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Keywords:

  • Caesarean section;
  • decision making;
  • mode of delivery;
  • qualitative research;
  • VBAC

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Contribution to authorship
  9. Ethical approval
  10. Funding
  11. Acknowledgements
  12. References

Objective  To obtain the views of women on their experiences of decision making about the method of delivery following a previous caesarean section and the role of decision aids in this process.

Design  Qualitative study nested within a randomised controlled trial, using repeat semi-structured interviews conducted pre- and postnatally. Data were analysed using a framework approach.

Setting  Three maternity units in south-west England and Scotland.

Sample  Purposive sample of 30 women participating in a randomised controlled trial of two decision aids for women making a decision about mode of next delivery following a previous caesarean section (Decision Aids for Mode of next Delivery).

Results  Thirty women were interviewed during pregnancy about their experience of decision making about the mode of delivery and 22 were re-interviewed postnatally. Key themes were: role of decision aids in reducing decisional conflict and uncertainty during the pregnancy; impact of decision aids on knowledge and anxiety; the relationship between prior preferences, decisions and actual outcome; and the mediating role of decision aids.

Conclusions  Women making a decision about mode of delivery following previous caesarean section value some form of structured information to help reduce decisional conflict. Information provision for women making this decision needs to be relevant to their individual needs. Decision analysis may help reconcile prior preferences and the actual mode of delivery.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Contribution to authorship
  9. Ethical approval
  10. Funding
  11. Acknowledgements
  12. References

Concerns have been expressed about the rising rate of caesarean section (CS) in the UK, from 8% of births in the 1980s to 23.5% in 2005–06.1 Dystocia, fetal distress, breech presentation and repeat CS account for 70% of CSs.2 For women with a previous vaginal delivery, the CS rate is 10%, while the repeat CS rate (elective and emergency) for women who have had at least one previous CS is 67%.3 The National Service Framework recommends that maternity care providers should ensure that interventions such as CS are only performed if there is clinical evidence of expected benefits to the mother and/or baby,4 while Changing Childbirth and Making it Better emphasise the role of women’s preferences in decision making.5,6 Women’s decision making regarding CS may be ongoing throughout pregnancy,7 and can be influenced by cultural norms,8 family commitments,9 clinicians’ framing of the risks associated with the decision,10 and negotiations between women and their healthcare providers.11 Furthermore, support organisations that once advocated ‘natural birth’ now provide women with information regarding a range of birth experiences, including CS.12

Decision aids may enhance the success of patient-professional encounters, by providing a systematic approach to decision making and enhancing patient autonomy.13 Decision aids (such as leaflets, interactive videos, CDRom, workbooks, counselling sessions and individualised decision analyses) assist people in their selection between various treatment strategies by providing information on the options and outcomes relevant to an individual’s health.14 However, a recent review of decision aids has raised concerns about both their content and the context in which they have been used.15

The Decision Aids for Mode of next Delivery (DiAMOND) study16 was designed to evaluate the effectiveness and acceptability of two decision aids (an information programme and an individualised decision analysis programme) for women planning a delivery following a previous CS. We used qualitative methods at various stages within the DiAMOND study for enhancing trial processes and providing in-depth information on outcomes that are important to participants.17 Qualitative methods were used within the development phase to inform the final design of the interventions.18,19 This paper reports on qualitative data we collected from participants during the trial on their experiences of decision making and the role of the two decision aids.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Contribution to authorship
  9. Ethical approval
  10. Funding
  11. Acknowledgements
  12. References

The protocol,16 interventions,19 and main quantitative results20 of the DiAMOND study are reported elsewhere. The overall aim of the study was to investigate the effects of two computer-based decision aids on decisional conflict, anxiety, knowledge, preferred mode of delivery and on actual mode of delivery. Both interventions provided women with detailed information about the potential outcomes for both mother and baby of planned vaginal delivery, planned CS and emergency CS. While the information programme and associated website gave information only, the decision analysis recommended a mode of delivery based on the probabilities and the individual woman’s utilities of relevant outcomes.16,18 A qualitative study was nested within the trial to explore women’s experiences of decision making and the perceived role of the decision aids in their choices about mode of next delivery. Ethical approval for the study was given by the South West Multicentre Research Ethics Committee.

