NICE guidelines for caesarean section

Beverley Lawrence Beech

AIMS Journal, Summer 2004, Vol 16 No 2

Beverley Lawrence Beech reports on the caesarean section guidelines for parents, birth supporters and those who work in the maternity services, produced by the National Collaborating Centre for Women's and Children's Health

When AIMS was campaigning about maternity care in the 1970s, the caesarean section rate was already climbing, most likely as a result of the policy to bring all women into hospital for birth. By 1980, it had reached 9 per cent, but obstetricians confidently assured the critics that it would not exceed 10 per cent as caesareans over this rate could not be justified as they were not beneficial for either the mother or the baby.

Despite these assurances, caesarean rates continued to climb. In 1985, I was the lay representative for the whole of Europe (among one for North America and another for South America) to the World Health Organization (WHO) Conference on Appropriate Technology for Birth1. Invited representatives included obstetricians, paediatricians, epidemiologists, economists, statisticians and ethicists (and probably a few others I've forgotten to mention) - making 62 delegates in all.

The WHO had called the meeting because of its concerns over the continuing rise in medicalised birth worldwide. Caesarean rates were already over 30 per cent in the US and more than 90 per cent in many South American hospitals. In Britain, some hospitals were approaching 18 per cent.

After considerable debate and examination of the scientific evidence, the delegates agreed that they should make a recommendation that there was no justification for caesarean sections to exceed 10 per cent. Both North American and South American obstetricians threw their hands up in horror, stating that, if the recommendation was set that low, their colleagues will just laugh and do nothing. So, as a compromise, it was agreed that "there is no justification in any specific geographic region to have more than 10-15 per cent caesarean section births". I had some disquiet about this as I believed that hospitals would simply focus on the 15 per cent - which is precisely what they did.

Since then, caesarean rates have continued to rise in almost every country in the world. In the UK, the rate is now 23 per cent, but many hospitals have rates approaching 30 per cent. If you book into the Portland private maternity hospital, almost 90 per cent of their patients emerge with a scarred uterus.

It is estimated that over 140,000 women a year undergo caesarean sections. On the basis that any operation over 10 per cent is unnecessary and avoidable, this means that over 75,000 women a year are having unnecessary major surgery. We have every reason, therefore, to welcome the NICE Caesarean Section Guidelines.

The guideline development group, comprising two consumer representatives, two obstetricians, two midwives, a neonatologist, an anaesthetist, a member of the UK Confidential Inquiry into Maternity and Child Health, and a GP.

The group's recommendations were graded A, B, C, D or GPP, depending on the strength and type of evidence (see box). Here are some of the graded recommendations.

Thirty-four were graded A

(based directly on level 1 evidence; see box):

Seventeen were graded B

(based directly on level 2 or extrapolated from level 1 evidence; see box):

Twenty-one were graded C

(based directly on level 3 evidence or extrapolated from level 1 or 2 evidence; see box):

Thirteen were graded D

(based directly on level 4 evidence or extrapolated from level 1, 2 or 3 evidence; see box):

Twenty-four were graded a Good Practice Point

(GPP; based on the view of the Guideline Development Group; see box):

While the NICE guidelines are a step in the right direction, it should be remembered that they are based on medical evidence - with the holistic and midwifery approach to birth in second place. Randomised controlled trials, and research in general, is set up by the medical profession for the medical profession and for drug companies. Encouraging the powerful self-interest groups involved to undertake trials that users and midwives want is exceedingly difficult. Because of this bias, midwifery practice is sidelined, and little attention is paid by researchers to what women's views and needs are.

While there is an extensive list suggesting future research issues, the guidelines have some glaring omissions - for example, research into midwifery-managed breech birth, active birth, water birth, midwifery-managed twin birth or into the basis for women's requests for caesarean section.

However, these recommendations do gain a number of plus-points for suggesting that research be carried out to look into the reasons that lead a pregnant woman to request a caesarean, and to compare planned births in a 'stand-alone' birthing centre with births in conventional maternity facilities or midwifery-led units.

Finally, user organisations have been vigorously encouraged to sign on as 'stakeholder organisations'. Rather than spend weeks compiling a written submission, we decided - this time - that we would contact the user representative, Debbie Chippington Derrick, directly so that she could include our views in the discussions.

Initially, the consumer representatives were not paid for the enormous amount of time and effort they had to dedicate to guideline development but, eventually, NICE agreed to an honorarium for the two user representatives.

Having now listed AIMS as a 'stakeholder organisation', we expected at the very least to be given a complimentary ticket to the launch and a complimentary copy of the final guidelines.

Not so! Instead, we were asked to pay 34 for a copy of the report (but RCOG members got a discount and 50 per cent off the 260 ticket).

So, it should come as no surprise that consumers consider that the main objective of user-group stakeholder 'involvement' is to enable NICE to put the consumer organisations' names on the publication. But as for respecting user groups as valued contributors - well, that clearly is another thing.

References

  1. World Health Organization. Appropriate Technology for Birth, ICP/NCH 102/m02s. Geneva: WHO, 1985
Levels of evidence

1a Systematic review or meta-analysis of randomised controlled trials
1b At least one well-designed controlled study without randomisation
2a At least one well-designed controlled study without randomisation
2b At least one well-designed quasi-experimental study, such as a cohort study
3 Well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, case-control studies and case series
4 Expert-committee reports or opinions and/or clinical experience of respected authorities.

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