What outcome information do women need to support an informed choice between planning a vaginal or caesarean birth? - a consensus study.

Through a three-phase consensus process involving systematic reviews, a Delphi survey, and stakeholder meetings, this study identified 62 priority maternal and child outcomes to be included in a decision aid that supports informed choices between planned vaginal and caesarean births.

The Gist

Imagine you are about to take a major trip, like a cross-country road journey. You have two main routes to choose from: the scenic, winding country road (a vaginal birth) or the direct, paved highway (a caesarean section). Both get you to the destination, but they come with different scenery, different risks of traffic jams, and different chances of getting a flat tire or a scenic overlook.

The problem, according to this paper, is that for a long time, travel agents (doctors and midwives) haven't been giving passengers (pregnant women) a complete map. They often talk a lot about the country road but might skip over the details of the highway, or vice versa. This leaves people feeling unsure, anxious, or even traumatized because they didn't know what to expect.

This study is about creating the ultimate "Trip Guide" (called a Decision Aid) to help women choose their route with their eyes wide open. But before they could write the guide, they had to agree on exactly which "scenic spots" and "potential hazards" to include.

Here is how they built that list, explained simply:

1. Gathering the "Travel Tips" (Phase 1)

The researchers didn't just guess what matters. They went on a scavenger hunt for information from three different places:

• The Library: They read hundreds of past studies and official medical rulebooks (like the NICE guidelines) to see what experts already knew.
• The People: They sat down and talked to 79 people—women who had recently had babies, their partners, and doctors. They asked, "What scared you? What surprised you? What do you wish you knew?"
• The Result: They ended up with a giant "Long List" of 71 possible things that could happen, ranging from "how long you stay in the hospital" to "the chance of a baby having a bruise on their head."

2. The "Voting Game" (Phase 2)

Having 71 items is too much for a single guidebook page. So, they played a game of "Prioritization" with a large group of people (160 participants, including women, partners, and doctors).

They used a method called a Delphi Survey, which is like a multi-round voting game:

• Round 1: Everyone looked at the list and rated every item on a scale of 1 to 9. A "1" meant "Not important at all," and a "9" meant "Critically important—you must tell me this!"
• Round 2: People saw how everyone else voted. If a doctor thought something was a 9 but the women thought it was a 3, they could reconsider their vote. This helped everyone get on the same page.

The Rule for Inclusion: To make the final cut, an item needed to be rated as "Critically Important" (7–9) by at least 70% of the group, and very few people could think it was "Not Important."

3. The "Town Hall Meeting" (Phase 3)

After the voting, they held a final meeting (a virtual town hall) with a smaller group of women, partners, and doctors to make the final call.

• They discussed the items that were close calls.
• They noticed some interesting disagreements: For example, women voted that "changes in sexual function" and "how long labor takes" were critical, but some doctors didn't think those were top priorities. Conversely, doctors thought "caesarean scar ectopic pregnancy" (a specific future risk) was vital, while women hadn't rated it as high.
• The Compromise: They respected the women's votes. If the women said it was critical, it stayed on the list. They also combined some items (like merging different types of placenta issues) to make the list clearer.

The Final "Trip Guide" List

After all the voting and talking, they trimmed the list down.

• Kept: 62 outcomes made the final cut. This includes 44 things that could happen to the mother (like pain, recovery time, or future pregnancy risks) and 18 things for the baby (like breathing issues or development).
• Discarded: 9 items were removed because the group agreed they weren't essential for making the big decision (like "coccyx pain" or "childhood cancer risk").
• The "Must-Include" Exception: Even though 8 items didn't get enough votes to be "critical," the researchers kept them anyway because official medical rules (NICE guidelines) say they must be discussed.

Why This Matters

The paper concludes that they have successfully built a consensus-based checklist. This isn't just a list of medical facts; it's a list of the specific things that real women, their partners, and their doctors all agree are necessary to know before deciding how to give birth.

Think of it as the difference between being handed a vague pamphlet that says "Driving is great" versus getting a detailed, honest map that says, "Here are the potholes, here are the beautiful views, and here is what happens if you take the highway versus the back road." This study ensures that the map is drawn based on what the travelers actually need to see, not just what the mapmakers think they need.

