Reducing caesarean rates

Jun 3 2007

A computerised decision analysis programme which helps women decide on the type of birth that is most appropriate for them could cut the number of caesarean sections performed in England and Wales by 4,000 a year, according to a study by researchers at Bristol University published on bmj.com.

Rates of caesarean section in the UK are rising - from 9 per cent of births in 1980 to 21 per cent in 2001.

Researchers from the Universities of Bristol and Dundee recruited 742 women at four maternity units in the UK where the rates of caesarean section ranged from 22 per cent to 25 per cent – approximately the UK average.  Each woman had had one previous caesarean section.  They were split into three randomised groups.

The first group were given the usual care a woman would expect from obstetric and midwifery staff. 

The second also had access to a computer based information programme which gave them descriptions and the risks of likely clinical outcomes of a normal delivery, an elective caesarean section and an emergency caesarean section.

The third group had access to a more complex computer based decision analysis programme.  They were given descriptions of the outcomes associated with a planned normal birth, elective caesarean section and  emergency caesarean section.  They were then asked to consider the value they attached to each possible outcome using a ratings system.  From that the programme produced a recommended "preferred option" which the woman could print out and discuss with her midwife.

Dr Alan Montgomery, Senior Lecturer in Bristol's Department of Community Based Medicine and his colleagues found a higher proportion of the decision analysis group (37 per cent) had a vaginal birth compared with the usual care group (30 per cent) and the information programme group (29 per cent).

The women in the two intervention groups also had lower anxiety scores and higher knowledge scores than those in the usual care group.  Satisfaction was also higher in the decision-analysis group.

The study found that computer based decision aids can reduce decisional conflict among pregnant women with one previous caesarean section.

The researchers said: “This is an important finding, as detailed descriptions and probability information about obstetric complications might be considered as potentially alarming."

They also acknowledge the mode of delivery results are intriguing and ask why should a more complex decision aid influence the mode of delivery?

"Ongoing parallel qualitative work indicates that explicit consideration of personal values attached to potential outcomes challenges women's  perceptions of the optimal decision and this may influence their resolve to achieve a vaginal birth."

They conclude: "Although the content was carefully designed to not favour one mode of delivery over another, even a small absolute change in decisions could have a substantial impact on national rates of caesarean section."

Two decision aids for mode of delivery among women with previous caesarean section: randomised controlled trial BMJ Online First

Please contact Dr Alan Montgomery for further information.