Abstract
BackgroundIn 2004, the National Institute for Clinical Excellence (NICE) recommended that an elective caesarean section for an uncomplicated pregnancy should not be carried out before 39 completed weeks due to increased risk of respiratory morbidity in newborns. We describe the trends and variation across 63 English NHS trusts in the timing of elective caesarean section (CS) for low-risk singleton deliveries.MethodsWe identified elective CS deliveries between 1st April 2000 and 28th February 2009 in English NHS trusts using the Hospital Episode Statistics. We selected women with uncomplicated pregnancies who had an elective CS delivery after 34 completed weeks of gestation, and analysed the trends and the trust-level variation in the timing of elective CS. The impact of the NICE guidance on the monthly rate of elective CS deliveries performed after 39 weeks was estimated using an interrupted time-series design with autoregressive integrated moving average (ARIMA).ResultsThere were 118,456 elective CS deliveries at the 63 NHS trusts. The overall proportion of elective CS deliveries done after 39 completed weeks steadily increased from 39% in 2000/01 to 63% in 2008/09. The proportions rose from 43% to 67% for women with breech presentation and from 35% to 62% for women with a previous CS. There was significant variation across NHS trusts in each year; in 2008/09, with the proportions of elective CS done after 39 weeks ranging from 28% to 89% (Inter-quartile range limits: 54% to 72%). We found a small but statistically significant increase in the proportion immediately after the publication of the NICE guidance, but its rate of growth rate declined slightly thereafter.ConclusionsNHS trusts in our study have responded to the new evidence on the benefits of delaying elective CS to after 39 weeks gestation. However, substantial differences between NHS trusts remain, which indicates there is room for further improvement. We suggest that maternity services and commissioners adopt the "timing of elective caesarean" as a quality indicator to support clinical practice.
Highlights
In 2004, the National Institute for Clinical Excellence (NICE) recommended that an elective caesarean section for an uncomplicated pregnancy should not be carried out before 39 completed weeks due to increased risk of respiratory morbidity in newborns
Since the mid-1990s, various studies have reported that elective caesarean sections (CS) performed before 39 completed weeks of gestation are associated with an increased likelihood of respiratory morbidity in newborns and admissions in neonatal intensive care [1,2,3,4,5], which has considerable economic costs as well as psychological costs of separating mother and baby right after birth
In 2004, the National Institute of Clinical Excellence (NICE) Clinical Guideline: Caesarean Section recommended that planned caesarean section should not be routinely carried out before 39 completed weeks of gestation [9]
Summary
In 2004, the National Institute for Clinical Excellence (NICE) recommended that an elective caesarean section for an uncomplicated pregnancy should not be carried out before 39 completed weeks due to increased risk of respiratory morbidity in newborns. We describe the trends and variation across 63 English NHS trusts in the timing of elective caesarean section (CS) for low-risk singleton deliveries. Since the mid-1990s, various studies have reported that elective caesarean sections (CS) performed before 39 completed weeks of gestation are associated with an increased likelihood of respiratory morbidity in newborns and admissions in neonatal intensive care [1,2,3,4,5], which has considerable economic costs as well as psychological costs of separating mother and baby right after birth. An increase in maternal requests for elective CS delivery has been reported [9]
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