Your report (Risk to women of severe bleeding after giving birth at five-year high in England, 13 December) rightly points out that the risk to women of severe bleeding after giving birth is at a five-year high. The article suggests that this is due to the declining quality and safety of NHS maternity care. But this is not true. The problem of increasing haemorrhage after birth is not simple, and neither women nor the quality of maternity care should be blamed.
In a recent World Health Organization analysis, the largest influence on the rate of haemorrhage was caesarean birth, and the only two factors that reduced the haemorrhage risk were home birth and early skin-to-skin contact/breastfeeding. Increased rates of haemorrhage are a natural consequence of high caesarean section rates. Sensationalist quotes of the “terrifying” risk to mothers of haemorrhage will only make the problem worse, as women seek to avoid labour in the NHS, either by choosing a caesarean (which increases the risk of haemorrhage) or by opting out of maternity care altogether (which increases the risk of death if haemorrhage occurs).
Increased intervention in childbirth has largely been to protect the baby. And yet, for the baby, childbirth in the UK is safer than it has ever been, with record low rates of stillbirth and neonatal death.
A large cultural change is rightly under way in the NHS, with a move away from paternalistic care and towards increased choice for women. We are hearing calls for increased caesarean rates and reductions in midwifery-led care, but sadly these will only increase haemorrhage rates. There is no simple way of giving birth – what is needed is expert compassionate care for all, along with high-quality education and maternal choice. But this will not be cheap. Conveyor-belt care is very cost effective – and a shift to true personalised care will take a large increase in resources. It is time for the government to step in to provide this.
Prof Andrew Weeks
Chair, Royal College of Obstetricians and Gynaecologists postpartum haemorrhage treatment guidelines committee; professor of international maternal health, University of Liverpool
Your article on postpartum haemorrhage overlooks the crucial link between mode of birth and haemorrhage risk. The lowest risk occurs when labour begins spontaneously and birth happens without significant intervention. Caesarean sections and induction of labour both significantly increase haemorrhage risk. Rates of intervention are rising sharply, with little improvement in neonatal outcomes, and worsening outcomes for women. The UK caesarean rate in England now stands at 45%, with inductions at 32%, and many women experiencing both in a single birth.
Attributing these trends primarily to women being older or heavier explains only a small proportion of the increase, and there is scant evidence that the higher intervention rates improve outcomes for these groups.
The continued denigration of midwifery care that supports physiological birth is contributing to poorer outcomes. Continuity of carer with a named midwife is well evidenced to improve maternal and neonatal outcomes, yet this model remains undersupported. Physiological birth, recently dismissed as an “ideology” in some quarters, is promoted by midwives partly because evidence shows it reduces the risk of postpartum haemorrhage. Research consistently demonstrates that planned, supported, midwife-led births have lower haemorrhage rates than hospital births.
Maternal wellbeing, including reducing haemorrhage and birth trauma, must be central to any changes arising from the national maternity and neonatal investigation.
Anna Melamed
Sonia Richardson
Midwives and midwifery lecturers, University of the West of England
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