Technical Summary

Technical Summary: Consensus on Outcomes for Mode of Birth Decision Aids

Problem Statement
Despite policy mandates (e.g., NICE Caesarean Birth guidance) and legal precedents (Montgomery vs Lanarkshire) requiring that pregnant women be supported to make informed decisions regarding their mode of birth (vaginal vs. caesarean), current antenatal care often provides suboptimal support. Information provision is inconsistent, with studies indicating that discussions regarding the benefits of caesarean birth occur less frequently than those for vaginal birth. While decision aids (DAs) are proven to enhance knowledge and reduce decisional conflict, a specific, evidence-based DA for planning mode of birth is currently lacking in routine UK National Health Service (NHS) care. A primary barrier is the lack of consensus on which specific outcomes (risks and benefits) should be included in such a tool to ensure they are relevant and critical to women, partners, and healthcare professionals.

Methodology
The study employed a rigorous, three-phase consensus process to identify and prioritize outcomes for inclusion in a planned mode of birth decision aid.

• Phase 1: Outcome Identification (Long-list Development): A comprehensive list of potential outcomes was compiled from three sources:
  1. Three systematic reviews covering information needs, birth mode preferences, and updates to NICE guidance.
  2. The 2021 NICE Caesarean Birth guidance.
  3. Qualitative interviews with 79 stakeholders (37 women, 5 partners, and 39 health professionals) across the UK, utilizing purposive sampling to ensure diversity.
• Phase 2: Delphi Survey Prioritization: A two-round modified Delphi survey was conducted with 160 participants in Round 1 (70 women, 5 partners, 85 health professionals) and 89 in Round 2. Participants rated outcomes on a 9-point Likert scale (1–3: not important; 4–6: important but not critical; 7–9: critically important).
  • Consensus Criteria: An outcome reached consensus if ≥70% of all participants (or ≥70% of women/partners specifically) rated it as "critically important" (7–9) and <15% rated it as "not important" (1–3).
• Phase 3: Consensus Meeting: A virtual open forum involving 19 stakeholders (including women, partners, and health professionals) was held over two half-days. This forum discussed outcomes that received critical support, those that did not, and potential combinations. Anonymous voting was utilized to mitigate power imbalances between lay participants and health professionals.

Key Results

• Initial Pool: 71 distinct outcomes were identified from the systematic reviews, NICE guidance, and qualitative interviews.
• Consensus Outcomes: Following the Delphi rounds and consensus meeting, 54 outcomes were rated as critically important by the stakeholder groups.
• Exclusions: 17 outcomes were consistently rated as non-critical. However, 8 of these were retained in the final list because they are explicitly recommended for discussion in the NICE Caesarean Birth guidance. Ultimately, 9 outcomes were excluded entirely (e.g., scar healing/physical appearance, coccyx pain, childhood cancer risk).
• Final List: The study established a final list of 62 priority outcomes for inclusion in the decision aid:
  • 44 Maternal Outcomes: Covering assistance with birth, complications at birth, recovery issues, pelvic floor function, psychological issues, sexual function, and future pregnancy risks.
  • 18 Child Outcomes: Covering morbidity, death, disease, obesity, and cognitive/physical development.
• Discrepancies: Notable differences emerged between stakeholder groups. For instance, women/partners rated "changes in sexual function," "duration of labour," and "cephalopelvic disproportion" as critical, whereas health professionals did not. Conversely, health professionals prioritized "caesarean scar ectopic pregnancy" more highly than women/partners.

Significance and Claims
The paper claims to have successfully developed a transparent, documented process for achieving consensus on the content of a mode of birth decision aid. By involving a diverse group of 70 women, 5 partners, and 85 healthcare professionals, the study identifies a broader range of informational needs than currently reflected in existing guidelines.

The authors emphasize that the resulting list of 62 outcomes represents the consensus opinion of diverse UK stakeholders and aligns with International Patient Decision Aid Standards (IPDAS). The study highlights that women's preferences for information extend beyond current NICE guidance, particularly regarding outcomes related to sexual function, labour duration, and specific birth processes.

The authors modestly acknowledge limitations, including the high attrition rate in the Delphi survey (44%), the smaller and less diverse sample at the final consensus meeting, and the potential for power dynamics to influence discussions despite mitigation strategies. They conclude that the decision aid should be viewed as a "living" tool that will require regular review as new evidence emerges and as it is tested in clinical practice. The paper serves as the foundational step for the Plan-A project's development of a decision aid and implementation guide for the NHS.