NICE are updating their guidance on caesarean sections. The draft document has been reviewed byÂ stakeholdersÂ (of which I am one) and aÂ new version is due out in Septemer 2011.
At first glance the draft is a marked improvement on the previous version, particularly now that it includes assessment of maternal request caesareans, this following active lobbying by members of the CCA – of which I am a founding member. However there are still many gaps.
Of particular interest toÂ me isÂ how practitioners handle caesarean requests from women whose request does not fit in with any formally recognised medical reason. With regards tokophobia (fear of childbirth) improvements have been made – counselling is to continue to be available and now, where a woman continues to request a caesarean after this, her request should be granted. However, significant hurdles face those women who wish to discuss the possibility of a caesarean where the medical reasons are not clearcut or tokophobia cannot be proven. This is despite clear evidence that many requests originate from previous trauma and pregnancy complications.
The decision to request a caesarean is rarely taken lightly yet NICE currently continue toÂ recommend that women undertake counselling. While balanced, comprehensive information and support during the decision-making process is of course crucial the guideline, as it currently stands in draft, implies that the role ofÂ this counselling is to change the minds of these women. It does not recognise that for someÂ the most appropriate option is still a caesarean.Â These womenÂ will not be able to gain agreement forÂ a caesareanÂ till they near the end of their pregnancy, if at all.Â ResultingÂ fear andÂ distress may significantly impair their pregnancy experience, affect their emotional wellbeing and critically, inÂ a small number ofÂ cases, may causeÂ them to abort their baby.
The UK health service needs to be clearer in its recognition that women have the right to make informed decisions about the way they give birth. They need to be more prescriptive about the information that is provided to ensure that it is truly balanced, discussing the risks of both caesarean birth and vaginal birth. Failure to do soÂ leaves many women poorly prepared for their birth creating extra unnecessaryÂ trauma for those unprepared for a caesarean outcome (after all, 1 in 4 will experience a caesarean – many in emergency situations) .
The NICE draft is a step in the right direction but there are still some major issues with it.