Sample

We purposively selected a subsample of all of the women in the DiAMOND trial who were due to deliver between February 2006 and July 2006. We aimed to achieve a maximum variation according to: study centre, previous CS (emergency or elective), intervention received within the trial (decision analysis, information programme or usual care), congruence between modes of delivery preferred by women and recommended by the decision analysis intervention, and consistency between preferred and actual mode of delivery. As the qualitative research in the development stage of the trial had previously captured the experiences of those receiving usual obstetric care,18 only two women receiving usual care were included in this sample to act as a broad comparison for those receiving the decision analysis programme (n = 14) and information programme (n = 14), which was the focus of this qualitative research.

Data collection and analysis

Semi-structured interviews were conducted by JF in line with Department of Health guidelines.21 Interviews lasted between 20 and 90 minutes and followed a topic guide devised by the research team (Table 1), drawing on the literature and topics of relevance to the main trial. Five pilot interviews were conducted prior to the main qualitative study to ensure that the interview schedule covered a range of proposed/preferred and actual delivery experiences. The schedule was used flexibly, allowing participants to introduce new issues of importance to them and enabling preliminary analysis of earlier interviews to inform questioning in later interviews.

Table 1.   Topic guides
In the prenatal interviews we explored:
Women’s experience of information provision and knowledge in preparation for their previous delivery
Women’s experience of information provision and knowledge inpreparation for their next delivery
How prepared women felt for the possibility of a vaginal or caesarean delivery, following a previous caesarean section
Women’s perceived usefulness of the two decision aids versus usual care
Women’s understanding of the risks and benefits associated with different types of delivery and any decisional conflict experienced
Women’s views on the decision making process; and their preferences for vaginal delivery or repeat caesarean section
In the postnatal interviews we also explored:
The relationship between prior preferences and decisions, (un)certainty, and the actual outcome
The extent to which these relationship were mediated by either the information programme or the decision analysis programmes

The prenatal interviews were conducted when women were approximately 37 weeks’ pregnant and had completed the primary follow up for the questionniare-based quantitative outcomes in the trial. Women in the information and decision analysis groups received the information at a mean of 21.3-week gestation. Prenatal interviews with women in the two intervention groups covered topics such as their preferences about mode of delivery, their experiences of the decision aids and feelings about the mode of delivery proposed by the intervention (for those receiving the decision analysis). Women in the usual care group were asked to identify factors which may have influenced their decision making. The postnatal interviews were conducted approximately 6–8 weeks after delivery. Postnatal interviews explored their actual delivery outcome, and how they felt about this compared to their prior preferences, the use of a decision aid and the delivery proposed by the intervention (for those receiving the decision analysis). The interviews were conducted in women’s homes and all were digitally recorded. The audio files were transcribed verbatim by a professional transcriber and JF then checked the transcripts against the original recordings.

The transcripts were provisionally coded by JF using Atlas.ti software.22 Similar to our qualitative research regarding the piloting of the interventions,18 and following iterative readings of the pilot interviews, we developed a thematic ‘framework’23 to organise and interpret the data. We chose a framework approach because we had pre-identified issues of interest, while requiring some flexibility to allow new themes or perspectives to arise from the data. Within our framework, we identified themes that could be broadly aligned with the outcomes of interest within the DiAMOND trial and could be flexibly applied to all the transcripts. Issues of particular interest to us in the context of the trial were: experiences of decision making about mode of next delivery and decisional conflict; how the decision aids impacted upon knowledge and anxiety; and how women reconciled their actual mode of delivery with their prior preferences. Three authors (JF, AS, DM) independently read and coded randomly allocated batches of transcripts using the framework, comparing codings and exploring negative cases at regular meetings, to verify the framework and ensure that the data could be accounted for by the identified themes. In addition, we were also able to identify themes that were outside the scope of immediate interest—such as the role of lay knowledge in decision making, and the emphasis which some women place on the sense of achievement associated with a particular mode of delivery—which are indicative of the wider context of women’s decision making. However, while we acknowledge that these additional themes emerged from the data, this paper focuses on those most relevant to the aims of the DiAMOND trial. The data presented represent the full range of views expressed by the women.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Contribution to authorship
  9. Ethical approval
  10. Funding
  11. Acknowledgements
  12. References

Of the 35 women approached, 30 agreed to participate in a prenatal interview, with those who declined citing mainly illness and lack of time. Twenty-two of these women were subsequently re-interviewed postdelivery. Reasons for declining a repeat interview included lack of time and emigration. Postnatal interviewees were broadly representative of women interviewed prenatally. Characteristics of participants in the interview study are presented in Table 2.

