New RCOG guidance urges CCGs to increase births without epidurals and reduce caesarean rates to 20%

Aug. 23, 2012 - PRLog -- Produced in collaboration with the Royal College of Midwives (RCM) and the National Childbirth Trust (NCT), RCOG’s 'Making sense of commissioning maternity services in England'[1] contains guidance for Clinical Commissioning Groups (CCGs) that is directly opposed to maternity care policies advocated by the National Institute for Clinical Excellence (NICE), the National Health Service Litigation Authority (NHSLA), and many charities, campaigners and doctors.

Pauline Hull, co-author of Choosing Cesarean, A Natural Birth Plan and editor of electivecesarean says,
"If this document had been published by the RCM or NCT alone, it would not be as shocking, but RCOG? I think its contents will raise eyebrows in OBGYN colleges around the world – if not within RCOG itself.”

It advocates:

- Reducing hospital caesarean (CS) rates to 20%
- Increasing rates of ‘normal birth’ (a definition not used by NICE, which means “without epidurals”, and cites “antenatal, delivery or postnatal complications” as normal outcomes)
- Midwifery-led birth units as the ‘default option’ for pregnant women

Professor Philip Steer, Editor-in-Chief of BJOG says,
"To try and achieve increased rates of uncomplicated births by reducing the availability of labour induction, epidural anaesthesia and caesarean section for informed women who request them, reduces choice without any guarantee of an improved outcome (and is likely to increase medicolegal costs substantially)."

Guidance:

“The NHS Institute has reviewed clinical practice and the organisation of services and has concluded that a 20% rate is achievable and sustainable. Every provider unit should have a clear action plan for increasing its normal birth rate…”
- The DH, NICE and NHSLA have all confirmed that they do not advocate CS rate targets
- The World Health Organization (WHO) stated in 2009 that 'no empirical evidence for an optimum percentage' exists and an 'optimum rate is unknown'
- Obstetricians worldwide have condemned the idea of setting CS rate targets[2]
- The NHS Institute also advocates >80% of women try VBAC    

“There is now a good argument to be made for multiparous women being advised to choose a non-obstetric unit birth.”
- Significantly, the wording reads “advised to choose” and not “offered the choice”. This refers to the 2011 Birthplace study,[3] which has been heavily criticised by statisticians and maternity groups,[4] (e.g. stillbirth is cited as low risk, yet stillbirths prior to onset of labour at gestational weeks when an ultrasound or planned CS could have been discussed or offered, were excluded). It is currently the subject of a charity’s formal request for review by the DH.

“…making midwifery-led services the default option for pregnant women.”
- Most women choose to give birth in hospital, where obstetric care is immediately available, and do not want this default option.[5] RCOG president’s BMJ response to the Birthplace study noted that up to 45% of first-time mothers required transfer from home or midwifery units.[6] Many centres have closed and with staff shortages, where are the resources for this?

“The consensus statement from the Maternity Care Working Party defines normal birth as “without induction, without the use of instruments, not be caesarean section and without general, spinal or epidural anaesthetic before or during delivery”. It is important to try to increase this rate as well as that of vaginal birth, which includes delivery by forceps and ventouse.”
- NICE says it does not support the use of ‘normal’ as a definition, and some MCWP members criticised the adoption of a phrase originally intended by The Information Centre to measure the process of labour, NOT as a goal or target to be facilitated and achieved.

- The suggestion that CCGs try to increase forceps and ventouse deliveries does not reflect best evidence, and doctors avoid these for their own births.[7] It may reduce CS rates, but it will NOT achieve better outcomes for mothers and babies. Instrumental delivery can have serious adverse outcomes, and for some women, offering a planned CS would be safer.
- It is NOT important for women to experience any type of birth without adequate pain relief; ideological beliefs do not belong in CCG guidance. In 2006, the RCM suggested charging women £500 for “unnecessary epidurals,”[8] which it had to back down on; it still talks about “unnecessary CS”. This does not represent the views of all maternity organisations, who vehemently disagree with denial of access to all legitimate choices as per NICE guidance. Wanted and unwanted are more appropriate values to consider in the context of patient choice, and going forward, RCOG needs to consult with organisations besides the NCT.

"If a trusted GP advices[sic] a low risk woman that her care pathway will be midwife led, or suggests to a woman after a caesarean section that VBAC is a good option to explore, she is likely to be more confident about achieving a normal birth outcome.”
- Offering VBAC is acceptable, but care must be taken with advising or pushing VBACs. Research just published in France, where VBACs are promoted, shows the “rate of litigations tripled in a decade [to 2010]. Uterine rupture was the most common cause of complaints.”[9]

“Every potential caesarean section that is enabled to be a normal birth saves £1200 in tariff price alone. [This] saves the NHS money.”
- NICE states that cost comparisons should be of PLANNED mode of birth outcomes, not outcomes alone; it estimates that a planned CS costs £710 more than a planned vaginal birth, but once urinary incontinence costs are factored in, this reduces to just £84.[10] Other downstream costs and litigation (e.g. failure to carry out timely caesareans) are huge, and not considered in this guidance.  

“Women must receive consistent, positive information and advice from their health professionals if they are to have confidence in a normal birth.”
- Though not mentioned by RCOG here, the definition of ‘normal delivery’ also includes:
“antenatal, delivery or postnatal complications (including for example post partum haemorrhage, perineal tear, repair of perineal trauma, admission to SCBU or NICU)”
- This is vital. These adverse outcomes may be ‘normal’ but they are not ‘positive’ or desirable, and since prophylactic CS and pain relief are possible in the 21st century, they should be available to women who actively want to avoid this definition of normal birth.
- Suggested wording: “Women must receive non-biased, factual and evidence-based information, if they are to have a more positive birth experience and safer birth outcomes.”

“…make clear that women have a choice about place of birth”
- NICE guidance emphasises choice about mode of birth, not just place of birth. Notably, the cost of homebirth, which involves two midwives per woman for an unknown time period, is not mentioned.

“Women with a BMI over 35 will have fewer choices about their place of birth… As weight increases interventions and PPHs increase, ultrasounds and epidurals become more difficult and women are likely to have larger babies… Clearly it is better for women if they can lose weight before they conceive.”
- This section of the document is very important, and correct. However there is no evidence that the rate of overweight and obese women is declining in the UK; in fact the opposite is true. And as long as this trend continues, and as long as women continue to delay motherhood until obstetrically advanced years and heavier birth weights at full term are recorded, the idea that hospitals in England can safely achieve a 20% CS rate is as outdated and unsafe as the WHO’s recommendation of a 15% threshold in 1985.

FULL PRESS RELEASE with quotes from DH, doctors and organisations, plus References [1-10 above] is available on PDF by clicking here: (http://www.electivecesarean.com/images//12-aug-24%20rcog%...)