Information needs & attitudes in next pregnancy

Women who become pregnant again after a previous caesarean have specific information needs. How much information women feel they need is a matter of personal preference, but usually they want to find out how having had a caesarean previously might affect their next pregnancy and birth. Many women we talked to said it was important to know that information was balanced and trustworthy and that it was presented without a hidden agenda. Several pointed out that it could be difficult to know which sources of information could be trusted. A few women thought it was safer to rely on information from health professionals than try and find out things for yourself. (See ‘Views on information from other sources‘ and ‘Views on information from health professionals’.)

The women we talked to in this study took part in a clinical trial that tested two computer-based decision aids. Both decision aids provided detailed information about a broad range of risks and benefits of different ways of giving birth after caesarean. All but two of the women used one version of the decision aid or the other.

She was surprised at how little information there was available for pregnant women who have had a…

Age at interview 36

Gender Female

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And did you have any information at the time about the implications of having a section for another delivery?

No.

And do you feel that you had that information at all?

No, not really. I mean, to be honest, if I hadn’t taken part in this study, I’d have felt very in the dark about it.

That’s interesting. I’ll just write that down. Could you say in what way?

I just, I feel that it seems to be that possibly the midwife expects the hospital to talk to me about it and maybe the hospital expects the midwife to talk to me about it.

Is it something that you were surprised about?

Yeah, I suppose so. I thought thered be lots of leaflets and information and, you know, have a’ I mean, we, we only talked to the hospital last week and the midwife said that we should have talked to them at the twenty week scan, and it was a very quick consultation.

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A few women had been told about the implications of caesarean for future pregnancies immediately or soon after their previous birth. Many others could not recall having received information about this issue from a doctor, midwife or health visitor, though some acknowledged that it might have just passed them by at the time because they were focussed on their new baby. A few women had assumed that they would just have to have another caesarean as a matter of course. Others were surprised to learn that they could choose to have a caesarean even if it was not medically necessary.

She assumed that after her first caesarean she was likely to need another one. Once she learned…

Age at interview 33

Gender Female

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What kind of information have you wanted with this pregnancy?

Basically, the sort of, the pros and cons of having had a section versus not having had a section, on a previous pregnancy and what that might mean for delivery’ again for myself, really, as well as for the baby, but more for myself.

Okay. That’s really important. If I can ask you a little bit more about that. How aware were you of the implications of having had a section before you became pregnant again?

Well, I think I always thought’ at the time I asked, when I’d had the section I asked the doctor on my check-up what would be the, you know, and they said well, the twins weren’t overly-big so maybe I’d have to have a section again, but they didn’t really have a reason as to why I hadn’t been able to deliver them. So, I kind of thought it was always at the back of my mind but it wasn’t a reason for sort of not having another pregnancy or anything like that. And when I was’ I presumed that the chances were that I would probably have to have another section. I wasn’t actually sure on what the protocols on- on that were.

And have you sought out more information about that with this pregnancy?

Yes

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Many women worried how having a previous caesarean scar on their uterus might affect them during pregnancy and birth. Almost all of them had heard about the risk of ‘uterine rupture’ – the very rare complication of the previous scar coming apart during labour or the late stages of pregnancy – but many did not know how much of a risk it really was. Several women who thought about having a planned caesarean felt unsure whether this would remove their choice over how to give birth for future pregnancies. Some had heard rumours about the maximum number of caesareans a woman could have and worried whether their risk of complications would increase with the number of caesarean they had. And because caesarean delivery is usually ‘quicker’ than vaginal birth, a few women wondered whether this meant it was ‘safer’ for the baby.

She wanted to know how feasible it was for her to attempt vaginal birth and was relieved to learn…

Age at interview 40

Gender Female

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And what kind of information have you wanted this time?

‘I’ve actually just wanted to know if I can have it naturally again if that’s’ well not again because I didn’t have it the first time – but if I could try and have it naturally. Having a friend who it’s stayed in my mind, she had a caesarean the first time and then had it naturally the second and’ I’m thinking I hope I can do that. But just’ I just made- just really wanted them to tell me if that’s feasible. Which it is, now. And just to go with the flow again, see what happens.

