title: The timing of elective caesarean delivery between 2000 and 2009 in England.
abstract: BACKGROUND
  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.
  
  
  METHODS
  We 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).
  
  
  RESULTS
  There 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.
  
  
  CONCLUSIONS
  NHS 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.
authors.affiliation: Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK. ipek.gurol@lshtm.ac.uk
authors.forename: Ipek
authors.initials: I
authors.lastname: Gurol-Urganci
authors.forename: David A
authors.initials: DA
authors.lastname: Cromwell
authors.forename: Leroy C
authors.initials: LC
authors.lastname: Edozien
authors.forename: Chidimma
authors.initials: C
authors.lastname: Onwere
authors.forename: Tahir A
authors.initials: TA
authors.lastname: Mahmood
authors.forename: Jan H
authors.initials: JH
authors.lastname: van der Meulen
mesh_terms: D000328:Adult; D001946:Breech Presentation; D002585:Cesarean Section / Q000639:trends*; D017604:Cesarean Section, Repeat / Q000706:statistics & numerical data; D017558:Elective Surgical Procedures / Q000639:trends*; D005260:Female; D005865:Gestational Age; D019983:Guideline Adherence; D006801:Humans; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D013222:State Medicine / Q000706:statistics & numerical data*; D006113:United Kingdom