Intended for healthcare professionals

Rapid response to:

Letters NICE on reproduction

NICE promises on infertility and caesarean section are unmet

BMJ 2013; 346 doi: (Published 18 June 2013) Cite this as: BMJ 2013;346:f3814

Rapid Response:

Re: NICE promises on infertility and caesarean section are unmet

We read with some alarm the letter published in the BMJ by Lawrence Mascarenhas, Zachary Nash and Bassem entitled, “NICE promises on infertility and caesarean section are unmet”. We concur with the authors that current underfunding in the NHS is having grave consequences upon our national maternal health service provision and deserves careful scrutiny and critical comment. Moreover, as researchers and health professionals working on the front line of maternity care delivery we recognise that these authors are excellently placed to offer such scrutiny and comment. What is unhelpful in this letter however, is the highly misleading medico/legal description of elective caesarean section. These authors claim that current NICE guidelines ‘state that all pregnant women should be able to choose an elective caesarean without obstetric or psychological indications.’ (our emphasis)

This is somewhat at variance with the procedure actually set out in the guideline, which aims to ensure that the woman’s decision is based on accurate information and, where the request is based on anxiety states that she should be offered referral to a perinatal mental health professional. The guidance recommends that a caesarean section should only be offered if this fails. (ref CG132 Caesarean section: NICE guideline. 08 February 2013. Accessed July 3 2013.

The authors’ reading of the 2011 NICE guideline (which incidentally appears to grossly underestimate the clinical severity of tokophobia, a condition that, in some cases, does not respond to the various antenatal inventions recommended by NICE and as a consequence may be resolved by a surgical delivery) suggests that medical treatment, such as surgery, is available to all NHS patients on demand regardless of clinical indication, best practice or health professional recommendation. We would like to take this opportunity to point out that this reading of these guidelines not only fails to pass the Bolam test but contravenes existing medico/legal precedent set in 2004 through the R (Leslie Burke) v General Medical Council case where the court of Appeal held that while the patient’s right to autonomy gives rise to an absolute right to refuse treatment, there is no comparable right to treatment on demand, whether ANH or some other treatment. (paras 30 – 31). What is in a patient’s best interests should not be automatically equated with the wishes of the patient (para 49).

We would like to stress therefore that current legal precedent and clinical guidelines hold that surgical interventions, such as caesarean section are NOT available on demand unless clinically indicated.

R (Leslie Burke) v General Medical Council [2004] EWHC 1879 (Admin)
Accessed 3.7.2013 from:

Competing interests: No competing interests

04 July 2013
Mandie Scamell
Midwifery lecturer
Alison Macfarlane, Christine McCourt, Juliet Rayment, Mary Stewart, Judith Sunderland
City University London
30 Bartholmew Close, London EC1A 7PN