Scientists to help pregnant women make childbirth choices

Researchers from the University of Aberdeen have been awarded almost £1 million to fund research looking into how pregnant women can be supported to plan their birth.

The National Institute of Health and Care Research (NIHR) awarded more than £973,000 to the collaborative team made up of scientists, clinicians, members of the public and those with lived experience of childbirth from across the UK and Ireland.

Over the next two and a half years, the group will develop an aid that can be used to guide discussion between pregnant women and health professionals during antenatal appointments. Ultimately the goal is to develop a decision aid that will help pregnant women make an informed choice between vaginal or caesarean birth.

Widely used in healthcare settings already such as in choosing between cancer treatments, decision aids provide a framework for discussion and are purported to increase knowledge, support choice, and reduce regret. However, no such aid exists for birth planning in routine maternity care. This project will address this gap to enable maternity staff to conduct balanced conversations with women about their birth plan options.

Dr Mairead Black, Senior Clinical Lecturer at the University, who is leading the research team, explains: “Childbirth is a safe and positive experience for most women in the UK, but it often involves intervention from doctors and midwives such as an unplanned caesarean section, for example. This can understandably be difficult for women, particularly those who were not expecting to need help, or those who are unaware of the possible risks.

“Also, there are women who may feel that they should have had more help to deliver their baby and lack of meaningful discussion around this can lead to disappointment, and physical or mental health problems – an outcome we see particularly in women from minority and under-served groups”

Professor Debra Bick, Chair of Maternal Health at the University of Warwick and co-applicant on the study, adds: “As a midwife, I know how important it is that all pregnant women have timely and appropriate information to support their birth choices. Too often we hear of women who felt that information was not shared with them or they were unaware of their different options for birth”.

In the last decade, national guidance from the National Institute of Health and Care Excellence has stated that the risks and benefits of both vaginal and caesarean birth should be discussed with women during pregnancy to help plan their birth. Changes in the law in 2015 re-emphasised the need for this discussion. However, as Dr Black explains: “Aiming for a vaginal birth or having a planned caesarean birth each have potential benefits and harms. Both are reasonable options, and with no guidance or resources to support these discussions between maternity staff and pregnant women, they do not happen consistently, if at all.

Dr Tara Fairley, a consultant obstetrician and clinical director within NHS Grampian sees the difficulty of the lack of these consistent birth planning conversations in her own clinical practice and in the concerns and complaints received from women within a large maternity service. Dr Fairley explains: “It is clear from feedback from women that despite clinicians’ best efforts there are inconsistencies in the information shared about this important decision. These inconsistencies may inadvertently influence the decision making of a given woman who, following the birth of her baby, discovers her peers have received different information which leaves her feeling disappointed with this consultation and, often, with the decision she made as a result.”

Highlighting the importance of this, maternity services reported a £2 billion compensation bill in 2018/19, with lack of informed consent and failure to offer a caesarean birth listed as key reasons.

The process of developing these decision aids will include patient and public consultation, comprising representatives of women’s birth-related support groups, women with different pregnancy and birth experiences, and representation of other women’s views. It will then be tested in real-life in five UK maternity units.

Sally Ashton-May, Director Midwifery, Policy, and Practice at the Royal College of Midwives (RCM) who are supporting the project added: “It is so important that women make the choice that is right for them about how they give birth and that they are armed with the information to do that. We hope the outcome of this project will be a valuable resource that enables them to be even better informed and supported – by midwives and their maternity colleagues – to make that decision. The RCM will be working with the project team to make this a reality.”

Dr Black adds: “This is an important piece of work because it addresses a substantial gap in routine antenatal care in the UK at present.

“This work recognises that women, including those who do not identify as women, who are pregnant, should be the primary decision makers in their birth planning. It will help both maternity staff and those planning their birth by providing balanced information about the options of planning a vaginal or caesarean birth. It will support them to choose the option that fits best in the circumstances of the individual woman or family.

“By working with members of the public, maternity staff and childbirth-related charities, we will develop a tool to help women decide between planning a vaginal or caesarean birth in routine antenatal care.

“We will also outline how the tool can best be embedded within routine NHS maternity care. Working alongside the NHS Maternity Transformation Programme, the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists we ultimately aim to ensure that the final tool is accessible to all who would benefit from its use.

“Historically, the default assumption has been that women are aiming for vaginal birth. This project recognises that this is no longer a reasonable assumption and that instead all women should be engaged in a conversation about their options, how these compare to each other and what would be right for them as an individual or family. At the moment, health professionals have very few tools to help them have these conversations. This work will address that gap.”