Table 2.   Characteristics of trial and qualitative study participants
Characteristicsn (%) in RCT Total n = 742n (%) in qualitative study Total n = 30
  1. RCT, randomised controlled trial.

  2. *As recorded on questionnaires, which were part of the documentation that women completed as part of the DiAMOND study, and which in some cases vary to preference expressed during qualitative interview. Less women were ‘unsure’ at interview (6 > 2), and more women expressed a preference for vaginal delivery (13 > 17).

Hospital
Ninewells186 (25)10 (0.33)
Southmead355 (48)16 (0.53)
St.Michael’s201 (27)4 (0.13)
Previous CS
Elective166 (22)5 (0.17)
Emergency569 (78)25 (0.83)
Intervention
Decision analysis245 (33)14 (0.47)
Information programme250 (34)14 (0.47)
Usual care247 (33)2 (0.07)
Preference for mode of delivery
Caesarean section155 (21)11* (0.37)
Unsure253 (34)6* (0.20)
Vaginal birth334 (45)13* (0.43)
Actual mode of delivery
Elective CS332 (45)14 (0.47)
Emergency CS151 (20)2 (0.07)
Vaginal birth154 (21)8 (0.27)
Vaginal birth + assistance70 (10) [96 missing]6 (0.20)

The quantitative results from the DiAMOND trial found that women in both intervention groups had lower decisional conflict and anxiety, and greater knowledge compared with women who received usual care. More women in the decisional analysis group (37%) delivered vaginally compared with usual care (30%) and the information programme (29%).20 The qualitative findings presented here augment our understanding of sources of decisional conflict and uncertainty during the pregnancy and any associated role of decision aids; the possible impact of decision aids on knowledge and anxiety; and the relationship(s) between prior preferences, decisions and actual outcome, and the mediating role of decision aids.

Theme 1: Role of decision aids in reducing decisional conflict and uncertainty (Text box 1)

Table Text box 1..   Role of decision aids in reducing decisional conflict and uncertainty
  1. UC, usual care; DA, decision analysis intervention; IP, information programme.

I’m not sure that there will be any decisions that I can be involved in. When it comes to something like this…I don’t have enough knowledge, medical knowledge to say anything…
Victoria (UC) Wanted elective CS, had elective CS
Q: To what extent did the [programme] actually help in making your decision making?
A: Probably about 85% of the decision was based on actually having a chance to think about the information outwith the, a hospital setting.
Alice (DA) Wanted VBAC, DA proposed elective CS, had VBAC + Ventouse
I’ve kind of gone [to Obstetrician] with questions from reading the DiAMOND study information, in order to sort of ask, sort of their medical opinion and their experience and what’s best to do…[from the website] I went through all the screens then I checked all of the statistics, I wrote down some of those statistics. The last time I saw the Obstetrician I took some of that information and asked her, for example, it says about infections, I said, you know: What kind of infections are they and the implications of them, because it doesn’t really go into that sort of information.
Natasha (IP) Wanted elective CS, had elective CS
Most information that you read are usually biased towards the vaginal, and as I said, I hate the fact that there is this pressure on, on women, this, this stigma about having an epidural or having a, a caesarean, but I can’t remember there being in, in the programme, no….It was very useful…it was very useful with the statistics and the information that it gave about, you know, how most women, what is it, sixty per cent of women, after having a caesarean section go on to have a vaginal birth. It was very interesting to read, and I think that a lot of people in a different situation to mine, who are considering a caesarean for a second child, yeah, would definitely find that information useful.
Isabel (DA) Wanted elective CS, DA proposed 1) VBAC, 2) elective CS, had elective CS
It provided me with, with a lot of information and, particularly after…completing the computer package, I was left thinking: right, I want more information now, I want to know more. So then I went onto the internet…and had a look. And also, in the book that I’ve, that I bought for my first pregnancy…that was very useful, so I think for me, it got me, it got me thinking…it set the wheels in motion for me.
Sophie (DA) Wanted elective CS, DA proposed elective CS, had emergency CS
I thought all the answers I’d given would reflect what I wanted, but of course they didn’t, they take into consideration the risks, don’t they? And the statistics, so, so it’s an unbiased opinion, which is different to my opinion…it was good to make me think about it.
Anna (DA) Wanted VBAC, DA proposed elective CS, had elective CS
When I went for this first consultation and said all the risks of a caesarean, with a natural birth you can have a tear, you can bleed, all sorts of things can happen and I think because it was pointing out both sides and, and I suppose it just highlighted the actual physical risks and then obviously my emotional thoughts linked in, so it kind of helped me make my decision, if you see what I mean…
Charlotte (DA) Wanted elective CS, DA proposed elective CS, had elective CS [private health care]
In terms of the actual decision analysis thing, because it didn’t really say how they’d worked, how the computer programme had worked it out, it was kind of, a bit like doing one of those personality quizzes in Cosmopolitan or something, you kind of think, ‘well, I suppose it could be true’, but, you know, but I didn’t…I didn’t sort of think ‘right, well this is, this means that this is the decision for me’.
Lucy (DA) Wanted VBAC, DA proposed elective CS, had VBAC + forceps

