What should be discussed when considering a caesarean birth? : A Delphi Study to develop a Core Information Set for caesarean birth.

What should be discussed when considering a caesarean birth? : A Delphi Study to develop a Core Information Set for caesarean birth. | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL BJOG: An International Journal of Obstetrics and Gynaecology This is a preprint and has not been peer reviewed. Data may be preliminary. 2 March 2025 V1 Latest version Share on What should be discussed when considering a caesarean birth? : A Delphi Study to develop a Core Information Set for caesarean birth. Authors : Carol Kingdon 0000-0002-5958-9257 , Benjamin Greenfield , Mahmoud Aljubeh , Eve Bunni 0009-0009-4991-3728 , Alexandra Hunt , Vicky Bradley 0009-0002-2551-4713 , Caroline Cunningham , … Show All … , Siobhan Holt , Andrew Demetri 0000-0002-2820-5919 , Christy Burden , Jo Ficquet , Elena Oteroromero , William Parry-Smith , Mairead Black , Fiona Bradley , Amy Elsmore , Jenna Frizelle , Tabitha Jones , and Abi Merriel 0000-0003-0352-2106 [email protected] Show Fewer Authors Info & Affiliations https://doi.org/10.22541/au.174093133.35026366/v1 498 views 367 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Objective To develop a caesarean birth core information set. Caesareans are the most common surgery performed in many countries. Women need information for informed decision-making and consent. Core information sets (CISs) provide baseline information, agreed upon by parents and clinicians, for discussion before a procedure. Design Two-phase consensus study using modified Delphi. Setting United Kingdom, 2024 Sample People planning a pregnancy/currently pregnant/new parents and maternity professionals Methods Phase 1: Long-list of information points identified from 273 systematic reviews, 50 patient leaflets, three pre-existing qualitative studies, and a stakeholder survey (n=230); Operationalised into a Delphi questionnaire comprising 11 information points with 108 items. Phase 2: Think-aloud interviews (n=9) informed questionnaire restructure into information about planned caesarean birth, unplanned caesarean birth (within 72 hours), and emergency caesarean birth (EMCB; ≤30 minutes), followed by two-round Delphi survey and consensus meetings. Results N=360 participated in the Delphi survey Round 1. All items were carried forward, and three were added for Round 2 (n=188/56.4% attrition rate). From Round 2, one item was removed, 73 included, and 37 items no-consensus. Free-text responses identified an unmet need for a postnatal EMCB-CIS. Over four meetings (n=36) consensus was reached for an antenatal-caesarean-birth-CIS (14 points), EMCB-CIS (5 points), and a postnatal EMCB-CIS (12 points). Conclusions This study has established three caesarean birth CISs to support informed decision-making discussions between women and clinicians: (1) CIS for planned and unplanned caesareans when there is time for discussion; (2) CIS for EMCB (within 30 minutes); (3) CIS post-EMCB pre-hospital discharge. What should be discussed when considering a caesarean birth? : A Delphi Study to develop a Core Information Set for caesarean birth. Authors Dr Carol Kingdon*, Joint first author, Senior Research Fellow, Centre for Women’s Health Research, Department of Women’s and Children’s Health, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK. [email protected] Mobile: 07935744004 https://orcid.org/0000-0002-5958-9257 Dr Ben Greenfield* Joint first author, Academic Clinical Fellow, Liverpool Women’s Hospital, Liverpool, UK. [email protected] Dr Mahmoud Aljubeh, Clinical Research Fellow, Liverpool Women’s Hospital, Liverpool, UK. [email protected] Dr Eve Bunni, Clinical Research Fellow, Centre for Women’s Health Research, Department of Women’s and Children’s Health, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK. [email protected] Ms Alexandra Hunt, Research Assistant, Health Data Science, University of Liverpool, [email protected] Vicky Bradley, Medical student, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK. [email protected] Caroline Cunningham, Research Midwife, Liverpool Women’s Hospital, Liverpool, UK. [email protected] Siobhan Holt, Research Midwife, Liverpool Women’s Hospital, Liverpool, UK. [email protected] Dr Andrew Demetri, Academic Clinic Fellow, University of Bristol, [email protected] , https://orcid.org/0000-0002-2820-5919 Dr Christy Burden, Assistant Professor of Obstetrics, University of Bristol, [email protected] Dr Joanna Ficquet, Consultant Obstetrician and Gynaecologist, United Hospitals Bath, [email protected] Ms Elena Otero-Romero, Research Midwife, Cambridge