Chairman of NHS Alliance apologises for mis-use of WHO target figure

The World Health Organisation’s (WHO) OLD caesarean target rate of 15% (retracted 2 years ago) is unfortunately still in circulation and now being used to explain the decision by some PCTs to ban maternal request caeseareans.

I contacted Dr Michael Dixon, Chairman on the NHS Alliance, after he used this figure on a BBC Tees interview with Ali Brownlee and I received this reply. “Very many thanks for your note about the WHO target rate.  I stand corrected and wont use the 15% figure again.”

Thank you Dr Dixon.

Unfortunately this figure is still being used by other professionals and the media to justify policy and inflame the debate that caesarean rates are simply too high. WHO admitted that there is “no empirical evidence for an optimum percentage” and world regions may now “set their own standards”. England has decided that they should not set a formal caesarean target rate.

Leigh East talks to Look North – Caesarean Ban

Talking once again about PCTs intention to ban planned caesareans that have no medical need. TV – a rather nerve-racking but worthwhile experience.

Much of the debate centred around the idea that maternal requests were a selfish choice taking money away from other areas of maternity care. Once again women falling into this category were all assumed to be ‘too posh to push’ but “What we need to think about is the number of women that actually fall into this category, the number is incredibly small. When you actually look at the reasons behind these choices the number that actually make this decision, as a ‘lifestyle’ choice alone, is very, very small.” As discussed in other posts, there is far more to it than lifestyle choice alone.

In answer to whether an elective caesarean is more expensive? In addition to the fact that the figures are based upon flawed data, “The issue of cost is a difficult one because actually the assumption that is being made is that a woman that is refused a planned caesarean is going to go on to have a natural birth. 50% of the women in this country manage to give birth vaginally without any form of intervention…the moment they do [experience intervention] the costs rocket and the actual likelihood of achieving the cost savings that are being talked about is very small.”

Leigh East talking to BBC York – Caesarean ban

Interviewed by BBC Radio York for a debate on PCTs banning planned caesareans where there is no medical need (in at 35 minutes). Useful comments later in the programme from independent midwife Chris Warren.

The majority of the debate centred around the question of whether or not women requesting caesareans really knew what they were doing and if so whether they had the right to make an informed choice in favour of a caesarean in the absence of any medical need.

“A woman ought to have the right to evaluate those risks for the planned side of caesareans and for vaginal birth. One of the reasons I think we are seeing an increase in the number of requests is that women are starting to do this. Women are starting to get access to that information and some women, not all because I agree there is a ‘lifestyle’ choice going on here for some women, but some women are making the choice for a planned caesarean to avoid the risks associated with a vaginal birth that goes wrong.”

“Some obstetricans would say that a prophylactic caesarean in certain situations is far less risky than the risk of giving birth [vaginally]. For example if you look at the twins scenario, that is one of those ‘grey’ areas where some practitioners will say no you shouldn’t try and give birth naturally and others will say ‘yes, go ahead’. The difficulty is you are then down to personal opinon of the practitioner that you are speaking to. Women are not given the information they need in order to make those choices for themselves. The National Institute of Clinical Excellence has spent the last 18 months reviewing the data regarding specifically maternal request caesareans and they have now decided and this is going to come out in the next few weeks…it is a reasonable thing for a woman to choose a caesarean. They have actually stated “If a vaginal birth is still not an acceptable option to the woman, her request for a caesarean should be supported within the health service.” NICE 2011

It was suggested that maternal request caesareans should be banned as proposed by some PCTs in order to save the NHS millions of pounds. This suggestion is born out of the NICE calculation that there is an £800 cost difference between these types of caessarean and vaginal births. However the figures used by NICE are based upon flawed data. The base case cost used for caesareans in the calculation includes ALL caesareans (including those which have medical indications and therefore additional costs due to complications arising). NICE justify this by saying “good quality UK cost data for caesarean section performed solely on the basis of maternal request is not currently available as far as we are aware.” But what this means is that the quoted savings use the cost of caesareans where problems are ALREADY identified, they specifically do NOT use the actual cost of a planned caesarean where there is no medical indicator. Not only this but the savings statements assume that all women refused a maternal request caesarean will go on to have an intervention free birth where they leave the hospital the same day. Given the 50% intervention rate of UK vaginal births, this is highly unlikely.

They [the PCTs] will find that the guidelines from NICE will shortly say the exact opposite and the PCTs need to take account of the research review that is coming out. The fact that PCTs use this figure, £800, as the cost difference between a natural birth and a planned caesarean does not take account of the fact that many births involve some form of intervention…the chances of achieving an £800 saving by putting more women into the natural birth scenario is unrealistic because actually a lot of women will not achieve a natural birth and so the costs will be much more similar to a planned caesarean.”

“There is no target for the rate of caesarean sections in England”

The Department of Health confirmed today that “there is no target for the rate of caesarean sections in England.” and it “never set an official target for caesarean sections, believing instead that focusing on promoting ‘normal’ is the best way to reduce interventions.” This follows a week where statements have been made by various health professionals using the old recommendation from the World Health Organisation (15%-a figure retracted in 2009) to boost their argument that maternal request planned caesareans without medical grounds should be banned.

There are very good reasons why this target rate has not been adopted in England and those contributing to the highly emotive debate on maternal request caesareans should check their facts before inflaming the debate with inaccurate information.

One Show – present inaccurate information on caesarean birth

Dr. Sarah Jarvis speaking on the One Show on Monday 22nd August made two inaccurate statements regarding:

1. the latest status of the NICE guideline on Caesarean Section regarding planning a caesarean in the absence of any medical need

2. the WHO recommendation of a 15% caesarean target rate

Firstly, the NICE guideline has been under review for the last 18 months. The new draft of the guideline, which is publically available, clearly states in 1.3 ‘Maternal Request Algorithm’ “Where there is no identifiable reason, discuss the overall benefits and risks of CS and vaginal birth. Facilitate a discussion with other members of the obstetric team…If a vaginal birth is still not an acceptable option to the woman, her request for a CS should be supported within the health service” (pg. 7 NICE 2011).

In this latest version NICE have validated women’s right to make informed decisions about their own births following clear advice from practitioners. In otherwords NICE recognise that there are many ‘grey’ areas where women have the right to make informed decisions in favour of a prophylactic caesarean over vaginal birth even in the absence of a identifiable medical need. If practitioners are going to talk about this issue then they should at least be up-to-date with the current status of the guidelines they are quoting.

Secondly, the 15% caesarean target rate that has been repeatedly quoted by the media and government for the last 25 years was also quoted to by Dr Jarvis. The WHO target was in fact retracted 2 years ago. WHO removed it from their ‘Monitoring Emergency Obstetric Care: A handbook’ because they finally admitted that there is “no empirical evidence for an optimum percentage”, an “optimum rate is unknown,” and world regions may now “set their own standards.” Not only this but England has NEVER formally stated that they subscribe to the target rate. Once again if practitioners are going to make these statements about caesareans on national television they should do so accurately.

The One Show reaches a significant audience and advisors appearing on the programme have a duty to present information correctly. I believe this is particularly important in the arena of healthcare where lives can be severely impacted by the decisions people take, often as a result of the ideas they have heard in the media. It is great that the One Show has professionals willing to give advice and comment on important issues, but it is imperative that these professionals represent the information accurately and fairly.