News

28th April 2004

New guidelines aim to reduce number of caesareans/NHS to cut caesarean rates

More than one in five women in England and Wales currently gives birth by caesarean section, a figure that experts believe is too high. Now, the National Institute for Clinical Excellence (NICE), has published new guidelines, in conjunction with the National Collaborating Centre for Women's and Children's Health (NCCWCH), to try to reduce this number and to set out the best care for women and their babies when a caesarean may be necessary.

When a woman is considering a caesarean with her doctor, the guidelines say that it is important for her to be aware of the risks and benefits for her and her baby, compared with vaginal delivery, so that she can make informed decisions about her care.

Some babies are born by caesarean because the position of the baby or placenta make a vaginal delivery impossible, while in other cases it is due to a medical problem with the mother or baby. A caesarean may also be suggested because difficulties develop during labour or because a woman has had a caesarean with a previous baby. Some women request a caesarean where there is no medical reason - this preference expressed by a few high-profile celebrities has led to them being labelled 'too posh to push'.

'The caesarean rate tends to go up in more affluent countries,' says babyworld GP, Dr Rory Symons, 'and it is very high in the UK. This may be for a variety of reasons, including pressure from pregnant women who don't want to give birth naturally.'

If a woman requests a caesarean where there is no valid medical reason, the guidelines recommend that her doctor does not automatically agree to arrange one, and should talk through exactly why she is choosing this option, offering counselling if necessary before a decision is made. However, the report states that 'maternal request is not on its own an indication for caesarean section.'

Suggestions for ways to reduce caesarean rates in other circumstances include: o undertaking more tests if a baby develops an irregular heartbeat during labour, before deciding to operate o offering external cephalic version (where a doctor tries to turn the baby with gentle pushing on the abdomen) to try to move a breech baby into a head-down position, if both mother and baby are healthy o informing women that continuous support from another woman during labour reduces the likelihood of a caesarean o supporting women who choose to have a vaginal birth after a previous caesarean.

The variation in the rate of caesareans in different parts of the UK is also a major cause for concern. David James, Professor of Fetomaternal Medicine and Director of Medical Education at Queen's Medical Centre, Nottingham, said, 'This guideline makes clear recommendations about when it is medically appropriate and necessary to carry out a caesarean section based on a comprehensive review of the available evidence. It will result in better care for pregnant women and their babies and a standardisation of services across the NHS in England and Wales.'

Babyworld's Dr Rory Symons welcomes the report as a 'positive move' that he says will encourage women to be more informed about their options for giving birth as well as standardising care across the country.

'These guidelines are trying to ensure that caesareans are used more appropriately,' he says, 'and to recognise that there can be both benefits and drawbacks - a caesarean section is major surgery, which carries a risk, however small.'

How will these guidelines affect you?

One important effect of the new guidelines is that all pregnant women should now receive the same level of care, wherever they live. This includes how the decision to perform a caesarean (or not) is made, the operation itself and the aftercare. For some women, very little will change as a result of the report. 'Most of the guidelines in the report are already in place in some areas of the country,' says Dr Symons, 'but it's important that the care offered is the same for everyone.'

Women will be encouraged to become as informed as possible about their options for labour and delivery. Dr Symons says, 'These guidelines differ from those issued previously in that they are aimed at both doctors and pregnant women, who have to share the responsibility of deciding whether a caesarean is the most appropriate course of action.'

If a woman is afraid of giving birth vaginally, the guidelines recommend offering information and support. 'The report says that women who are frightened of giving birth should be offered counselling,' says Dr Symons, 'which has not always been the case in the past, partly because of time constraints.'

Women will still be able to choose to have a caesarean privately. However, those using NHS services will find it more difficult to opt for a planned caesarean unless there is a valid medical reason. For every mother-to-be, these guidelines give a clear message that she should have access to reliable information about the risks and benefits of caesarean section and vaginal birth, based on the individual circumstances of her and her baby. she said.

• What will happen if I need a caesarean? Find out more
• Do you think too many babies are born by caesarean? Have your say