University Hospitals NHS Foundation Trust UCLH, [email protected] Professor William Parry Smith, Professor of Obstetrics and Gynaecology University of Keele, [email protected] Dr Mairead Black, Reader in Obstetrics, University of Aberdeen, [email protected] Dr Fiona Bradley, Year 1 Foundation Doctor, University Hospitals of Liverpool Group [email protected] Dr Amy Elsmore, Clinical Research Fellow, University of Keele [email protected] Dr Jenna Frizelle, Obstetric Consultant, Liverpool Women’s Hospital, Liverpool, UK. [email protected] Tabitha Jones, Medical Student, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK., [email protected] Dr Abi Merriel, Senior Clinical Lecturer in Obstetrics, Centre for Women’s Health Research, Department of Women’s and Children’s Health, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK. [email protected] , https://orcid.org/0000-0003-0352-2106 On behalf of the Options Collaborative Group Corresponding author Name: Dr Abi Merriel Role: Senior Clinical lecturer and honorary consultant obstetrician, University of Liverpool. Tel: 07740334922 Email: [email protected] Running title: Caesarean Birth Core Information Set ABSTRACT Objective To develop a caesarean birth core information set. Caesareans are the most common surgery performed in many countries. Women need information for informed decision-making and consent. Core information sets (CISs) provide baseline information, agreed upon by parents and clinicians, for discussion before a procedure. Design Two-phase consensus study using modified Delphi. Setting United Kingdom, 2024 Sample People planning a pregnancy/currently pregnant/new parents and maternity professionals Methods Phase 1: Long-list of information points identified from 273 systematic reviews, 50 patient leaflets, three pre-existing qualitative studies, and a stakeholder survey (n=230); Operationalised into a Delphi questionnaire comprising 11 information points with 108 items. Phase 2: Think-aloud interviews (n=9) informed questionnaire restructure into information about planned caesarean birth, unplanned caesarean birth (within 72 hours), and emergency caesarean birth (EMCB; ≤30 minutes), followed by two-round Delphi survey and consensus meetings. Results N=360 participated in the Delphi survey Round 1. All items were carried forward, and three were added for Round 2 (n=188/56.4% attrition rate). From Round 2, one item was removed, 73 included, and 37 items no-consensus. Free-text responses identified an unmet need for a postnatal EMCB-CIS. Over four meetings (n=36) consensus was reached for an antenatal-caesarean-birth-CIS (14 points), EMCB-CIS (5 points), and a postnatal EMCB-CIS (12 points). Conclusions This study has established three caesarean birth CISs to support informed decision-making discussions between women and clinicians: (1) CIS for planned and unplanned caesareans when there is time for discussion; (2) CIS for EMCB (within 30 minutes); (3) CIS post-EMCB pre-hospital discharge. Funding This study was funded by National Institute for Health Research (NIHR302530 AF R7). The funders have played no role in designing the study, data collection, analysis, interpretation of data, writing of the report and decisions for publication. Keywords Caesarean, birth, choice, consent, core information set, Delphi Trial registration COMET Initiative | Development of a core information set for caesarean birth (comet-initiative.org) What should be discussed when considering a caesarean birth? : A Delphi Study to develop a Core Information Set for caesarean birth. Manuscript 3,500 words INTRODUCTION Global caesarean section use doubled between 2000 and 2015, 1 current projections suggest this trend will continue. 2 In England during 2023-2024, 42% of births were caesarean births. 3 Optimising caesarean use is a global health priority. 1-2,4-5 The operation should be available to all in need, the surgery safely conducted, and when performed for maternal request decision-making informed by evidence in context. In the United Kingdom (UK), particular emphasis is placed on choice, 6-7 decision-making, 8-9 and consent. 10 Since the UK Supreme court Montgomery ruling women should receive information about material risks and reasonable alternatives to clinicians’ recommended treatment. 10 The UK’s National Institute for Health and Care Excellence’s (NICE) Caesarean Birth Guideline recommends women be offered information and support to make informed decisions when planning mode of birth. 11 Existing research shows that women’s receipt of information and involvement in decision-making impact their satisfaction with their childbirth experience. 