Tuesday, June 11, 2013

New NICE Quality Standard Reinforces Support for Maternal Request

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)

 ·         Overview: “A person-centred approach to provision of services is fundamental…”

 ·         QS 2 Maternal request for a caesarean section: maternity team involvement: “The purpose of this statement is to inform decisions about the planned mode of birth. It is important that the woman can talk to the most relevant member of the maternity team… It is important that access to members of the maternity team is possible at any point during the woman’s pregnancy and promptly arranged following a request. Outcome measure: “Women’s satisfaction with the process of discussing options with the maternity team.” Definitions: “The core membership of the maternity team should include a midwife, an obstetrician and an anaesthetist.”

 ·         QS 1 VBAC: “Pregnant women who have had 1 or more previous caesarean section have a documented discussion of the option to plan a vaginal birth.” i.e. it is not compulsory.

 ·         Q 4 Definitions. Pregnant women who may require a planned caesarean section have consultant involvement in decision-making: “This includes both women who have clinical indications… and women who request a caesarean section when there are no clinical indications.

 ·         QS 3 Pregnant women who request a caesarean section because of anxiety about childbirth are offered a referral to a healthcare professional with expertise in perinatal mental health support

·         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:

Anonymous said...

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.

Anonymous said...

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?