The organization "electivecesarean.com" registered as a Stakeholder for the NICE Caesarean Section Quality Standards, and as such, its founder Pauline Hull was involved in providing comments and feedback on its draft during a consultation period spanning December 21, 2012 to January 24, 2013. The evidence submitted and proposed changes to the text can be read below. The final version of the Quality Standards was published on June 11, 2013 and our press release can be read here.
*June 11, 2013
QS32 Caesarean section Quality Standards published.
January 24, 2013
WHAT IS MOST WELCOME FROM THE QUALITY STATEMENTS (with my 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 plannedmode 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.”
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 outcomeis 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 requestbirths (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)