12-15 A qualitative evidence synthesis of 52 studies, from 28 countries reports women’s can feel disempowered during discussion and decision-making about caesarean birth. 16 However, little research exists into what information clinicians’ should give about caesarean birth, when, and how. 17 Studies repeatedly report women want information, but also differ in their information needs. 6.9,18 A vast amount of information about caesarean birth exists in the public domain. This includes information from the UK’s National Health Service (NHS), 19 Royal Colleges, 20 and charities, 21-24 experiential knowledge shared between women in communities, and information on social networks, internet and mass media. 25 Multiple studies report women want consistent information about caesarean birth compatible with what clinicians say in clinical consultations. 26 A recent study suggests women are more likely to trust NHS-branded information. 27 However, there is no single go-to source of information about caesarean birth for clinicians and/or women. Core information sets provide baseline information of importance to patients and clinicians, agreed upon by consensus, which should be discussed with every person before experiencing a procedure. 28 Core Information Sets offer a way to improve the consistency and quality of information patients receive and offer clinicians a means to balance over- and under-disclosure of information, which is different to decision-aids which deliberately provide information about alternative treatment choices. 29 Core information sets already exist for operations in different specialities. 28-30 This study is part of the Options programme which includes developing core information sets for planning mode of birth. 31-32 The objective of this study was to develop a caesarean birth core information set. Study design and setting We conducted a consensus study in the UK using a modified Delphi design adapted from core outcome sets for randomised controlled trials methods, 28-29 and an earlier core information set study. 31 The study was registered with the Core Outcome Measures in Effectiveness Trials (COMET) Initiative (2599). 32 Adapted Core Outcome Set–STAndards for reporting (COS-STAR) were used. 29-34 Phase 1 – Development of information long-list We collated our long-list of information points about caesarean birth from four sources. Systematic review of systematic reviews We searched electronic databases (SF1) for information items and outcomes of interest. We sought systematic reviews in the English language, published within 5 years. These timeframes were deemed current and sufficient to achieve data saturation. No studies were excluded based on methodological quality or risk of bias, as this was irrelevant for extracting information points. Key information items were extracted from full-texts and data summaries created. Review of existing patient information We used Google to identify trusted sources of patient information leaflets, articles and electronic information from Royal Colleges, NHS Trusts, and charities (e.g. National Childbirth Trust). Information points were extracted. Review of existing qualitative studies We re-analysed existing data from three qualitative studies about information provision and decision-making to extract information points. All studies were conducted 2018-22, and permitted data to be used in other studies. • Antenatal Care Education project (IRAS262911-REC19/SW/0073) information points from focus groups with women (n=46) and staff (n=21) about decision-making during pregnancy. 35 • Shared decision-making for labour and birth (IRAS277301-REC20/SW/0035) information points from interviews with women (n=11 postnatal), (n=10 paired antenatal and postnatal), 27 and focus groups with staff (n=24) about information for decision-making during birth. 18 • Dataset 3: Vaginal Birth Core Information Set (University of Bristol REC10530). We sought information points from 17 interviews with women who discussed vaginal and caesarean birth. 31 Online survey of key stakeholders We conducted a UK-wide REDCaP survey, 36 advertised on social media, exploring the information women want for caesarean birth. We sought participants who were women/people planning a pregnancy/pregnant/new parents and maternity professionals. Responses were analysed for information points. Following duplicate removal and item grouping in consultation with patient advisors, the long-list for a Delphi questionnaire was produced. Phase 2 – Modified Delphi consensus process We developed the Delphi survey using REDCap software; 36 piloted the survey using Think-aloud interviews; completed a two-round Delphi survey; held consensus meetings to agree content; consulted with patient advisors about format. Developing the Delphi survey REDCap 36 software was used to create an on-line survey comprising key study information, consent, the questionnaire, and a free-text box for any additional comments. The target population was maternity care stakeholders (as in the survey above). Piloting and refining of Delphi questionnaire To ensure usability and clarity of survey questions we planned think-aloud interviews with parents and professionals. 