Caesarean section rate in England and Wales

Editor—Dobson reports that deliveries by caesarean section in England rose from 4% in 1970 to 19% in 1999.¹ Potentially, this created substantially increased demand on postnatal 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.

For 477 women in two former London health trusts, 86 aspects of maternity care were surveyed in 1999.² In general, the survey showed problems with postnatal hospital care. We re-examined the data to contrast the postnatal experiences of women after a caesarean (88, 18.4%) with those who had a “normal” vaginal delivery (340, 71.3%). We focused on 69 caesarean deliveries without any general anaesthetic (in case anaesthesia affected mothers' recall), 34 in the first trust and 35 in the second trust. We used non-parametric statistics (χ², Spearman's rank correlation, Mann-Whitney U test), and our threshold for significance was P<0.05.

Caesarean deliveries were associated with some unsurprising differences (such as greater length of stay or more problems with infant feeding) compared with a normal delivery. One key question about postnatal care in both trusts was, “Did you ever feel the midwives were too busy to spend enough time with you?” Patients' answers to this question were highly correlated with overall ratings of their postnatal care while in hospital. Our concerns about the rising rates of caesareans were borne out in the first trust. The 34 women were significantly more likely to feel that the midwives were often too busy and less likely to report that they had known any of these midwives before, compared with the normal group. But this was not the picture in the second trust. Those 35 women were no more likely to report 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.

Only a few miles apart, both trusts had a similar range of clients. Organisational responses to more caesarean sections differed. For example, an independent consultancy reported that the first trust exemplified the special difficulties in recruiting and retaining staff in London. The maternity and neonatal workforce group is investigating the organisation of gold standard care.³ A forthcoming national service framework for children's and maternity services offers midwives a fresh chance to develop their work in responsive and far sighted ways.