Too NICE to push? The cost of caesarean sections in the NHS.

Has caesarean section now become safer than natural birth? If not, why is the National Institute for Health and Clinical Excellence proposing to oblige the NHS to provide elective caesareans on request?

As usual, the reporting of this matter is dire. None of the reports I’ve seen so far point to where the draft guidance can be read, much less link to it.

Let’s begin by correcting that omission: you can download the draft here; the progress towards publication is here.

The key change is on page 12 of the new guidance. Recommendation 38 reads:

For all women requesting a CS, if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS. [new 2011]

(emphasis in original)

The effect of this is simple and straightforward: if a pregnant woman wants a elective caesarean section for non-medical reasons, she will now generally be entitled to have one. There are caveats, of course, and obstetricians can decline to perform the operation – but are obliged to refer the patient on. There will still be health-related circumstances where doctors may refuse to conduct the procedure (see, for example, recommendations 24-33, which deal with the transmission of infectious diseases such as Hepatitis from mother to child). But a healthy woman who simply wants to have a caesarean section will be entitled to do so.

(It is important to remember that in NHS statistical terminology “elective caesarean section” includes planned caesarean sections carried out for medical reasons – i.e. not simply at the patient’s option. I suggest, however, it is reasonable to assume that those who require caesarean sections for medical reasons are by and large already receiving them. Moreover, I suggest that the 10% elective rate already includes a proportion of patients who have chosen to have a caesarean section for non-medical reasons, but that we must recognise that such choice currently requires the support of the obstetrician.)

Does a change in NICE guidance indicate that planned caesarean section is now safer than planned vaginal delivery? This does not appear to be case. On pages 28 to 30 of the draft guidance (Table 4.5), various comparisons are drawn between risks to maternal health associated with planned caesarean section and planned vaginal delivery. In each case, the quality of the evidence supporting each comparison is rated as “Low” or “Very Low”. On page 32 of the draft guidance is this comment:

To provide more meaningful information to women when they are choosing their mode of birth, there is a pressing need to document medium- to long-term outcomes in women and their babies after a planned CS or a planned vaginal birth. First, it should be possible to gather data using standardised questions (traditional paper-based questionnaires and face-to-face interviews) about maternal septic morbidities and emotional wellbeing up to 1 year after a planned CS in a population of women who have consented for follow-up. Internet-based questionnaires could also be devised, to achieve the high response rates required for a full interpretation of the data. Similarly, it would be important to collect high-quality data on infant morbidities after a planned CS compared with a planned vaginal birth. A long term morbidity evaluation (between 5 and 10 years after the CS) would use similar methodology but assess symptoms related to urinary and gastrointesinal function.

If the evidence on specific health outcomes remains of low quality, is it, perhaps, the case that caesarean sections are cheaper? Is NICE’s guidance intended as a cost cutting measure? In 1997 the Audit Commission reported that:

A CS costs hospitals an average £1,701 while a vaginal delivery costs an average £749. [We estimate] that a 1% rise in CS rates costs the NHS an extra £5million/year.
Parliamentary Office of Science and Technology;
Postnote 184 (PDF)

2009 figures used by the NHS Institute suggest a marked reduction in cost over the preceding decade, putting the cost of a caesarean section at £1415 and the cost of a natural birth at £595. This leaves caesarean sections still almost £1000 more expensive that natural births and it’s not clear whether the Audit Commission “rolled up” the cost of longer in-patient stays for those receiving caesarean sections (which would further increase the differential).

In 2009-10, 10% of all NHS deliveries were by elective caesarean section, more 65,000. If the changed NICE guidelines increase this rate just to 11%, the additional cost to the NHS (based on the costs referred to above) would exceed £5.3 million.

NICE provide their own, sophisticated calculations of the cost in Section 13.3 of the draft guidance. They attempt to model the rates of different levels of complication – and associated costs – and produce weighted mean costs which are much higher than those quoted above: £1,741 for a planned vaginal birth; and £2,365 planned caesarean section; an additional cost of £624. On this basis, if the rate of planned caesarean sections increased from 10% to 11%, the additional cost would exceed £4 million.

To their credit, NICE have not simply provided those immediate costs. They have attempted to model post-natal costs of complications arising from each delivery method – which further increases the differential – and then gone beyond this to model the impact of a key post-natal complication – stress urinary incontinence – which becomes crucial.

(There’s a question as to whether the rates of stress urinary incontinence assumed by NICE for their model are valid – they specifically state that the rates are assumed in the paper on which their analysis is based. NICE note this and other potential weakness on page 220 of the draft guidance.)

If stress urinary incontinence is more likely to arise from a planned vaginal delivery than from a planned caesarean section, then the costs of dealing with this complication increase the cost of the former – to a point at which, while the cost differential is not eliminated or reversed, it is dramatically reduced. Taking this downstream cost into account, planned vaginal delivery has a total cost of £3,275, compared with £3,359 for planned caesarean section, and the additional cost of an increase in the rate of planned caesarean sections from 10% to 11% would be c.£0.5 million.

But there’s one final factor which might just tip the balance in favour of planned caesarean section – NICE’s QALY measure of cost-effectiveness:

Including urinary incontinence greatly reduces the incremental costs of a maternal request caesarean section, because the “downstream” costs of a planned vaginal birth increase more due to the higher risk of stress urinary incontinence with vaginal birth. Similarly, the greater reduction in health related quality of life arising in women having a planned vaginal birth from stress urinary incontinence now leads to caesarean section on maternal request having a higher QALY. An incremental cost-effectiveness ratio of £373 per QALY would suggest that a maternal request caesarean section could be considered a cost-effective alternative to planned vaginal birth.
Page 218

In other words, planned caesarean section may be preferable not because it is more cost-effective in absolute terms – as seen above, it isn’t – but because it is marginally more expensive but slightly reduces the risk of a specific negative outcome.

This may all sound pretty technical and economic, but this is the beating heart of the debate about the role and future of the NHS. At the extremities, is the NHS to be a provider of basic, essential medical care in a cost-effective manner? Or is to be a provider of “lifestyle” medical care which enhances the overall well-being of its customers?

This isn’t about resurrecting the old “too posh to push” debate. It isn’t about criticising people who make the choice to deliver via caesarean section rather than vaginally. It’s about asking whether we are prepared to continue increasing the cost of health care for smaller and smaller incremental improvements in outcome.

Our media (“too posh to push”) and our politicians (“we must save the NHS!”) are utterly divorced from the complicated, technical realities of that debate. If we are lucky, one or other might focus in on the details set out above. If it’s a blue moon, one or other might bother to question whether the additional cost arising from the new NICE guidance is justified by the small incremental benefit that might accrue. If the stars are in alignment, you might see them exploring whether there are other, more cost effective way to achieve the same benefits.

But I’m not holding my breath.

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