‘I wasn’t aware that they wouldn’t induce me so that was very useful to have that information, they provided that voluntarily. You know I thought I would go through that same process. To be honest I’m glad that’s not the case really, I don’t fancy lying on a bed for sixteen hours with a monitor on me if they get to the stage where they’ve broke the waters and nothing is happening, then you know that’s it.

Does that reassure you more this time?

It does, it does, yeah.

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Many women who thought about attempting vaginal birth after caesarean (VBAC) wanted to find out how likely they were to have one. They also wanted to know how their labour would be managed and monitored, at what stage they should go into hospital and what kind of interventions they would be likely to receive.

Women who wanted to attempt VBAC were especially keen to refresh their knowledge about labour and pain relief. A few of them hadn’t experienced labour previously, so they felt very much as if it was their first birth. One woman wanted a planned caesarean but went into labour before the scheduled date. Looking back she wished she could have had more detailed information about the kinds of pain relief available to her. A couple of women had wanted to attend antenatal classes again, but didn’t manage to get a place. However, another woman who was given a place didn’t attend the full course because she felt she knew as much as she needed to already (Interview 26).

She would have liked to attend antenatal classes to refresh her knowledge of labour and pain…

Age at interview 32

Gender Female

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I went to one, the revision parentcraft class, which is for second time mums. And you could ask, you know, what you wanted generally, but it was very quick. And that was quite interesting because there was one other girl in there that had had a Caesarean and she wanted to know ‘she wanted to revise labour and pain relief and things because we obviously didn’t retain the information last time because we didn’t use it. And most other people were like not wanting to talk about that because they could remember that. They’re wanting to talk about how they’re going to, you know, how the baby would interact with, or how the toddler would interact with the baby and all that sort of thing more. Whereas obviously I wanted’

So it wasn’t an issue to them, it wasn’t on their radar’

No, no.

Right, did you speak to the woman who had a section?

Whereas for me I, I didn’t know because she rushed off afterwards. We did talk about that, we did talk about labour and things but, you know, you did feel’ I did actually mention earlier on in the pregnancy that I might like to go to antenatal classes but they didn’t tell- they didn’t mention it to me and I sort of forgot how, you know, it sort of went by and I haven’t been invited so’ so I don’t know whether that would have been useful.

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With hindsight, it would have been helpful to know more about the different kinds of pain relief…

Age at interview 31

Gender Female

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And now you’ve been through your second delivery, is there anything at all that you think you would have liked to have known more about?

Pain relief would have been’ a wee bit more information on that. I, I’m not, I can’t remember whether or not that was in the program or not, but the fact that you’re having, if you have a section rather than a natural delivery, and also which point in your labour you can have different pain relief. I wasn’t aware that you could only have morphine or gas and air if you were having a section, and I didn’t realise that once you were in advanced labour you couldn’t get anything other than gas and air. I think I would have been shouting a wee bit louder going, ‘I need some please, now!’

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Several women commented that they had less contact with their midwives than in their previous pregnancy and therefore less opportunity to seek information or advice from them when they felt they needed it. They thought that having available written information that they could read and revisit in their own time, such as that provided by the decision aids, could go some way to addressing this need.

Her questions changed throughout her pregnancy. She would have liked to talk to a midwife outside…

Age at interview 37

Gender Female

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I think you do need- well, I felt through my pregnancy, and all the decisions that I had to make, I felt like I needed someone at the end of the line or, to go onto say, a website and have a look at, at information, because every day you might have different questions, and you can’t keep phoning your health visitor every day. So, yeah, I thought it was quite good.

And what did you feel about the information on the website compared to the information that you got from other sources?

‘Yes, good, I’m just trying to think. It’s probably in a way, better because you’ve got more time, you’ve got your own time to sit and read it and digest it and ‘and you can do it as and when you need to. Whereas often you go to see, you have your appointment to see a health professional and you forget what you want to ask them or, you might be having a very good week and theres no problems.

