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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)

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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

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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.

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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

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• 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

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©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

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©Birthrights2018