In England, caesarean section rates have increased from 9.0% of deliveries in 1980 to 15.5% in 1994–19951, the last year for which national data are available. This means about 100,000 caesarean sections are performed annually in the UK. A consensus statement from the World Health Organisation suggests there is no increase in health benefits associated with caesarean section rates above 10%–15%, although this is not based on any empirical evidence.
Why are caesarean section rates rising? The distribution of maternal age and parity has changed over the last 20 years with many women choosing to delay childbirth and limit the number of pregnancies they have. This alone can only explain some of the increase1. There is little that the clinical community can do to change this trend; however, while demographic transitions have contributed to the increase, there is evidence that variations in caesarean section rates between hospitals cannot be accounted for by differences in hospital populations and casemix alone2. The use of repeat elective caesarean sections for women who have had a previous caesarean section and policies to deliver breech presentations and multiple pregnancies by caesarean section2 are also contributory factors.
Another factor which has been hotly debated but little researched, is women's request for elective caesarean section. Changing Childbirth3 explicitly conveyed the right of women to be involved in decisions and have a choice in childbirth. However, the right of women to choose a caesarean section where there is no ‘medical indication’ has been much debated4. The contribution of maternal request for caesarean section to the variation in caesarean section rates is less clear. In addition, there is little robust evidence documenting the magnitude and balance of short or long term risks, associated with either caesarean section or vaginal birth. In such a vacuum can decisionmaking be ‘informed’ and is choice alone sufficient justification for opting for caesarean section?
As a consequence of these uncertainties a National Sentinel Caesarean Section Audit will be undertaken this year, funded by the Department of Health, through the National Institute for Clinical Excellence. The aim of this audit is to determine factors associated with variation in the caesarean section rates. All maternity units in England and Wales have been invited to take part. The project is a multidisciplinary collaboration involving the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, the Royal College of Anaesthetists and the National Childbirth Trust. Data collection for the main project will start on 1st May 2000 and will continue for three months. Data will be collected on all women having a caesarean section with an emphasis on the decisionmaking process and the indications for caesarean section. In order to have uniformly defined and nationally comparable denominator data, key data items will be collected on all births during this period. Information on hospital facilities, staffing levels and policies will also be collated at a unit level. Later this year a survey of women's views and involvement in the decisionmaking process in relation to caesarean section will also be undertaken in a sample of hospitals.
The standards to be evaluated include some that have been derived from evidence in systematic reviews, and others which are drawn from published standards3,5,6. The findings of the audit will be published anonymously and sent to participating trusts, so that they can compare their performance to others. Finally, to complete the investigation, another survey to meaure trends should be undertaken. Any future surveys would be made easier if there were good quality national maternity data. The results of this survey will identify appropriate methods by which valid comparisons between maternity units can be made. In the future this improved routine data will enable both clinicians and women to make more informed choices about childbirth.
For further information about this audit please contact your hospital facilitator or the RCOG Clinical Effectiveness Support Unit.