While women who received usual care appeared unsure of their role in decision making about mode of next delivery, those receiving the information or decision analysis programmes discussed factors that could impact upon decisional conflict or uncertainty. Many women commented upon the perceived degree of choice over the mode of their next delivery, and this was typically discussed in relation to their previous experiences of delivery and information provision, and perceptions of risk related to the next delivery. While some women found decision making so difficult that they wanted health professionals to make the decision regarding the mode of the delivery for them, a few held strong personal preferences about how they wanted to deliver. Many women also discussed the paradoxical tension between receiving fewer opportunities for consultation with health professionals in a subsequent pregnancy compared to a first pregnancy, despite some feeling that there is more to discuss regarding the uncertainty around the planned delivery. A small number of women also discussed the notion of ‘a hidden agenda’, such that they perceived that health professionals managed information provision to encourage women to deliver in a particular way.

Women who received the information programme often suggested that the quality and the depth of the information provided facilitated their decision making, and reduced their uncertainty. There was an appreciation that without this information, women were often unsure of what to ask or where to seek additional information that could inform their decision making. Some suggested that they saw the information programme as a ‘starting point’ for further information seeking, while others saw it as a means to facilitate discussion with health professionals and partners.

Women who used the decision analysis intervention were more likely to discuss how specific pieces of the information provided in the programme related to their role in decision making. Similar to those who received the information programme, some women saw the decision analysis as a starting point for further information seeking. Others discussed the process of ranking possible outcomes of delivery as helpful in itself, by enabling the explicit consideration of the importance they placed on the avoidance of each outcome. However, for a minority of women an increased perception of risk arising from use of the decision analysis added to their uncertainty about the decision. A few women did not find the decision analysis helpful in their decision making for the following reasons: they did not understand how the decision tree produced a recommended ‘preferred option’ for delivery; they did not think that the programme considered their individual circumstances; or they did not agree with the recommended ‘preferred option’ for delivery.

Theme 2: Impact of the decision aids upon knowledge and anxiety (Text box 2)

Table Text box 2..   Impact of the decision aids upon knowledge and anxiety
Q: What do you think the risks are of having a vaginal delivery?
A: I don’t know genuinely what they are, I’ve never been told, I don’t think…
Q: And what do you think the risks are at all for having a repeat section?
A: I don’t know. I suppose I should know, I don’t remember anybody telling me
Victoria (UC) Wanted elective CS, had elective CS
I just think it gives you many things to kind of think about: the risks to the baby and the benefits to the baby and also to the mother, in a very comprehensible kind of way, you know, you don’t have, as I say: lots of pictures and frills. It just sort of stated, and I liked that aspect.
Elizabeth (IP) Wanted elective CS, had elective CS
I think it was useful because it’s all in one place, and rather than having to rely on information that I wasn’t 100% sure of, I knew that with this programme that it was, you know, it was medical, proper scientific based information.
Tracey (IP) Wanted elective CS, had VBAC
It was a very good, very informative, very factual…it was portrayed as, you know: these are the risks for VBAC, these are the risks for elective caesarean, these are the benefits, it was very, very to the point.
Sophie (DA) Wanted elective CS, DA proposed elective CS, had emergency CS
It [Decision analysis] educated me in risks that I didn’t know about. Definitely….very, particularly with me having had such a traumatic first birth, the fears that I’m taking into this one, it’s nice to have been able to do this and learn the things that, I mean the medical things about the risks, I didn’t, I don’t know, I’m trying to remember examples of ones that I learned through the DiAMOND study that I didn’t know through the medical profession and I think really, there was the hemorrhaging, I didn’t really, and the hysterectomy aspect, and there was a couple of other ones that I hadn’t been told…by anybody else.
Anna (DA) Wanted VBAC, DA proposed elective CS, had elective CS
I wasn’t particularly happy with [Decision analysis] at all. I thought a lot of the things, was just a lot of scary information, it was quite scare-mongering, to a certain degree, and there were very negative things towards having a natural delivery.
Hannah (DA) Wanted VBAC, DA proposed elective CS, had VBAC [doula]
I think to some extent, you have to be blunt, to say: Look, this is what could happen. Because if you sugar coat too much…and then something actually happens to someone, you know, they’re kind of shocked then.
Olivia (DA) Wanted VBAC, DA proposed elective CS, had VBAC
I think I tend to shy away from thinking about the risks, you don’t really want to think about things like brain damage or blood clots or baby having breathing difficulties or things like that. What I tend to think about are more practical things like, you know, being able to pick up the baby after, after an operation or getting an infection or things like that, because, partly because those are things…in terms of thinking about things actually going wrong in the delivery room, or…I think I tend not to think about those sorts of things because I would rather not…
Lucy (DA) Wanted VBAC, DA proposed elective CS, had VBAC + forceps