‘I think it would be probably useful to have more options to speak to people and to phone midwives or to be able to see your midwife more often than you do, maybe towards the end. Or even just throughout the whole pregnancy. I did sometimes feel, you know, you have all these questions but you can’t really see anybody or talk to anybody’ until your next appointment. And by that time you’ve probably found out the answer or you’ve got past that stage, you know, so I think I’d like, almost like to have a hotline [slight laugh] that you could phone and get advice, or’

That makes sense, because I think theres a tendency also to forget, isn’t there, because it’s a burning question, but by the time you get there it’s kind of gone out of your mind?

That’s it, and nine out of ten times, when you have your midwife appointment, you’re having a good week and everything seems rosy. And it can, it can just turn the next day into the most awful pregnancy ever.

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She did not see her midwives much in her second pregnancy and was unsure where to look for…

Age at interview 31

Gender Female

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It was just, it was nice to know that it was a decision that I could make and there actually was, you know, I did have a choice, because that’s not explained to you at all. It’s a case of you see the midwives very little the second time round anyway, in your second pregnancy, and it’s very much a case of ‘oh, you’ve had a section before because your daughter was breech, but you know, this child may not be breech and so theres no problem, you can go through a trial of, you can have a normal delivery. Well what happens if I don’t? ‘Oh, we won’t talk about that now’, it’s, it’s very much a case of that’s their attitude so for me it was’ and also I was thinking you know, how am I going to get some more information. I know that I can go on the internet and I can, you know, but it would be great if there was someone in the health profession that I can talk to that’s really unbiased and they can just give you the facts as they are, basically. And, to’ when I was approached to be part of the study, well, I nearly bit the lady’s hand off, I was like ‘yeah! You must have been reading my mind, this is what I need’ [laughs].

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Not all women agreed that having had a previous caesarean had increased their need for knowledge. A few women said that they hadn’t been looking for as much information as they had with their first pregnancy. As some of them pointed out, looking after a young child meant they simply had less time available to read or search the internet. However, they also thought they knew more about what to expect second time round or questioned the practical value of gathering lots and lots of information. Two women who were certain that they wanted a planned caesarean thought they knew enough about the possible risks from their previous experience. A few women who were hoping to have a vaginal birth thought that seeking out too much information might worry rather than reassure them. One woman felt that ‘a little knowledge can be a dangerous thing,’ and another one pointed out that ‘no matter how much you read, you still won’t know what it’s going to be like’.

She did not experience many worries during her pregnancy and was happy to leave things to…

Age at interview 33

Gender Female

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And what kind of information have you wanted this time with this pregnancy?

Well, I’ve asked as and when if I’ve been with the midwife, or if something’s cropped up and I’ve been at home, I’ve just rang the midwife, and whatever’s been on my mind I’ve been able to ask her over the phone or, or when I remember something at the surg’ you know, like [midwifes name] I’ve mentioned it to her, but I’ve not had really much, much in the way of sort of worries, really.

And again, you’ve not gone to any ante-natal classes or anything like that this time?

No, I went to one out of the four [laughs]. Me and my partner went and I just thought, I’ve watched programmes and I’ve read the books, and you know, you’ve got to have a bit of common sense with it really, because I think it’s the same sort of thing, being open-minded as to which way it’s going to swing. At the end of the day, it’s a call away from the hospital, you know, the staff are there, they can sort of see for themselves how, how far you’re dilated and what your blood pressure is and you sort of leave the professional judgements to them really.

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Several women said they liked using the decision aids because it stated the risks of complications clearly and without bias. Many women took the view that even though learning about the risks of different ways of giving birth could be scary, it was better to know than not to know. As one woman said ‘If you know what’s ahead of you, you can accommodate it better’. Several women said they had felt empowered by having additional information through their participation in the DiAMOND trial, but a few felt that with increased knowledge also came the burden of responsibility.

In her experience, midwives will often gloss over the risks to reassure women.

Age at interview 26

Gender Female

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I mean, I think to some extent you, you have to be blunt, to say look, this is what could happen, because if you sugar coat too much, do you know what I mean, and then when someone- something actually happens to someone, you know, they’re kind of shocked then. It’s like, ‘Whoa, I didn’t realise it was going to be like this and ahh'”, you know?

I think in some ways you do need to be blunt and sort of say this is this and that’s that.

