Making decisions about birth after caesarean

About the interviews and the DiAMOND trial

The women who were interviewed for this website were also participants in a large randomised clinical trial, the DiAMOND trial. DiAMOND stands for 'Decision Aids for Mode of Next Delivery' and the aim of the trial was to evaluate two decision aids designed to support women in their decision-making about how to give birth to their next child after a previous caesarean. Previous research had found a lack of readily available information for women in this situation. It suggested that many women would find it helpful to have access to information about the risks and benefits of different ways of giving birth when making the decision about whether to have a planned caesarean or a vaginal birth after caesarean (VBAC).

The trial was conducted at three hospitals located in two cities in the UK between May 2004 and January 2006. Women were invited to take part during their first hospital appointment (which for some took place at 10 -12 weeks and for some at 20 weeks of pregnancy). Over 700 women decided to take part. They were allocated to one of three different groups to receive either usual care or one of the two decision aids. Both decision aids were computer-based and designed to give balanced information about the risks and complications associated with different ways of giving birth. One aid, the information program, provided statistical risk information in different visual formats and helped women to compare risks and benefits across options. The other aid, the decision analysis program, asked women to rate how they felt about various complications and then gave them an individual recommendation for planned caesarean or VBAC based on those ratings. The design of the decision aids was intended to present the available information in a neutral fashion without influencing women's preferences in a particular direction.

A researcher with a laptop visited all women who were in one of the groups receiving a decision aid to ensure that women were able to access and navigate the decision aids without problems. Women who received the information program were able to access it again in their own time by logging onto a website. All women were also asked to fill out a set of questionnaires at three points during the trial to gather information about their birth preference, their understanding of the risks associated with different ways of giving birth, how difficult they found it to reach a decision and how anxious they were feeling. 

Three measures were used to assess the effects of the decision aids on women' 'anxiety', 'knowledge' and 'decisional conflict' - a measure which assesses how far someone feels content they have made the right decision or not. Women who received either of the two decision aids experienced less 'decisional conflict'. They were also more knowledgeable about risks and benefits of different ways of giving birth and they felt less anxious compared to women who were in the usual care group. A greater number of women in the decision analysis group gave birth by VBAC, compared to women in the information or usual care groups (37% compared to 29% and 30%, respectively). The quantitative findings of the DiAMOND trial have been published in the British Medical Journal (BMJ  2007;334:1305 (23 June), doi:10.1136/bmj.39217.671019.55)

Alongside the trial, a smaller qualitative study was conducted to explore how women experienced the process of decision-making, whether and how the decision aids might have helped them in reaching a decision, and what other factors might have influenced their birth preference. 30 women took part in this smaller study. All women were interviewed 2-3 weeks before the birth of their next child, and 21 of them were interviewed again 6-12 weeks after giving birth. 27 of these women kindly agreed to donate their personal experiences for this website and their stories have formed the basis for this resource. 

The women who took part in the qualitative study were not a representative sample of the general population of women who have had a previous caesarean, but were selected to include a wide range of different birth preferences and experiences. For all but one of the women, their experience of caesarean was also their first experience of childbirth. Six of the women had a planned first caesarean, and twenty-one had an emergency caesarean, three of them under general anaesthetic. 12 of the women received the information program, 13 used the decision analysis program and two received usual care. 11 women in the qualitative study decided to have a planned caesarean and 16 decided to attempt VBAC. Six of the women had a birth that was different from what they had hoped for: four women who wanted a vaginal birth had an emergency caesarean, and two women who had booked a planned caesarean went into labour early: one gave birth by emergency caesarean and the other one had a vaginal birth.

Two further papers have been published about the results of the DiAMOND study:

Frost J, Shaw ARG, Montgomery AA and Murphy DJ. Women’s views on the use of decision aids for decision making about the method of delivery following a previous caesarean section' qualitative interview study. BJOG 2009;116:896–905
 
The second is another qualitative study reporting health professionals' views of the decision aids.
 
Reference' Rees KM, Shaw ARG, Bennert K, Emmett CL and Mongomery AA. Healthcare professionals’ views on two computer-based decision aids for women choosing mode of delivery after previous caesarean section' a qualitative study. BJOG 2009: 116; 906-914
 

Last reviewed April 2015.

Last updated November 2012.

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