Your report(Women's risk of heavy bleeding after childbirth at five-year high in England, December 13) rightly points out that the risk of heavy bleeding after childbirth in women is at a five-year maximum. The article suggests that this is due to a decline in the quality and safety of NHS care. But this is not true. The problem of increased bleeding after childbirth is not simple, and neither the women nor the quality of obstetric care can be blamed for this.
In recent World Health Organization analysisCaesarean section had the greatest effect on bleeding rates, and the only two factors that reduced the risk of bleeding were home birth and early skin-to-skin contact/breastfeeding. Increased bleeding is a natural consequence of frequent cesarean sections. Sensational claims about the “horrifying” risk of bleeding for mothers will only make the problem worse as women seek to avoid giving birth on the NHS, either by choosing a caesarean section (which increases the risk of bleeding) or by refusing maternity care altogether (which increases the risk of death if bleeding occurs).
The increase in intervention in childbirth was mainly aimed at protecting the child. Yet giving birth in the UK is safer than ever for a baby, with stillbirth and neonatal mortality rates at record lows.
There are major cultural changes currently taking place. National Health Servicewith a shift from paternalistic care to increased choice for women. We hear calls to increase the rate of caesarean sections and reduce the provision of obstetric care, but unfortunately this will only increase the rate of bleeding. There is no easy way to have a baby – professional, compassionate care is needed for everyone, as well as quality education and maternal choice. But it won't be cheap. Pipeline care is highly cost-effective, and the transition to truly personalized care will require a significant increase in resources. It is time for the government to step in and ensure this happens.
Professor Andrew Weeks
Chair of the Royal College of Obstetricians and Gynecologists' Guidelines Committee for the Treatment of Postpartum Haemorrhage; Professor of International Maternal Health, University of Liverpool
Your article on postpartum hemorrhage misses the crucial connection between mode of delivery and risk of bleeding. there is the least risk when labor begins spontaneously and delivery occurs without significant intervention. Caesarean section and induction of labor significantly increase the risk of bleeding. The frequency of interventions is increasing dramatically, with little improvement in neonatal outcomes and worsening outcomes for women. Caesarean section rates in the UK is now 45%With induction by 32%and many women experience both during the same birth.
Attributing these trends primarily to women being older or heavier explains only a small portion of the increase, and there is little evidence that higher intervention rates improve outcomes for these groups.
The continued disparagement of obstetric care that supports physiological labor contributes to poorer outcomes. There is strong evidence that continuity of care with a designated midwife improves maternal and newborn outcomes, but this model remains poorly supported. Physiological birth, recently dismissed in some quarters as an “ideology”, is promoted by midwives in part because evidence shows it reduces the risk of postpartum haemorrhage. Research has consistently shown that planned, midwife-assisted births have lower bleeding rates than hospital births.
Maternal well-being, including reductions in haemorrhage and birth trauma, should be central to any changes resulting from National Inquiry into Maternity and Newborns.
Anna Melamed
Sonya Richardson
Midwives and Midwifery Teachers, University of the West of England
