightslegalteamisscrutinisingtheCCG’sresponse.
WehavemadetheTrustandCCGawarethatwehopetoresolvethisissuewithoutlitigation and we hope that Oxford University Hospitals NHS Trust and itscommissionerswillworkwithusconstructivelytochangetheirpolicy.Otherwisewewilllooktoexplorealloptions,includingjudicialreview,toensurethatwomenlivinginOxfordgettherespectfulcaretheydeserveandthatthelawobligestheircaregiverstoprovide.
Annex 3: List
of Trusts Trusts offering MRCS
• AshfordAndStPeter’sHospitalsNHS
FoundationTrust
• BirminghamWomen’sNHSFoundation
Trust
• BoltonNHSFoundationTrust
• CambridgeUniversityHospitalsNHS
FoundationTrust
• ManchesterUniversityHospitalsNHS
FoundationTrust
• ChelseaAndWestminsterHospitalNHS
FoundationTrust
• ColchesterHospitalUniversityNHS
FoundationTrust
• CountessOfChesterHospitalNHS
FoundationTrust
• CountyDurhamAndDarlingtonNHS
FoundationTrust
• DumfriesandGalloway
• EastCheshireNHSTrust
• EastSussexHealthcareNHSTrust
• EpsomAndStHelierUniversity
HospitalsNHSTrust
• GloucestershireHospitalsNHS
FoundationTrust
• HeartofEnglandNHSFoundationTrust
• HomertonUniversityHospitalNHS
FoundationTrust
• Lothian(Scotland)
• MaidstoneandTunbridgeWellsNHS
Trust
• MidCheshireHospitalsNHSFoundation
Trust
• MidEssexHospitalServicesNHSTrust
• MidYorkshireHospitalsNHSTrust
• NorthBristolNHSTrust
• NorthernDevonHealthcareNHSTrust
• NorthernLincolnshireAndGoole
HospitalsNHSFoundationTrust
• NottinghamUniversityHospitalsNHS
Trust
• PennineAcuteHospitalsNHSTrust
• RoyalSurreyCountyHospitalNHS
FoundationTrust
• ShefXieldTeachingHospitalsNHS
FoundationTrust
• SouthEasternHealthandSocialCare
Trust
• SouthTynesideNHSFoundationTrust
• StGeorge`sHealthcareNHSTrust
• StHelensandKnowsleyHospitalsNHS
Trust
• TamesideHospitalNHSFoundation
Trust
• TheDudleyGroupNHSFoundation
Trust
• TheRotherhamNHSFoundationTrust
• UniversityHospitalsCoventryAnd
WarwickshireNHSTrust
• WalsallHealthcareNHSTrust
• WrightingtonWiganAndLeighNHS
FoundationTrust
• WyeValleyNHSTrust
TruststhatpartiallyofferorofferMRCSwithconcerns
• AiredaleNHSFoundationTrust
• AyrshireandArran(Scotland)
• BarnsleyHospitalNHSFoundationTrust
• BartsHealthNHSTrust
• BasildonAndThurrockUniversity
HospitalsNHSFoundationTrust
• BedfordHospitalNHSTrust
• BelfastHealthandSocialCareTrust
• BlackpoolTeachingHospitalsNHS
FoundationTrust
• Borders(Scotland)
• BradfordTeachingHospitalsNHS
FoundationTrust
• BrightonAndSussexUniversity
HospitalsNHSTrust
• CalderdaleAndHuddersXieldNHS
FoundationTrust
• Cardiff&ValeUniversityLocalHealth
Board
• CityHospitalsSunderlandNHS
FoundationTrust
• CwmTafLocalHealthBoard
�20
• DoncasterAndBassetlawHospitalsNHS
FoundationTrust
• DorsetCountyHospitalNHSFoundation
Trust
• EastAndNorthHertfordshireNHSTrust
• EastKentHospitalsUniversityNHS
FoundationTrust
• EastLancashireHospitalsNHSTrust
• Fife(Scotland)
• ForthValley(Scotland)
• FrimleyParkHospitalNHSFoundation
Trust,(includesWexhamPark)
• GatesheadHealthNHSFoundationTrust
• Grampian(Scotland)
• GreaterGlasgowandClyde(Scotland)
• HampshireHospitalsNHSFoundation
Trust
• Highland(Scotland)
• NorthWestAngliaNHSFoundation
Trust
