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Caesarean rule-change investigated

Sensationalist stories surrounding the provision of elective caesareans have been dominating the mainstream media. We dive beneath the headlines to get to the truth about the new recommendations.

Back in November, the news that NHS caesarean rules would be relaxed to allow women without a physical or mental reason to opt for the op sent shockwaves throughout the national media.

Has it been blown out of all proportion, or are those that say this is the first step to a 'free caesareans for all' culture flourishing not that wide of the mark after all?

After much to-ing and fro-ing, NHS drugs watchdog the National Institute for Health and Clinical Excellence (NICE) eventually published its hotly-anticipated position on elective caesareans, and said its recommendations would ensure women's fears and anxieties around childbirth are taken seriously.

Many warn, however, there is a danger such fears will be taken too seriously.

Under the guideline, midwives will be obliged to offer counselling to women requesting a caesarean, with the ultimate decision lying squarely with the mother-to-be. 

The provision of such emotional support is set to cost the NHS £1.1 million.

This extra emotional burden could not have come at a worse time for midwives - a 22% rise in the birth rate since 2001 and staffing cuts of almost 5,000 have led to a stark warning of a “looming crisis” from the Royal College of Midwives.

Elizabeth Duff, a Senior Policy Advisor at the National Childbirth Trust, told NiP there is a real chance midwives will be spread too thinly under the new guidelines.

“It is really hard on midwives when they are unable to do what they should be doing because of the increasing demand and the excessive admin pressures,” she said.

“More depressing is the reality that more staffing cuts are likely to be made.”

The funding pot looks to be depleted further, as NICE estimates reveal that elective caesareans are around £800 more expensive than natural births - £1,512 and £2,369 respectively.

Duff said the stretched NHS has led to an increasing number of women “falling through the gaps” leading to them “lacking in the necessary confidence” to give birth naturally.

Nina Khazaezadeh, a Consultant Midwife at St Thomas' Hospital and guideline developer, defended NICE's timing in publishing the update.

“Clinical guidance is about setting best practice,” she told NiP.

“The NICE panel has to remain objective and not allow themselves to get too bogged down with knock-on environmental factors it cannot control.”

Khazaezadeh predicted an upgrade in staffing levels will follow the change in practice.

NICE has said recent media speculation has been wrong to suggest the revised guidelines could open the doors to the possibility of all pregnant women being offered the possibility of an elected caesarean section.

“The guideline is not about offering free caesareans for all on the NHS; it is about ensuring the women give birth in the way that is the most appropriate for them and their babies,” said Dr Gillian Leng, Deputy Chief Executive for NICE.

“For women who ask for a caesarean section in the absence of any clinical indication, physical or mental, the guideline says they should be asked why they are requesting the operation, and be provided with full information about the risks and benefits. They should be offered the opportunity to discuss the procedure with other members of the obstetric team. If after this, they still want to have a caesarean, they should be allowed to have one.”

“Offering these women a planned caesarean in these circumstances is a very long way from saying that caesareans should automatically be offered to every woman.”

Midwife Khazaezadeh claimed the change in caesarean requests will affect around 10% of pregnant women suffering from “extreme anxiety” and expects the number to reduce further once their concerns are addressed.

The National Childbirth Trust(NCT) agrees with those elective caesareans that carried out because of “real need” - whether physical, mental, or now, emotional - but continues to call for a significant reduction in the UK caesarean rate, which varies from 15% to 34% in some NHS Trusts.

Emotional needs are always going to be seen as irrational, and will never hold quite the same gravitas as a person's physical or mental needs, which are quantifiable, tested and scientific as opposed to subjective, easily-changeable and hard to measure.

The fact the NCT has embraced emotional needs as an “acceptable” reason to opt for an elective caesarean has added weight to the updated NICE guideline and initially raised eyebrows.

However, NIP learned this support only exists on an individual basis and not that of a population basis.

When pressed on the issue, Duff told NiP she believes any increases to the caesarean rate in the UK following the guideline change will show up “failings in the system”.

“The guideline urges health professionals to intervene and provide emotional support to pregnant women earlier, allowing them to better equip prospective mums-to-be for a natural birth,” said Duff.

“If health professionals cannot free such women of their childbirth fears, meaning they still opt for an elective caesarean after counselling, then there is a failing in the system.

“It is very unfortunate if surgery becomes the answer for an emotional problem.”

So the NCT's support of NICE's change in elective caesarean guidelines is not so straightforward after all.

All this worry may be in vain, however. A spokesperson from NICE told NiP the watchdog does not expect the caesarean rate to “significantly rise or fall” following the relaxed rules.

She said any changes would be “difficult to quantify with certainty and are likely to vary widely around the country”.

The headline-grabbing nature of the guideline also overshadowed other 'less sexy' important developments, which may actually lead to an overall reduction in the elective caesarean rate.

For the first time, women who are HIV positive and can prove they are taking their medication will be allowed to opt for a natural birth.

This is expected to lead to savings of around £600,000.

Scores of women who have previously had a caesarean will also be able to give birth naturally for subsequent pregnancies, as the NICE guidelines rubbish the old saying 'once a caesarean, always a caesarean'.

At the heart of the matter, it seems that if the individualistic nature of the updated guidelines is to be successful then mums-to-be need to receive personal and individualised care.

A failure to meet such demands will render the plans naïve and disjointed.

Unfortunately, the odds are stacked against those at the frontline and responsible for making this possible. Trying to juggle two or three pregnant women at any one time is a nigh-impossible task for many midwives, and the addition of demanding emotional counselling may do more harm than good for both patients and professionals.