Although only two of the women interviewed received usual care, neither could identify the possible health outcomes associated with the different modes of delivery. In contrast, women in the information programme group identified general risks associated with both vaginal delivery and CS. Women in the decision analysis group, however, were more likely to identify specific risks associated with vaginal and caesarean delivery, such as risk of haemorrhage and tearing.

Perceptions of the risk information provided in the information programme ranged from boring to alarming, although there was often an acknowledgment that information provision is essential. It is difficult to disentangle the extent to which the programme may have contributed to or alleviated some of the women’s anxiety, as some suggested that pregnancy and the uncertainty surrounding mode of delivery inherently create anxiety, such that their questions and concerns naturally changed throughout their pregnancy. To this end, several women suggested that they would have liked the opportunity to discuss the information in the programme with a health professional to address any issues or concerns. Overall, however, most of the women were comfortable with the form and content of the information programme, perceiving it as relevant and timely. Several women also used the website subsequently and valued the opportunity to consolidate their learning.

Similarly, some women who used the decision analysis found the risk information to be quite unsettling, and a few suggested that they would have liked more information alongside the programme, possibly provided by a health professional. Most women suggested that rating possible health outcomes along a visual scale encouraged them to confront their fears. While they might not have liked having their preconceptions challenged, this often encouraged them to rethink their decision. However, there were a small number of women who were concerned about the generalisablity of the information in the decision analysis and the relevance for their specific circumstances. These views seem to reflect both women’s lack of understanding about how the decision tree produced a recommended ‘preferred option’ for delivery; as well as the perception that the programme was in some way colluding in a ‘hidden agenda’ to promote particular modes of delivery. Typically though, women suggested that the decision making ‘process’, central to the decision analysis programme, was helpful and each decision aid appeared to increase understanding of the decision to be made without unduly increasing their anxiety.

Theme 3: The relationship between the prior preferences/decisions and actual outcome (and the mediating role of decision aids) (Text box 3)

