Making decisions about birth after caesarean

Roles of health professionals in decision-making

Health professionals have an important role to play in women's decision-making about birth after caesarean. Clinical guidance recommends a model of shared decision-making between health professionals and women*. In this model, doctors and midwives provide women with information about birth choices and support them in reaching a decision. Hospital consultants can usually provide women with information about why they had a caesarean previously and how likely they are to experience similar complications again. Community and hospital midwives will also often be able to advise women about the risks associated with different ways of giving birth and to reassure them about any concerns they have.

For most women we talked to, advice and information received from health professionals played an important role in reaching a decision, but they also considered the views of their partners, family and other women. (See also 'Women's experiences of making the decision' and 'Role of partners and others in decision-making'.) All but two of the women also used one of two versions of a decision-making aid that provided them with additional information about the risks and benefits of different ways of giving birth as part of their participation in a clinical trial (see 'About the interviews and the DiAMOND trial').

Many women felt very happy with how health professionals had supported them in their decision-making. Most had not received much information about birth after caesarean before attending their first hospital appointment. While most had a preference for how they wanted to give birth to their next child, many felt uncertain about how realistic their wishes were. Many also had questions and concerns that they wanted clarified before making a final decision. Several women said getting support for their birth preference from an experienced doctor or midwife was very helpful and reassuring. For a few who had felt uncertain, talking things through with a sympathetic health professional helped to make up their minds. (See also 'Information needs & attitudes in next pregnancy' and 'Views on information from health professionals')

Specific bits of information from health professionals often acted as final puzzle pieces in women's decision-making, making them feel more confident about the preference they had already. A couple of women were considering a vaginal birth but worried that they might end up with another long labour followed by an emergency caesarean. They felt reassured when health professionals told them that they would be closely monitored and not be left to labour for as long as previously. A couple of women also felt relieved to learn that they would not be induced. On the other hand, a couple of women said that not getting precise information about how their labour would be managed should they decide to attempt vaginal birth had contributed to their decision to have a planned caesarean instead.

For a few women, their midwives became important emotional allies in the decision-making process. This was particularly the case for one woman who decided to attempt VBAC and refused to be closely monitored during labour against the advice of her consultant. Women found it particularly helpful when midwives had personal experience of either VBAC or planned caesarean themselves.

Women differed in how much they wanted to be involved in the decision about how to give birth to their next child (See also 'Women's views on choice about birth'). This influenced the expectations they had towards health professionals. Some women described encounters with doctors and midwives that had followed the model of shared decision making outlined in the clinical guidance. 

A few other women encountered a more paternalistic style, with health professionals telling them firmly what they thought was best. On the other hand, several women described health professionals as taking a 'hands off' approach, asking them for their birth preference without providing any kind of guidance. All of these models worked well as long as they matched women's own preferences for involvement. 

However, conflict arose in situations where women expected either more or less guidance from health professionals than they actually received. A few women who felt well-informed about all the risks and had very clear preferences of how they wanted to give birth saw the purpose of their hospital appointment mainly as informing health professionals of the decision they had reached rather than discussing it afresh. 

A couple of women were surprised when doctors just asked for their preferences instead of engaging them in discussion. Another couple of women who were told that the decision was up to them, said they would have preferred to get more guidance as they did not think they had the medical expertise to make such an important decision by themselves. One woman was pleased that a midwife she trusted was prepared to give her firm advice rather than just leave things up to her.

Several women felt that health professionals in general, and midwives in particular, were more supportive of VBAC then planned caesarean. A few women said health professionals had tried to push them into attempting vaginal birth. On the other hand, a couple of women said they had felt pushed into having a caesarean by their consultant. Several women felt that the information they had received from health professionals was biased and reflected doctors' and midwives' own agendas. They were pleased that, as participants in the DiAMOND trial, they had access to a decision aid with information that they perceived to be balanced and comprehensive. 

Women's accounts of health professionals' roles in their decision-making suggested that doctors and midwives can make a very positive difference in helping to reach what many women experience as a very difficult decision. However, they also showed the importance for health professionals to be sensitive to women's own preferences for involvement in decision-making and highlighted the challenge of building trusting relationships in a busy healthcare environment.

The National Institute of Health and Care Excellence – NICE guideline on caesarean section (CG132) was published in 2011. 

Last reviewed August 2018.


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