electivecesarean.com 2013 NICE Quality Standard Reinforces Support
for Maternal Request Caesareans and Mothers’ Satisfaction with Maternity Care PRESS
RELEASE
Embargoed
until 00:01 Tuesday 11th June 2013 (GMT)
Published
by electivecesarean.com
Following the
National Institute for Health and Care Excellence (NICE)’s publication of its Caesarean Section Guideline (update) in
November 2011, which recommended ultimate support for women who choose to plan
a caesarean birth without any clinical indication, and highlighted a cost
difference of just £84 with planned vaginal birth when the adverse outcome of
urinary incontinence was considered,[1] electivecesarean.com welcomes NICE’s Quality Standard for Caesarean Section, and hopes that it results
in greater adherence by hospitals and health professionals to its 2011
caesarean recommendations.
It is this
organisation’s experience, through communication with parents, midwives,
doctors and hospital trusts, that arbitrary refusal of maternal request planned
(primary and repeat) caesareans continues to occur, and more widely, that women
without a personal preference for any particular birth plan are being encouraged
to focus on the benefits of planned
vaginal delivery and the risks of
planned caesarean – with the emphasis on reducing overall caesarean rates and
increasing rates of ‘normal birth’ – rather than being provided with balanced
information and an evidence-based assessment of their individual risk factors
associated with a trial of labour.
WHAT
IS MOST WELCOME FROM THE QUALITY STATEMENTS (with emphasis)
·
QS 5 Timing of planned caesarean section:
The woman should be given a specific day and time at which the caesarean
section will be performed. A model for delivering planned caesarean section
is for services to have dedicated planned caesarean section lists. The lists
should have protected surgical and anaesthetic time and appropriate staffing
to ensure that planned caesarean section are not delayed because of surgical
time being prioritised for emergency cases.
·
NICE press release: She should also be
able to talk to the most relevant member of the maternity team depending on her
question or concern at any time during her pregnancy. A consultant
should be involved in decisions surrounding caesarean sections because they
are best placed to advise about the potential benefits and risks. Quote from Dr Malcolm Griffiths, Consultant
Obstetrician and Gynaecologist, Luton and Dunstable Hospital and chair of this
QS expert group: “…Most women want to avoid the major surgery of a
caesarean section. However, it is important that the NHS ensures all women
can give birth in the most appropriate way for them, and for some women, this
will mean having a caesarean section...”
WHAT
WOULD ALSO HAVE BEEN WELCOME IN THE QUALITY STANDARD
·
NICE press release: While the number of caesareans
“has gone up dramatically” in the last 30 years from 9% in 1980 to around 20-25%
in 2013, in 2011, NICE made clear that “Many of the factors contributing to CS
rates are often poorly understood. This guideline has not sought to define
acceptable CS rates.”[1]
Over the same
period, rates of infant deaths have decreased significantly. The neonatal mortality rate fell by 62%,
from 7.7 deaths per 1,000 live births in 1980 to 2.9 in 2010, and the perinatal mortality rate (which includes
stillbirths) fell by 44% from 13.3 deaths per 1,000 total births in 1980 to
7.4 in 2010 (and in October 1992, the legal definition of a stillbirth was
changed to include deaths after 24 completed weeks of gestation or more,
instead of after 28 completed weeks of gestation or more; therefore improvements in perinatal mortality
outcomes may be even greater.)
·
QS 9 Outcome: “Rates of complications in women
who have had a caesarean section.” For this information to be
useful, it’s essential that type of caesarean is recorded here.
·
QS 2 Outcome: “Women’s satisfaction with
the process of discussing options with the maternity team.” Women’s satisfaction
with actual birth outcome is crucial to record here too (whether she has
her maternal request CS or is persuaded to plan a vaginal birth), as is the actual
number of maternal request births (so that we finally know this % rate).
“For women
requesting a CS, if after discussion and offer of support (including perinatal
mental health support for women with anxiety about childbirth), a vaginal birth
is still not an acceptable option, offer a planned CS.
“An obstetrician
unwilling to perform a CS should refer the woman to an obstetrician who will
carry out the CS.”
“On balance,
this model does not provide strong evidence to refuse a woman's request for CS
on cost effectiveness grounds.” (Health
Economics p.100-1 & see p.220 for £84 figure)
Contact for Further Information
Pauline Hull
Co-author of ‘Choosing
Cesarean, A Natural Birth Plan’ (Prometheus
Books, New York. 2012), and founder of electivecesarean.com
and cesareandebate.blogspot.com
Telephone 07780
308 455
2 comments:
On the whole I am please with what I have read on this so far.
For me the most significant change is to rephrase the following:
'Pregnant women who request a CS (when there is no other indication) discuss this with members of the maternity team within a suitable time frame depending on the number of weeks left in their pregnancy'.
to
‘Pregnant women who request a CS (when there is no other clinical indication including anxiety) have a documented discussion with members of the maternity team’
Previously whenever this issue is discussed anxiety is all to frequently labelled as not being a mental health issue. This change very clearly includes anxiety as being a clinical issue that can indicate the need for a CS. This means that anxiety can not be as easily dismissed by HCP, as perhaps it has in the past.
Its a tiny change, but I do think this is actually a fairly significant one.
However I do feel that the removal of time frame from the statement and the move to simply document discussion, actually removes an urgency and emphasis on the fact this needs to be done promptly; instead I fear the danger is that it might be simply easily to phob someone off until too late in the pregnancy to have a discussion which is both meaningful and can be of benefit to the woman concerned.
Several contributors to the consultation actually commented on this area and suggested actually adding timescales. Instead, the route decided is to say that a woman can talk about this at any point in her pregnancy, but they have buried this in the rationale section below the statement, rather than it being a key core part of it and stressing this need for urgency.
Nor is there any reference to women who are not pregnant. I understand that they are not trying to cover every aspect of care, but women who face anxiety over childbirth are no acknowledged ANYWHERE and if there is a move to make decision at any point in a pregnancy, I fail to understand why this can not include outside of pregnancy too.
Incidentally, I am impressed at the quality reporting of this displayed by the Evening Standard, Telegraph & Daily Mail.
The Telegraph states: 'The rate has more than doubled since 1980, and some research suggests that the rise has been driven partly by the requests of affluent mothers, who are named “too posh to push” by critics. Experts say that some women are “confused” about the procedure and would choose a natural birth if they were given more information.'
Who ARE these experts doing this research? What research is this, because NICE didn't use it! Why on earth didn't they reference it in their guidelines in 2011 or in these quality standards?
Post a Comment