For the first time, the German Institute for Quality and Efficiency in Health Care (IQWiG) supported professional societies in the development of an interdisciplinary S3 guideline. For this purpose, the Institute searched for studies on different questions regarding the topic of "vaginal birth", assessed them, and presented them in eight evidence reports. On this basis, a guideline group lead by the German professional societies of gynaecology and obstetrics (DGGG) and of midwifery science (DGHWi) is now developing recommendations for the new S3 guideline "vaginal birth at due date" (commonly referred to as "natural" birth to distinguish it from caesarean birth). In view of a growing number of caesarean sections, the new S3 guideline is developed to provide medical professionals with better guidance and support regarding their decision and intervention options. The guideline group praised the high quality of the IQWiG reports.
Commission from the Federal Ministry of Health
Commissioning agency of the Institute was the Federal Ministry of Health (BMG), which is the only institution besides the Federal Joint Committee (G-BA) that can request such assessments from IQWiG.
The guideline group, which consists of experts from different disciplines, had formulated a total of eight key research questions IQWiG was to investigate. The questions covered a range of different issues, including shaping of the environment during birth, use of ultrasound scans in the different phases of birth, and mobilization during birth.
Not all questions can be answered with certainty
The IQWiG researchers found out that the evidence base regarding some aspects of natural birth was not satisfactory. Partly studies were lacking, and partly the results were not robust.
This was the case, for example, for ultrasound scans during birth (intrapartal) because there were only data on the position of the baby's head and back in a certain constellation. In case of the position of the baby's head, ultrasound diagnosis was associated with an increase in caesarean sections. In case of the position of the baby's back, in contrast, the number of spontaneous births increased. This was due to interventions initiated based on the ultrasound scan.
Due to the limited informative value of the studies, it remained unclear whether modifications to the shaping of the environment, such as providing seating furniture or changes in room temperature or lighting, had favourable or unfavourable effects on the birthing experiences of the women giving birth or could help prevent caesarean sections. It was shown, however, that fewer oxytocics were needed.
Systematic development of S3 guidelines
The new S3 guideline aims to make a contribution to enabling midwives and physicians to offer labour and delivery care that is consistent with current scientific knowledge.
Whereas S1 guidelines, which still constitute about 45% of all guidelines, only require an "informal consensus" of the authors from the professional societies, S3 guidelines have to "undergo all elements of systematic development". Among other aspects, this includes a literature search for scientific studies and an assessment of their methodological quality and clinical relevance.
AWMF: successful cooperation
"The literature search and the assessment of clinical studies can be very complex, so IQWiG's expertise was a valuable support," says Rainhild Schäfers (DGHWi), one of the coordinators. "Since we have already been able to establish that all eight reports are of high quality, the cooperation has already proven successful," she adds. The Association of the Scientific Medical Societies (AWMF) also underlined the good cooperation with IQWiG.
Jürgen Windeler, IQWiG's Director, comments: "It was a pleasant and constructive cooperation throughout all phases of the project. We are glad that, in the case of the S3 guideline on vaginal birth, we are able to contribute to improving the care of pregnant women and their babies. So far, the results of our benefit assessments have been included in guidelines only selectively and indirectly. This time, we investigated precisely those questions where the guideline authors saw a need for clarification. It was a perfect example of the cooperation between IQWiG and professional societies," he adds.
Process of report production
The BMG awarded the commission in September 2016. Each of the eight subreports and a summarizing report were sent to the commissioning agency immediately after their completion between April 2017 and December 2018. All documents are now simultaneously published by IQWiG.