Wednesday, August 7, 2013

Refusal to follow NICE caesarean guidance is unjustified

My letter (with the title above) was published in the British Medical Journal today; I wrote it in response to another letter, NICE promises on infertility and caesarean section are unmet, sent in by Lawrence Mascarenhas, a consultant obstetrician and gynaecologist, Zachary Nash, a medical student, and Bassem Nathan, a consultant surgeon.

It reads:

"Firstly, I’d like to commend Mascarenhas et al[1] for their efforts in highlighting the lack of implementation of NICE caesarean guidance in many hospitals.

Mascarenhas et al write that the “updated NICE guidelines will perpetuate the belief that these guidelines are only implementable for a select educated few who can successfully argue their case with professionals”, and unfortunately, in too many hospitals this is not simply a belief but precisely what happens. Even the most educated women can face blatant refusal to follow NICE guidelines, and are directed towards private maternity providers they can ill afford.

Furthermore, Mascarenhas et al confirm anecdotal evidence I have gathered from numerous women that “commissioners are unwilling to fund caesareans at maternal request [and] women with previous caesareans are being pushed down the road of a trial of vaginal birth because of targets for reducing these operations.” Except in my experience, this erroneous practice is not limited to the London area, and the effects are far greater reaching than “great disappointment and anxiety”. Through my voluntary work, I have known women terminate pregnancies, lose babies through stillbirth, see their babies injured during instrumental deliveries, suffer post-traumatic stress disorder and depression (needing counselling), require surgery for incontinence, prolapse and sexual health problems, lose careers (in cases of fecal and anal incontinence) and sue (or try to sue) the NHS. Over and over again they say, “I wanted a caesarean but it was refused.”

Yet the fact is NICE would not have recommended supporting maternal request unless there was sufficient evidence to demonstrate a justifiable balance of prophylactic benefits of a caesarean versus risks associated with a trial of labour. It could also not have made these recommendations without demonstrating cost-effectiveness. The problem arises because of ignorance and misunderstanding about how NICE arrived at these recommendations:

          - For women requesting a caesarean section, 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, a planned caesarean section should be offered.
          - An obstetrician unwilling to perform a caesarean section should refer the woman to an obstetrician who will carry out the procedure.[2]

It is important to stress the word “offer” above, since the only compulsory action for women is an individualised “discussion” to ensure that they are fully informed of both the risks and benefits of surgery. Even women with anxiety or fear are under no obligation to enrol in mental health support.
Furthermore, NICE’s Quality Standard for Caesarean Section,[3] published in June 2013, reinforces support for maternal request[4] and emphasises the importance of maternal satisfaction. It recommends informing decisions based on “the planned mode of birth” and ensuring that women “can talk to the most relevant member of the maternity team*…at any point during [their] pregnancy”; this should be “promptly arranged following a request.” Other statements make it clear VBAC is an “option” but not compulsory; there should be “consultant involvement in decision-making”; and “dedicated” lists that provide “protected surgical and anaesthetic time and appropriate staffing” for planned caesareans. I believe it is these much improved standards of care for informed women choosing a caesarean that may be the “raised expectations” Mascarenhas et al are referring to.

However, compared with the costs associated with many of the outcomes women experience when their request for a caesarean is refused, it is not necessarily “current underfunding of the NHS” that makes these recommendations “unachievable”; but rather the false perception that pushing as many women as possible to have a vaginal birth is unquestionably the most cost efficient strategy. It is not.
Unfortunately, a traditional and persistent focus on intrapartum costs alone has underestimated the true cost of PVD, and obfuscated the potential cost-savings of maternal request support. NHS treatments of birth injuries and trauma, not to mention its colossal obstetrics litigation bills, have largely been ignored. For example, in the NICE guideline’s Health Economics discussion, one of the cost models comparing PCD and PVD includes urinary incontinence (i.e. just ONE downstream adverse outcome of birth; and there are many others that need to be considered), which reduces the cost difference to just £84. NICE says, “On balance, this model does not provide strong evidence to refuse a woman's request for CS on cost effectiveness grounds.” The reality is that adverse birth outcomes are costly, and potentially more so when evidence-based guidance is wilfully ignored.

I fear that until maternity care policy takes further steps away from widely criticised arbitrary targets[5] to reduce caesarean rates (which NICE does not recommend) and to increase “normal birth” rates (NICE does not use the terms “normal” or “normalising” birth), the ideology that every woman should at least attempt a vaginal birth will continue to leave promises on caesarean section “unmet”. An urgent and unbiased reconfiguration of maternity services is needed, with recognition that midwifery-led care is not the choice of every woman, and that a trial of labour should not be forced on anyone who understands the risks of prophylactic surgery, and who is in fact making the exact same choice as a very high percentage of doctors (for their own children’s births)."


[1] Mascarenhas L, Nash Z, Nathan B. NICE promises on infertility and caesarean section are unmet. BMJ2013;346:f3814. (18 June.)

[2] National Institute for Health and Care Excellence. Caesarean section (update). CG132. 2011.

[3] National Institute for Health and Care Excellence. Caesarean section. QS32. 2013.

[4] New NICE Quality Standard Reinforces Support for Maternal Request. (11 June 2013)

[5] New RCOG guidance urges CCGs to increase births without epidurals and reduce caesarean rates to 20%. (24 August 2012)

* The core membership of the maternity team should include a midwife, an obstetrician and an anaesthetist.

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