• HywelDdaLocalHealthBoard
• ImperialCollegeHealthcareNHSTrust
• IpswichHospitalNHSTrust
• IsleofWightNHSTrust
• KetteringGeneralHospitalNHS
FoundationTrust
• King’sCollegeHospitalNHSFoundation
Trust
• KingstonHospitalNHSTrust
• Lanarkshire
• LancashireTeachingHospitalsNHS
FoundationTrust
• LeedsTeachingHospitalsNHSTrust
• LiverpoolWomen`sNHSFoundation
Trust
• LutonAndDunstableHospitalNHS
FoundationTrust
• MedwayNHSFoundationTrust
• MiltonKeynesHospitalNHSFoundation
Trust
• NorthCumbriaUniversityHospitals
NHSTrust
• NorthamptonGeneralHospitalNHS
Trust
• NorthumbriaHealthcareNHS
FoundationTrust
• RoyalCornwallHospitalsNHSTrust
• SherwoodForestHospitalsNHS
FoundationTrust
• ShrewsburyAndTelfordHospitalNHS
Trust
• TorbayandSouthDevonNHS
FoundationTrust
• SouthTeesHospitalsNHSFoundation
Trust
• SouthportAndOrmskirkHospitalNHS
Trust
• StockportNHSFoundationTrust
• Tayside(Scotland)
• TheHillingdonHospitalsNHS
FoundationTrust
• TheNewcastleUponTyneHospitals
NHSFoundationTrust
• ThePrincessAlexandraHospitalNHS
Trust
• TheRoyalWolverhamptonNHSTrust
• TheWhittingtonHospitalNHSTrust
• UniversityCollegeLondonHospitals
NHSFoundationTrust
• UniversityHospitalsofNorthMidlands
NHSTrust
• UniversityHospitalSouthamptonNHS
FoundationTrust
• UniversityHospitalsBristolNHS
FoundationTrust
• WarringtonAndHaltonHospitalsNHS
FoundationTrust
• WesternHealthandSocialCareTrust
• WesternSussexHospitalsNHSTrust
• WirralUniversityTeachingHospital
NHSFoundationTrust
• WorcestershireAcuteHospitalsNHS
Trust
• YeovilDistrictHospitalNHSFoundation
Trust
• RoyalUnitedHospitalsBathNHS
FoundationTrust
TruststhatdonotofferMRCS• BarkingHaveringandRedbridge
UniversityHospitalsNHSTrust
• RoyalFreeLondonNHSFoundation
Trust
• BuckinghamshireHealthcareNHSTrust
• BurtonHospitals
NHSFoundation
�21
©Birthrights2018
Trust
• DerbyHospitalsNHSFoundationTrust
• GeorgeEliotHospitalNHSTrust
• GreatWesternHospitalsNHS
FoundationTrust
• Guy’sAndStThomas’NHSFoundation
Trust
• HarrogateAndDistrictNHSFoundation
Trust
• HullAndEastYorkshireHospitalsNHS
Trust
• LewishamandGreenwichNHSTrust
• NorthWestLondonHospitalsNHS
Trust
• OxfordUniversityHospitalsNHSTrust
• PooleHospitalNHSFoundationTrust
• PortsmouthHospitalsNHSTrust
• RoyalBerkshireNHSFoundationTrust
• SalisburyNHSFoundationTrust
• SandwellAndWestBirmingham
HospitalsNHSTrust
• SouthendUniversityHospitalNHS
FoundationTrust
• UniversityHospitalsOfLeicesterNHS
Trust
• WestHertfordshireHospitalsNHSTrust
• YorkTeachingHospitalNHSFoundation
Trust
TrustswithanunknownpolicyonMRCS• AbertaweBroMorgannwgUniversity
LocalHealthBoard
• AneurinBevenLocalHealthBoard
• BetsiCadwaladrUniversityLocalHealth
Board
• ChesterXieldRoyalHospitalNHS
FoundationTrust
• JamesPagetUniversityHospitalsNHS
FoundationTrust
• NorthTeesAndHartlepoolNHS
FoundationTrust
• NorthernHealthandSocialCareTrust
• OrkneyHealthBoard
Trusts which did not provide aresponse• CroydonHealthServicesNHSTrust
• DartfordandGraveshamNHSTrust
• NorfolkandNorwichUniversity
HospitalsNHSFoundationTrust
• NorthMiddlesexUniversityHospital
NHSTrust
• UnitedLincolnshireHospitalsNHS
Trust
�22
�23
©Birthrights2018