My letter (title above) was published in the British Medical Journal today; I wrote it in response to another letter, NICE says caesarean section is not available on demand unless clinically indicated, sent in by Mandie Scamell, a lecturer in midwifery, Alison Macfarlane, a professor in women’s and child health, Christine McCourt, a professor in women’s and child health, Juliet Rayment, a research fellow, Judith Sunderland, a lecturer and programme lead in midwifery, and Mary Stewart, a research midwife.
"I am equally “alarmed" by Scamell et al’s letter (“NICE says caesarean section is not available on demand unless clinically indicated”). Mainly because of the inaccuracies it reveals in maternity professionals’ knowledge and understanding of current NICE guidance (CG132) on caesareans, but also because of the potential dissemination to a wider body of student midwives and the subsequent effect on pregnant women.
NICE guidance does not refer to “demand” but rather “maternal request”, and in Mascarenhas et al’s letter, they refer to women who “choose” surgery. Semantics in the context of maternal autonomy is imperative here, not least because the language of birth has become increasingly political, derisive and divisive, but also because with “demand” correctly substituted here, it is erroneous to state that NICE guidance does not recommend scheduling surgery for informed women who request a caesarean “unless clinically indicated.” It does.
Firstly, these ‘no exceptions’ criteria in the Clinical Audit Tool “Implementing NICE caesarean guidance” are quoted directly from CG132:
- 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.
Notice the word “offer” in the first criterion. This is extremely important to stress because the only compulsory action is an individualised “discussion” to ensure that the woman is fully informed of both the risks and benefits of surgery. Even women with anxiety or fear are under no obligation to accept the offer of mental health support. So when Scamell et al write, “The recommendation is that a caesarean section should be offered only if this fails”, their assertion is incorrect. A woman is at liberty to decline the offer of additional support, but more importantly, the use of the word “fails” in this statement (which does not appear in the NICE guidance) betrays a belief that only by changing a woman’s birth plan to vaginal would the referral be considered a success. Indeed in practice, knowledge or expectation of what this type of “support” might entail is precisely why many women prefer to decline its offer.
Secondly, and in addition to the above, in June 2013 NICE published its Quality Standard for Caesarean Section, which reinforces maternal request support 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…
Maternal Request Cost
I also think it’s likely that much of the confusion surrounding NICE’s updated recommendations, and how to make them workable in the current economic climate, has come about for a number of reasons, not least of which include:
a) too many people have never actually read the guidance in full, and
b) there is a widespread misunderstanding of the comparative cost of a maternal request caesarean.
NICE has confirmed that the document attached to the 2011 press release distribution was the (much shorter, 57 page) NICE version of its updated caesarean guideline, and not the (282 page) FULL version. Yet it is this latter document that contains the Health Economics discussion in which a cost model including urinary incontinence (i.e. just ONE downstream adverse outcome of birth; and there are many others that need to be considered) reduced the cost difference between PVD and PCD to just £84. The guideline says, “On balance, this model does not provide strong evidence to refuse a woman's request for CS on cost effectiveness grounds.”
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.
Commissioners need ALL facts and evidence
In contrast with Scamell et al, what alarms ME most in Mascarenhas et al’s letter is confirmation of anecdotal evidence I’ve had for some time now: 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.” It alarms me because this stance doesn’t just result in “disappointment and anxiety” of women, but more importantly – mortality, morbidity, higher overall costs, maternal dissatisfaction and increased litigation. Adverse birth outcomes are costly - but potentially more so when evidence-based guidance is wilfully ignored.
Until maternity care policy takes further steps away from widely criticised arbitrary targets 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).
 Scamell M, Macfarlane A, McCourt C, Rayment J, Sunderland J, Stewart M. NICE says caesarean section is not available on demand unless clinically indicated. BMJ 2013;347:f4649. (30 July).
 Mascarenhas L, Nash Z, Nathan B. NICE promises on infertility and caesarean section are unmet. BMJ2013;346:f3814. (18 June.)
 National Institute for Health and Care Excellence. Clinical Audit Tool. Implementing NICE caesarean guidance. 2013 http://guidance.nice.org.uk/CG132/ClinicalAudit/MaternalRequestForCaesar...
 National Institute for Health and Care Excellence. Caesarean section (update). CG132. 2011. http://guidance.nice.org.uk/CG132.
 National Institute for Health and Care Excellence. Caesarean section. QS32. 2013. http://guidance.nice.org.uk/QS32.
 New NICE Quality Standard Reinforces Support for Maternal Request. (11 June 2013) http://cesareandebate.blogspot.co.uk/2013/06/new-nice-quality-standard-r...
 New RCOG guidance urges CCGs to increase births without epidurals and reduce caesarean rates to 20%. (24 August 2012) http://www.electivecesarean.com/images//12-aug-24%20rcog%20ccg%20press%2...
* The core membership of the maternity team should include a midwife, an obstetrician and an anaesthetist.