Of the 50 invited healthcare professionals, 34 agreed to participate in the study and 16 did not reply. Six were unable to attend focus groups because of time constraints, so 28 professionals finally took part. The participants’ characteristics are detailed in Table 1. They varied in age, gender, level of experience, country of training, number of own children and method of their children’s delivery. Three participants had seen the decision aids prior to the focus group. Focus group participants may have had women under their care who had used the decision aids during the RCT as they were working in the same locality.
Three recurrent themes relating to decision aid implementation were identified through the analysis. Verbatim quotes are used to illustrate the themes and the quotes presented reflect the full range of views expressed in the focus groups. To maintain anonymity, the quotes are identified by the participant’s professional role and unique identifier.
Detailed comparison and appraisal of the content and presentation of the two decision aids is outside the scope of this study. Further details of the aids can be found elsewhere.8,23 The two aids were often referred to synonymously by participants in this study. The findings we present here focus on the professionals’ views on implementation of these decision aids into the routine care of women choosing mode of delivery after a prior caesarean section.
In general terms, participants spoke positively about the decision aids. Many preferred the simpler information website to the more complex decision analysis program.
Practicalities of decision aid implementation: when, who and how?
Most participants felt that information about the existence of the decision aids should be offered as early in pregnancy as possible, ideally close to the booking visit (when women are around 12 weeks pregnant). However, some thought the aids should be accessible throughout, reflecting the view that decision making occurs over time and can change during the pregnancy.
I think the booking visit, as we said before, because that’s when the midwife takes the whole history, sees how many sections the woman’s had before, and then identifies the patient. (Obstetrician, DA5)
There was consensus within and across the focus groups that community midwives were the most appropriate healthcare professionals to first introduce the aids to women, particularly as they would have more personal knowledge of the woman and her circumstances. However, many felt that any questions generated should be discussed with an obstetrician nearer to term.
I think it would be best if it were the community midwife because it’s the community midwife that has got to know them and knows their individual circumstances, and might know the circumstances of their previous delivery, so I think that’s the most relevant person to do that. Am I just talking myself into more work? (Community midwife, MC4)
I think their community midwives can very easily tell them that there’s a, you know, there’s an aid around that can help them make those decisions which will then be discussed then when they come to see the doctor. (Hospital midwife, MA4)
Professionals other than community midwives gave reasons, such as lack of knowledge or not being available at the right time during pregnancy, as reasons why they were not the best professional group to first introduce the aids to women.
We don’t know that much about all these complications. (GP, DC2)
I think it depends when, when you’d offer it, ‘cause we don’t often see women until later on. (Obstetrician, DA1)
The majority of professionals felt that all women with a previous caesarean section should be offered a decision aid. However, others felt that there should be some targeting, notably towards ‘those interested’ or ‘those undecided’ and some stated that women with more than one previous section should be excluded. There seemed to be a hospital/community divide in terms of views on which groups of women may benefit most from the aids. Several hospital professionals suggested that ethnic minorities and deprived groups should be targeted, whereas some community staff identified educated and higher socio-economic groups as those most likely to benefit.
It may be very important, more useful towards…populations where you just can’t get across the information, ‘cause of the language barrier. (Obstetrician, DA4)
DC3: I think by definition you’re going to use it on an educated population, because...they are the people who are most likely to benefit from it.
DC5: Yeah and to want it and to be worried about it.
DC2: It’s your white middle-class interested people.
DC4: Yeah, it’s like the worried well isn’t it? (GPs)
Participants also discussed how the aids could be implemented. The venues highlighted as the best placed for implementation included women’s homes (via their personal computer), antenatal clinics and public facilities, such as libraries or evening classes. While feeling that community midwives were best placed to introduce the aids to women, participants tended to agree that self-access would be the best option for actually viewing and reading the program contents. This would enable more women to receive the information and pose fewer barriers to access than if use of the aids needed to be guided by clinicians (see ‘barriers’ below).
MC1: Yeah, it would have to be self-accessed.
MC4: Yes, more and more people do have their own personal computers and access to websites, and even, even the poorer end of the scale … they’ve usually got access to, to the web.
MC2: I think self-access would be fine. (Community midwives)
Is it something that would be feasible to just say ‘sit down, have a look at this, you know, before we see you.[In clinic] It’s gonna be an hour before we see you, have a flick through and see what you think’…they don’t need to see a nurse, they don’t need to see a midwife. There just needs to be a computer available. (Obstetrician, DA3)
Barriers to implementation of the decision aids
Several potential barriers to implementation of the decision aids were identified by the participants, and these fell into three categories: service issues, computer issues and people issues.
Service issues that were viewed as potentially preventing implementation of the decision aids included: professionals’ time and workload, workforce shortages, money and space. All groups raised the issue of the aids impacting on clinicians’ time and workload, in a context, where there is a perceived workforce shortage. This was more of a concern if clinicians were required to guide women through the aids or if access to the aids was in a community clinic or hospital setting. However, individual midwives and doctors felt that using the aids could ultimately be time-saving and enhance women’s care, as the aids could provide women with information that professionals did not have the time to provide.
It’s a bit of a time factor as well. I don’t think midwives, the main community midwives, have the luxury of actually women going and spending an hour doing that and then having the chance to actually spend a lot of time talking to them about it. I think that could be quite a pressure to be honest. (Hospital midwife, MA1)
It gives the chance to deliver information that we don’t necessarily have time for, we, you know, omit to mention at the time, I think. (Obstetrician, DA3)
The four hospital focus groups also raised the cost of setting up, maintaining and updating the decision aids and space limitations within their departments for women to view the aids on a computer, as possible service issues that would acts as barriers to implementation.
