Category: csections commentary

Michael Odent is releasing another book. When the Telegraph spoke with him last week about his latest ideas, for a few days I couldn’t think of how best to respond without ranting then a friend pointed me towards an excellent response. Take a look – enough said!

Yesterday NICE issued their Quality Standard for Caesarean Section.

Contrary to media reporting NICE statements regarding maternal request caesareans are NOT new. They published a guideline for caesarean section back in 2011. In this they recommended that women requesting a caesarean be offered documented discussion about the benefits and risks of all birth options and clarified that if a woman continued to prefer a caesarean they should be supported in achieving this.

Once again the media has  jumped on the emotive labelling of women ‘too posh to push’ blaming them for this rise in caesarean rates. NICE does not believe this group of women are responsible for the rise and conclude that “Many of the factors contributing to CS rates are often poorly understood.” And as Mcdonagh points out currently hospitals do not categorise births accurately. We have no way of knowing the actual number of maternal requests (where there are NO medical reasons for it) and unfortunately the new Quality Standard does not require hospitals to improve upon their reporting in this regard.

In actual fact, over the 30 year period in which caesarean rates have risen from 9% to 25% “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.)” McDonagh

The popular press rarely report this issue accurately. NICE are absolutely right to continue to recommend that balanced discussion be documented. It is critial the imbalance is tackled to ensure women can make informed decisions.

Today NICE issued their Quality Standard in support of their Caesarean Section NICE guideline (issued 18 months ago). This Quality Standard serves to qualify key quality statements which should actually already have been put into practise by NHS hospitals over the last 18months.

Csections.org in conjunction with elective cesarean.com surveyed all NHS hospitals in England and Wales last year to determine the extent to which specific aspects of the guideline were being implemented. In particular we wanted to know how hospitals planned to deal with women who requested a caesarean when there was no medical need. We were very disappointed to discover that a significant proportion had not only failed to implement a policy but that they were actively banning all maternal request caesareans! At csections.org we find that actually many women face an incredible battle to plan a caesarean where there is no medical need and most fail to gain agreement.

Today’s Quality Standard purely serves to highlight that NICE stands by its recommendation from 18 months ago and continues to strongly advocate that women should have access to balanced information, they should be able to request a caesarean and if, following documented discussion they still wish to proceed down this route they should be actively supported in doing so.

“Statement 2 Pregnant women who request a caesarean section (when there is no clinical indication) have a documented discussion with members of the maternity team about the overall risks and benefits of a caesarean section compared with vaginal birth…The discussion should include the reasons for the request and ensure that the woman has accurate information (including written information) about the relative risks and benefits associated with different modes of birth.” The guideline itself then says “…but if, after this, the woman still prefers a caesarean this should be granted.”

Hospitals are ignoring this advice.

RCOGs latest report looking at practises and outcomes across the UK has found that some hospitals have been carrying out planned caesareans prior to 39 weeks when there is no clear medical reason to do so.

39 weeks has been defined (by NICE) as the preferred time to perform a planned caesarean (where there are no medical reason why it should be carried out earlier). This is because at 39 weeks the lungs are sufficiently mature to be able to cope with birth and the risk of breathing difficulties is no longer statistically significantly different to that of vaginal birth at the same stage. In addition, delaying beyond 40 weeks means that mum is more likely to go into labour prior to the caesarean and this increases (very slighlty) the difficulties associated with performing a caesarean on a womb that is contracting. (See also When is it safe to schedule a caesarean?)

Much of the data used to generate the report has been taken from caesareans carried out AFTER the NICE guidelines were issued in 2011, so it does beg the question – why do some practitioners continue to ignore clear medical evidence as captured by the NICE guidelines. Some practitioners/hospitals continue to pick and mix those elements which suit their purposes. Hence why we see some hospitals performing caeareans prior to 39 weeks and others banning planned caesareans entirely. Is it any wonder women have no idea who to trust and what to believe.