Evidence
Surveillance decision
We propose to update the section on maternal request in the NICE guideline on caesarean birth.
Exceptional surveillance review summary
Reason for considering this area
During recent guideline consultation of caesarean birth, a number of stakeholders responded with concerns that the section on maternal request for caesarean birth was not being implemented consistently across the country. This could represent an inequality in access as it may have made it particularly difficult for some women to request a caesarean birth, such as women with limited transport options or who do not speak English as a first language. The recommendations within this section were also considered to potentially be out of line with other parts of the guideline which had been fully updated. This section was not within scope of the 2020 update of the guideline but the committee considered this was a valid concern and requested that NICE undertake a review of this additional area.
Methods
To review the impact of this query on NICE guidance we took the following approach:
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Assessed the stakeholder comments against the current recommendations.
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Considered the evidence used to develop the NICE guideline on caesarian birth related to the section on maternal request for caesarean birth.
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Discussed the consultation feedback with the NICE quality assurance team to understand the issue that was discussed during stakeholder consultation and why it was not addressed during guideline development.
It was concluded that updated literature searches were not needed because the information we obtained was enough to establish whether an update to the guideline was needed.
For further information, see ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual.
Surveillance proposal
How the guideline was developed
2011 guideline
In the 2011 version of the guideline the following review question was developed which informed the section on maternal request for caesarean birth:
What is the appropriate care pathway for women who request a primary caesarean section where there is no obstetric or medical indication?
There was no evidence of interventions for women requesting caesarean birth. One prospective cohort study in Sweden that compared planned caesarean birth with planned vaginal birth found increased satisfaction with planned caesarean birth compared with planned vaginal birth, but increased length of hospital stay. An economic model was also developed to compare planned vaginal birth with planned caesarean birth, which found that planned vaginal birth dominated planned caesarean birth, although the analysis did not include all side effects of procedures (such as urinary incontinence) and results were uncertain.
At the time of the 2011 guideline development, the committee noted that they believed it was important for an individual obstetrician to be able to exercise their own beliefs about what is the best course of action in any given situation. Thus, if an obstetrician feels a woman's request for caesarian birth is not appropriate after the woman has received appropriate counselling and support, then the obstetrician should be able to decline to support the women's request. However, this does not overrule the woman's rights to express a preference for a caesarean birth, and in this instance the obstetrician should transfer care of the woman to an obstetrician who is happy to support the woman's choice.
2020 update
The section on maternal request in the NICE guideline contains 7 recommendations covering how a woman's request for caesarean birth should be managed. In particular, this section has these recommendations:
1.2.30 If a vaginal birth is still not an acceptable option after discussion of the benefits and risks and offer of support (including perinatal mental health support if appropriate; see recommendation 1.2.28), offer a planned caesarean birth for women requesting a caesarean birth. [2011, amended 2021]
1.2.31 If a woman requests a caesarean birth but her current healthcare team are unwilling to offer this, refer the woman to an obstetrician willing to perform a caesarean birth. [2011, amended 2021]
Managing maternal requests for caesarean births was not within scope of the 2020 update; existing recommendations were retained and amended for clarity where needed.
Recommendation 1.2.30 was amended by the committee to make it clearer that perinatal mental health support will only be necessary for women as defined in the earlier recommendation, and not all women requesting a caesarean birth.
Recommendation 1.2.31 was amended by the committee to clarify that this referral is for women who have requested a caesarean birth.
Whilst the section on maternal request for caesarean birth was not within scope for update, the following relevant review question was considered during the update:
What are the benefits and risks (short and long-term) of planned caesarean birth compared with planned vaginal birth at term for women and neonates/infants/children?
This review question was used to inform the section on benefits and risks of caesarean and vaginal birth in the NICE guideline. During their consideration of this evidence, the committee were aware that there may be variation in access to maternal request caesarean birth, and that choice of mode of birth should be supported, appropriate to a woman's clinical needs and the decisions they have made about mode of birth, regardless of service configuration in their local area. They noted that the guideline already contained a recommendation to this effect in the later section on maternal request for caesarean birth.
The following relevant research recommendation was also retained from the 2011 guideline:
What support or psychological interventions would be appropriate for women who have a fear of vaginal childbirth and request a caesarean birth? [2011]
New intelligence and evidence
During stakeholder consultation on the 2020 update of the NICE guideline a number of stakeholders raised issues around maternal request for caesarean birth. An extract of comments is presented below:
'We strongly disagree with the change from "obstetrician" to "current healthcare team" (within recommendation 1.2.31). Individual obstetricians may theoretically have the right to opt out of a caesarean if they really believe this will harm the patient (although this is very debatable on the basis that any woman who has her decision overridden will suffer psychological harm and caesareans are routine procedures for obstetricians) – but there is no basis for a team opting out. In addition, some women, who cannot drive for example, have no choice when it comes to changing hospital. Trusts need to ensure that they have obstetricians within their workforce who are happy to perform maternal request caesareans.'
The recommendations on benefits and risks of planned caesarean birth were updated in 2020 and the guideline committee concluded that choice of mode of birth should be supported, regardless of service configuration in their local area. Maternal request for caesarean section was not addressed during the guideline update as it was not within scope. However, based on the stakeholder comments during consultation, the committee requested that NICE consider the issue.
A Birthrights report on maternal request for caesarean (August 2018) also highlights the disparity in access to maternal request caesarean sections across the UK. Only 26% of trusts were deemed to offer maternal requests for caesarean births in line with NICE guidance, a further 47% were partially offering maternal requests for caesarian births (for example incomplete guidelines or compulsory mental health assessments), and 15% of trusts did not offer maternal requests for caesarian births. The report also highlighted that there are clinical commissioning groups that are not supportive of maternal request caesarean births. The report cites that often NICE guidance is used as a justification for referring women to other trusts, and recommends that NICE provide further clarity on the recommendations related to maternal request for caesarean birth.
At the time of development, the committee expressed 2 main concerns. Firstly, to ensure there is no stigma around women who choose caesarean birth and ensure that women are well informed and able to make an informed choice. Secondly, to ensure there are no barriers to health professionals in reaching a shared decision over birth mode and allowing women to make an informed choice around planned caesarean versus planned vaginal birth. In addition to this, it was noted that some of the content in the section on maternal choice may well be redundant as it overlaps with the section on planning mode of birth as well as the NICE guideline on shared decision making. This will be considered during the update.
Equalities
Stakeholders raised concerns that women wishing to have a caesarean birth but attending a maternity unit that has a policy of declining maternal request caesarean birth, may mean that women have to travel to another unit which could be a considerable distance away. This may disadvantage women with limited transport options, as well as those who did not speak fluent English, had disabilities, or did not feel confident to request a second opinion.
Overall decision
We propose to update the section on maternal request in the NICE guideline on caesarean birth.
ISBN: 978-1-4731-4186-5
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