Table Text box 3..   The relationship between the prior preferences/decisions and actual outcome (and the mediating role of the decision aids)
Q: Do you think that the information programme helped you prepare and plan for the delivery?
Q: Yes, I think it informed me fully about what…the benefits and the risks. I think that’s something that you constantly kind of think about but in a way, in a much more informed way through the programme, because other mothers that I had, you know, knew at the time, expecting when I did and we would sort of, you know, in conversation discuss various sort of little things and they didn’t seem to know and I didn’t really want to often burden them, you know, with the information that I had got from the programme, so in that way, I felt empowered by it, if you can put it like that. So it gave me food for thought really.
Q: Do you think it actually prepared you for the delivery as well as informing the decision?
A: Yes. Yes.
Elizabeth (IP) Wanted CS, had elective CS. Repeat interview.
Q: To what extent, if any, did using the information programme influence your decision?
A: It definitely did influence, yeah, I think so because the information you gave on the, the things that could go wrong during either a natural or a caesarean section, that’s how I came to the decision that I would go for an elective section…And then if I went early, have natural, because I kind of came to the conclusion that there was pros and cons to both.
Tracey (IP) Wanted CS, had VBAC. Repeat interview.
Q: To what extent if any, was your decision informed by the information programme?
A: It definitely helped make my decision…I remember thinking it was a good programme to have, to look at, and I think all the information that I read all helped me in my decision.
Chloe (IP) Wanted VBAC, had VBAC + Ventouse. Repeat interview.
I had a big list of questions when I went to see my midwife, especially when it was on to the birth plan…because obviously I wanted to make sure I knew all about the pros and cons and what I would do in those situations, so I had a birth plan, but like two birth plans really, because I was prepared either way.
Imogen (DA) Wanted VBAC, DA proposed elective CS, had VBAC + Ventouse. Repeat interview.
Q: What method was proposed by the decision analysis programme?
A: Elective caesarean section…I was quite relieved actually, that it had come out with that, because that was my gut feeling all throughout this pregnancy, but there was something in the back of my mind, I don’t know, niggling me to maybe have a trial of labour, but then answering the questions and going through that exercise, all my fears were sort of, my fears were actually put into black and white and on a screen, and it made me realise that that was the best possible outcome really for me.
Sophie (DA) Wanted CS, DA proposed CS, had emergency CS. Repeat interview.
Q: Looking back on it now, how useful do you think the decision analysis was?
A: Very useful, because…before I had that research, I didn’t know anything about all the pros and cons of having certain deliveries. I just thought, ‘yeah, let’s go for a natural delivery’, and I probably would have been more shocked if I went for the natural delivery and something happened, one of those things happened to me because…I wouldn’t know what was happening, and…it would just be really strange, whereas the minute they say ‘oh, you’re haemorrhaging’, or something’s going wrong, I would have know what they were likely to do about it, what it’s going to mean for me.. for the baby, so I found it very helpful.
Imogen (DA) Wanted VBAC, DA proposed CS, had VBAC + Ventouse. Repeat interview.
I think [the Decision Analysis] was good for making me aware of more risks than I was and for making me think more about the decision I’d made. I think it probably made me feel better about the consequence of having to have a caesarean at the end of the day.
Q: And, and to what extent, if any, did it assist you in making your decision, do you think?
A: I don’t think it assisted me, but it…because it came out with a conflicting result to what I wanted to do, but it was definitely beneficial, definitely. I think even if it’s just for putting across all the risks of birth, because although there’s all the information out there, that one seemed to have things I hadn’t read and heard about.
Anna (DA) Wanted VBAC, DA proposed CS, had VBAC. Repeat interview.

The longitudinal nature of this research allowed us to explore women’s reflections on the perceived role of the decision aids in mediating or reinforcing their decisions both before and after delivery.

Postdelivery, women in the information programme group described the information as contributing to ‘informed choice’. Although women suggested that the information had contributed to their decision, few were able to explain directly how the information programme might have had a direct and measurable influence upon their subsequent decision for a particular mode of delivery.

Some women who had received the decision analysis intervention suggested that the programme had confirmed their prior preference for a particular mode of delivery, while others suggested that the interactive nature of the decision analysis facilitated the exploration of certain topics in depth, allowing further clarification of the risks and benefits of different modes of delivery. A few would have liked the information to be broader, or to include personal experiences.

After birth, we were also able to examine the extent to which the decision aids may have played a role in helping women to accept the need to alter the planned mode of delivery, due to clinical circumstances or events as they unfold in labour. In the postnatal interviews, several women suggested that the decision analysis helped them to reconcile the actual mode of delivery with the delivery that they had hoped and planned for. If the decision proposed by the programme was different to the woman’s preference, but was the same as the actual mode of delivery, the consideration of possible outcomes could be viewed retrospectively as a type of ‘prior warning’ that their plans might need to change. For example, for some women as the events of their labour unfolded, the need for a particular delivery may have become more evident. For such women, the decision analysis was seen with hindsight as beneficial. When the delivery proposed by the decision analysis conflicted with the actual mode of delivery, some women felt able to draw on both the decision analysis process and/or the provision of risk information to re-evaluate their actual birth experiences and the various factors influencing their actual mode of delivery. This led them to conclude that, although their birth was not necessarily as they would have wished, they had an understanding of why this particular delivery was necessary with this specific pregnancy and labour. However, for some women, having a proposed mode of delivery that contrasted with their clear pre-existing preference (typically a proposed CS with a clear maternal preference for a vaginal delivery), appeared to have polarised their decision further towards their original preference.