I think with midwives, they can sometimes skirt round things a little bit, whereas obviously the program, if you wanted to know about a certain thing, it would give it to you, you know, in plain English. It’s like, ‘Yes, this is this, that is that, boom, boom’, whereas like I said, I think sometimes- I don’t think they mean to but I think sometimes they can skirt round it a bit and say, ‘Oh, well that’s nothing to worry about’, or ‘Well, no, no’, or you know, so, but if you really do want to know about certain things then yeah, I think that’s quite a good thing to, to click on and have a look at, I think.

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Finding out about the risks can be scary, but she thinks it’s better to know than not know…

Age at interview 19

Gender Female

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Do you think there are any benefits to using this kind of programme generally?

Yeah, I think it all depends on why you’re what type of person’ I think all people are different, I think that it’ especially like the computer way I think. Because computers now, people are always using them, I think it’s the easy way and people find it more instead of sitting there reading through books and things like that, I think the computer makes it more accessible really now. And it easy, it is really easy to use I would say.

Could you see there be any harm to using something like that, any problems?

Not really. Some people worry, don’t they, more, and like facts and figures can worry people. Like when they say like they do say like sort of how many people have major complications and things with the caesarean. That could scare some people, but I think I’d rather know than not know, than people say ‘Oh, you’ll be fine and then something does go wrong.

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She felt empowered by the information she got from taking part in the DiAMOND trial but at the…

Age at interview 40

Gender Female

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And to what extent, if any, do you think that the information program helped you prepare and plan for the delivery this time?

Yes, I think it informed me fully about what, as I said, you know, 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 program. Because other mothers that I knew at the time, expecting when I did ‘and we would, 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 with the information that I had got from the program. So in that way, I felt empowered by it, if you can put it like that. So it gave me food for thought really.

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However, a couple of women felt that using the decision aid had given them more information than they wanted or needed. One woman thought that knowing too much about all possible complications might put off women getting pregnant again. Another one said that the task of ranking risks according to her personal values had felt like ‘tempting fate’.

Women used information in different ways to support their decision-making. Some women wanted to find out as much information as possible before making up their mind about how to give birth. They were keen to make a decision that was informed by weighing up all the risks as much as possible. For some of these women, additional information gained from using the decision aid had influenced the outcome of their decision.

Statistics about the likelihood of women having a vaginal birth after caesarean confirmed her…

Age at interview 31

Gender Female

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I suppose looking at the statistics, like the likelihood of women that had’ I mean, one of the things that stuck in my head was, was out of all the women that try for a natural birth after having a section, only seventy percent will, and thirty percent will end up with another section. So there were those kind of things that did kind of niggle in my head, but they didn’t’ I wouldn’t say they ultimately influenced my decision, I mean, it was for personal reasons that I’ve chosen another section. But I suppose having the information there did kind of back up some of my reasoning in my head.

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However, other women said that factual information had not been all that important for reaching a decision and that they had been guided more by personal values. Nevertheless, they, too, found it useful to find out more information because they thought it would help them to prepare themselves for the birth and feel more confident about the decision they had made.

She gathered information from as many sources as possible, but her decision to attempt VBAC was…

Age at interview 37

Gender Female

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So where did you get the best information from? If you had to cite one source of where you got the most important information?

Oh, I got it everywhere. I did’ I mean, I’ve done research and studying and stuff like that, so I would say’ everything. I went online and spoke to support groups and just everywhere, absolutely everywhere, midwives, everything. But I had made up my mind I was going to do it anyway, despite all the information. Everywhere, so there wasn’t any one, one particular’ that one book, and unfortunately I can’t remember, that reference, was very helpful towards the end in the psychological sort of, “You can do it”, “It’s a natural process”, way.

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She thinks women are likely to look for information that confirms rather than challenges the…

Age at interview 38

Gender Female

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Where else have you looked for information, you’ve said about the internet. Have you looked at any books or magazines?

Not magazines no.

So it’s been mostly the internet?

Yeah.

And what’ to what extent has the information that you’ve got helped inform you decision do you think?

I think you look for information that supports what your mind is thinking anyway. I think I could have probably gone either way. If I’d gone in with an open mind, which I don’t think I probably did I would have found information’ you know you look for what you want to look for don’t you?

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