We haven’t got enough seats and people are standing and we’re running out of rooms now, aren’t we, as we’re getting bigger and doing more. (Hospital midwife, MB3)
Computer-related issues raised by the groups often focused on the computer literacy of potential decision aid users, especially if the aids were to be implemented for self-use. Together with language barriers (e.g. for ethnic minority groups) and potential lack of access to a computer, this was seen as a barrier to implementation that might result in inequitable access to the decision aids. There was consensus about these issues, both within and across the groups.
DB5: I think the internet way would suit some women but some groups who maybe don’t have a computer or aren’t as confident then they’d be disadvantaged.
DB3: And you’d have to be computer literate too. Many women may not be. (Obstetricians)
What about people that can’t read? I mean, you’d have to have it in different languages as well and stuff like that. We’ve got lots and lots of different ethnicities haven’t we? (Hospital midwife, MB2)
The final category of barriers to implementation was people issues. Professionals within all focus groups felt that women’s prior preference for a delivery method may act as a barrier to decision aid use, as those with a strong preference may show less interest in learning more about different delivery options and their associated risks and benefits.
There’s a lot of women who are quite pro vaginal birth, aren’t there. But I think there’s some women that, if they’ve had a really traumatic first delivery that’s ended up in a caesarean, then they just don’t want to go through that again. (Hospital midwife, MA5)
Individual clinicians’ delivery preference was also raised as a barrier by eight individuals in three of the focus groups, notably by midwives. It was felt that clinicians who had a preferred recommended mode of delivery for women with a previous section may not advocate the use of a decision aid that does not promote one mode of delivery over the other.
It really depends on how you can get the consultants behind something like this, because some of them don’t seem to care about the section rate...It’s just that they, they’ve just all got different opinions and you’re never going to get a programme that suits them all. (Hospital midwife, MB1)
But don’t you find that a lot of consultants do push them towards having an elective section or that it depends on the consultant? (Community midwife, MC3)
An additional people factor raised by some was the potential for decision aid use to result in longer more complex consultations with more challenging patient-professional dynamics, because of the additional information that women might want to discuss. However, there were a variety of views as to whether this would act as a barrier to implementation: some felt that it might, while others viewed the aids as potentially leading to improved consultation dynamics and more informed women asking fewer questions.
A lot of this isn’t something that you could discuss in, in a couple of minutes. I think, you know, if someone has spent a lot of time going over this website, then it’s not really going to be a ten minute consultation, I think it would be longer. (GP, DC1)
I think it would lessen them [consultations] a little bit. Like, if they can go away and read information, they might have less questions when they come in. (Hospital midwife, MA3)
There were some concerns that the aids would only help women who were already informed and interested and wanted to be involved in their care, rather than those who were less interested in information and more reliant on professionals to decide for them.
It would probably make no difference to the people that wouldn’t necessarily want to access the information in the first place and would rely on the doctor to give them the information and want them to make the decision for them. (Obstetrician, DB5)
Facilitators to implementation of the decision aids
A range of factors that might support or enable implementation of the decision aids were also raised by the group participants. The decision aids were viewed by some participants as potentially time-saving (see above). In addition, many participants described the decision aids as facilitating women’s access to information from reliable and standardised sources. This was particularly raised by some of the midwives and was viewed as beneficial as they felt that women often received conflicting advice from doctors within their usual care or sought information from unreliable sources. The decision aids would give the professionals confidence that the women were receiving trustworthy information.
MB1: I think it might sort of standardise the advice they’re given, that’s I think the main advantage. Because at the moment they get very conflicting advice depending on which doctors they see, so I think it would be a way of standardising them.
MB3: At least with a site like that [the decision aid] you know what’s on it, whereas some of the things they look at …Yeah, some of the questions, I say ‘Where on earth did you get that from?’(Hospital midwives)
Another valuable facilitator to implementation, raised within five of the six focus groups, was the potential for the decision aids to empower women, by helping them to think more carefully about the decision regarding mode of next delivery, to process and organise their thoughts, to stimulate questions and enable them to reach a decision that is best for them. In turn, this might result in greater satisfaction among women regarding the decision that is made. Participants from four of the groups also thought the aids would be a good educational aid and resource for professionals, similarly stimulating them to be more systematic in their use of information regarding birth options after caesarean section.
DA2: It’s systematically going through everything, isn’t it? Whereas we may not do that, we may be more biased
DA1: Partly it’s useful, because it just makes women think a lot about the decision, isn’t it? Cos I think sometimes women don’t think enough about the decision, so some of its usefulness is actually just in time spent thinking. (Obstetricians)
I agree with MA1 that the more information you can give a woman the more actually they’ll feel happier I think with the decision they make and they won’t feel they’re being forced into a decision kind of either way. (Hospital midwife, MA5)
Finally, there was consensus across most groups that uptake of the decision aids (or at least the opportunity to signpost them to women) would be most likely if they were incorporated within existing antenatal care, rather than requiring additional appointments or funds to implement provision. Increasing healthcare professionals’ awareness of the decision aids and obtaining their support for the use of the aids as an adjunct to clinical care were ways that were discussed to improve implementation success. In terms of actually using the aids, as noted previously, self-accessing the aids (for example via a website on one’s home computer), was viewed by professionals as a way of reducing many ‘service’ barriers to implementation.
I think if you make it an extra appointment ...you’re almost suggesting that the time they have now isn’t enough. (Hospital midwife, MB2)
If a lot of healthcare professionals know that those options are out there then hopefully somebody somewhere will be able to point it out to the right people (Hospital midwife, MA3)
It’s not just education of patients it’s education of healthcare providers as well. If you get them on your side and be motivated enough to, you know, roll it out to the community isn’t it? (Obstetrician, DB3)