Postnatally, we also examined whether decision aids had played a role in assisting women come to terms with the uncertainty inherent with planning a mode of delivery and the need to consider the range of potential options. This contrasted with the experience of one woman who received usual care, who suggested that women who are faced with the uncertainty inherent with planning a mode of delivery only look for information to support their position.

Women in the information programme group alluded to their consideration or acceptance of a range of possible options during their delivery due to their wider knowledge, although few directly attributed this knowledge to the programme.

Women in the decision analysis group, however, often made direct references to the role of the knowledge acquired through the decision analysis and the process of rating possible outcomes in their feelings about their actual delivery. They alluded to the possible dissonance between the preferred mode of delivery, the delivery proposed by the decision analysis and the actual mode of delivery. As such, some women interpreted this mismatch as symbolic of the inherent uncertainty associated with planning a delivery.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Contribution to authorship
  9. Ethical approval
  10. Funding
  11. Acknowledgements
  12. References

In this research, qualitative interview methods were used to explore the views and experiences of participants in a randomised controlled trial of two decision aids for mode of delivery following a previous CS.

Providing decision aids helped most women by increasing knowledge without increasing anxiety, and they helped women to appreciate and cope with the uncertainties of labour and delivery.

While the DiAMOND trial ascertained that the two decision aids reduced decisional conflict compared with usual care, the qualitative data have illuminated a range of possible sources for decisional conflict, including previous experiences, family pressures, notions of ‘choice’ and perceptions of a ‘hidden agenda’ for particular modes of delivery. These findings suggest that both computerised decision aids for planning mode of delivery among women with a previous CS may enhance decision making, by providing a systematic approach to decision making. The decision analysis intervention may also help women to reconcile a mismatch between their prior preference and actual mode of delivery. Elwyn et al.13 have attributed this to enhanced patient autonomy and the provision of a structured approach to decision making. However, while the DiAMOND trial concluded that both interventions reduced decisional conflict compared with women in the usual care group, this qualitative investigation found that, for some, the decision analysis intervention added to uncertainty in women’s decision making prior to delivery.

Our qualitative findings are not generalisable to wider populations in a statistical sense. The women we interviewed were broadly representative of women delivering in the south-west of England and Scotland, although some caution is needed when translating these findings to minority ethnic populations. The women in our study may have been self-selected—being more prepared to tell their stories. The detailed accounts in the follow-up interviews indicated that recall was not as problematic as we had anticipated. The analysis was undertaken by a multidisciplinary team to ensure that categories and themes were robust and that agreement was reached. The convergence of the ideas presented here with other research regarding decision aids suggests that our results may be transferable to other clinical settings—for example, in relation to other obstetric decisions.24,25

The findings of this qualitative research are consistent with those of previous studies which have identified the contextual and fluid nature of women’s decision making regarding mode of delivery.7 This supports the results of qualitative research during the development stage of the DiAMOND trial, where women with prior experience of making a decision about mode of next delivery after a previous CS (without use of a decision aid) expressed concerns regarding practical and experiential factors, rather than concerns for safety.18

Although the notion of informed maternal choice is now enshrined in professional guidelines,4,26 many service providers are unable to account for the effectiveness of information provision in informing women’s mode of delivery.27 Along with previous studies regarding obstetric decision making,24,28 the findings of this qualitative research suggest that decision aids have a role in reducing decisional conflict for most women, although uncertainty may be increased for a minority. Quantitative data from the main trial suggested that total decisional conflict was reduced in all three groups at follow up compared with baseline, and both interventions reduced decisional conflict more than usual care.20 In addition, our qualitative interviews with DiAMOND trial participants suggest that there are many possible sources of decisional conflict and uncertainty, and that the relationship between information provision and informed choice is complex.

The findings of the DiAMOND trial suggest that anxiety scores were higher in all three groups at 37-week gestation compared with baseline, and highest among women in the usual care group.20 This qualitative research found that the majority of the women interviewed were satisfied with the information about interventions or suggested that confronting one’s fears and anxieties was necessary to make an informed decision. This is in contrast to previous suggestions that women avoid engaging with information that may challenge their preferred mode of delivery,29 but confirms notions that anxiety may be more to do with the inherent nature of uncertainty in pregnancy and women’s perceived responsibility for the ‘right’ choice.7

While most women were satisfied with the computer-based format of the decision aids, similar studies suggest that women value the opportunity to receive information in a range of formats, including verbal- and paper-based information.13,24,29 While women in the decision analysis group received a printout of the suggested optimal mode of delivery, several reported that they would have valued a print-out of their utilities for the various outcomes, which they could have subsequently referred to in consultation with their health professionals. Perhaps different formats could meet women’s preferences and serve various functions, such as reviewing information and decision making at different stages in pregnancy further augmenting learning, and possibly reducing anxiety.

Mode of delivery data from the trial suggested that women in the decision analysis group had a higher rate of vaginal delivery than in the information programme group and those receiving usual care.20 The qualitative interviews allowed us to explore the extent to which the decision aids had a role in reinforcing women’s decisions or alternatively in aiding them to reconcile the need to alter the planned mode of delivery due to clinical circumstances or changing events in labour. Earlier research has suggested that while many women want to be involved in the process of decision making, rather fewer are confident about taking responsibility for the final decision.7 In contrast, some of the women in the decision analysis group of the DiAMOND study suggested that, as well as informing their decision, the intervention could also confirm their existing preference, or enable them to reconsider pre-existing assumptions.

In this qualitative study, women also discussed the extent to which the decision analysis, and to a lesser extent the information programme, enabled reconciliation of their preferred and actual delivery experience. When there was congruence between the preferred, proposed and actual delivery, many women identified the confirming role of the interventions, but when there was conflict between the preferred and proposed and actual mode of delivery, many women drew on their knowledge and suggested that this reflected the intrinsic uncertainty associated with planning a pregnancy and delivery.7

Our findings suggest that health professionals need to consider the wider psycho-social context in which they frame risk information for women making decisions about mode of delivery.10,11 The DiAMOND trial reported that women in the two intervention groups had higher knowledge scores and lower anxiety scores than those in the usual care group; while women in the decision analysis group had a higher rate of vaginal delivery, and reported higher satisfaction than either those in the usual care and information programme groups.20 It is possible, as in a similar Australian study,28 that this result is simply artefactual. However, this finding seems to be supported by responses in the qualitative interviews, where women emphasised the utility of the decision analysis in enabling them to both question and clarify any prior preferences. This is consistent with the findings of a trial of a decision aid for breech presentation at term: women receiving the decision aid intervention felt significantly more informed and experienced greater certainty about their decisions than those receiving usual care; they also reported clearer values; felt more supported and felt that they had made more effective choices.24

Conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Contribution to authorship
  9. Ethical approval
  10. Funding
  11. Acknowledgements
  12. References

Women making a decision about mode of delivery following previous CS value some form of structured, relevant information to help reduce decisional conflict. Decision analysis may help reconcile prior preferences and the actual mode of delivery. We therefore recommend the use of decision aids to augment clinical consultations when women are planning the method of delivery following a previous CS.

Contribution to authorship

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Contribution to authorship
  9. Ethical approval
  10. Funding
  11. Acknowledgements
  12. References

AM, DJM and AS designed the study. JF conducted the interviews, prepared the transcripts and undertook data coding. All authors developed the thematic headings and JF, AS and DJM contributed to the analysis and interpretation of the transcripts. JF drafted the paper, with help from the other authors; DJM will act as guarantor for the paper.

Ethical approval

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Contribution to authorship
  9. Ethical approval
  10. Funding
  11. Acknowledgements
  12. References

Ethical approval was obtained from the South West Multicentre Research Ethics Committee, for contacting women from both time periods.

Funding

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Contribution to authorship
  9. Ethical approval
  10. Funding
  11. Acknowledgements
  12. References

This research was funded by the BUPA Foundation (Grant no. 657/G10). The guarantor accepts full responsibility for the conduct of the study, had access to the data, and controlled the decision to publish.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Contribution to authorship
  9. Ethical approval
  10. Funding
  11. Acknowledgements
  12. References

We thank the women who took part in the study. Other members of the Decision Aids for Mode of Next Delivery (DiAMOND) Study Group are as follows: Clare Emmett, Tom Fahey, Peter Gregory, Sandra Hollinghurst, Clare Jones, Beverly Lovering, Maureen Macleod, Irene Munro, Roshni Patel, Tim Peters, Ian Ricketta, Anne Schlegelmilch, Kav Vedhara, Kate Warren and Helen Watson.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Contribution to authorship
  9. Ethical approval
  10. Funding
  11. Acknowledgements
  12. References
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