37 They are a form of cognitive interviewing that asks participants to discuss the content of the survey they are completing whilst completing it. Two-round Delphi Survey The first round of the survey (April 2024) was advertised on social media, via professional and parenting networks, five NHS hospitals and community children’s centres. Participants rated the importance of information domains on a 9-point Likert scale, ranging from 1 (limited importance) to 9 (Critical importance) (Figure 1). To enhance accessibility surveys were available in English, Arabic, and Polish. We added a captcha to prevent Internet bots which can threaten sample validity and data integrity. 38 Items were discarded or carried forward from Round 1 to Round 2 according to predefined criteria (see data analysis). Round 2 questionnaires were sent to Round 1 participants, together with their scores, and the median scores and histograms for all participants. Round 2 of the survey closed in July 2024. Consensus Meetings Participants in the survey were invited to online consensus meetings using Microsoft Teams. The retained items from Round 2 were presented, followed by discussion and voting on items for which consensus still had to be reached. Consensus to include was defined as ≥80% of attendees voting to “include” the item, exclusion was defined as ≥80% of attendees voting to “exclude” the item. Participants were shown graphs of patient and professional voting to inform discussions. Anonymised voting took place using Poll-Everywhere software which produced instant results. If no consensus was achieved after the first vote, discussion and re-voting occurred, followed by discussion about grouping of items and order. Sample size We undertook secondary data analysis from three qualitative studies, which collectively were sufficient to reach saturation for information items about caesarean birth. For the stakeholder survey we sought a pragmatic sample with a minimum of 100 participants. There are no agreed methods to set the sample size for Delphi surveys or consensus meetings. Thus. we sought to obtain a sample with a broad range of experience, an approach supported by the COMET guidelines 39 and previous studies. 29 Using an opportunistic approach we sought to engage at least 100 participants in the Delphi survey (patients and professionals) and a smaller group in the consensus meetings. Data analysis A-priori consensus criteria were set for the Delphi survey. Consensus to include criteria: if ≥80% of either stakeholder group scored an information item as critically important (7-9) and (1-3). Consensus to exclude criteria: ≥80% of one of the stakeholder groups voted the item as being of limited importance, and Items that did not meet criteria for inclusion or exclusion were carried forward from Round 1 to Round 2, and from Round 2 to consensus meetings. Ethical approval A favourable ethical opinion was granted 06/04/2023, by the Southwest Central Bristol Research Ethics Committee (REC23/SW/0022). Patient involvement A GRIPP 2 reporting checklist is provided (SF2). 40 Eighteen parents helped design the Options Programme. Options has a core patient involvement group and convened ad hoc groups to inform the Delphi format and information set(s). Ad hoc groups have been held with patients to inform the style, language, and graphics used. In response to patient’s requests, these were a mixture of on-line and in-person meetings, with two of the latter held in Children’s Centres to encourage attendance from communities that do not typically participate in research. RESULTS A summary of the results is shown in Figure 2. Phase 1: Information domain generation From all data sources, we identified a total of 442 information items; 316 from 273 systematic reviews (SF3), 60 from 50 patient information leaflets, 54 from qualitative studies (n=59 individual interviews; 21 focus groups), and 12 from the stakeholder survey (n=230 participants comprising parents (n=58 planning pregnancy; n=94 pregnant; n=46 new parents; n=7 partners), and professionals (n=9 midwives; n=7 obstetricians; n=9 other)). Most respondents were white British (89%), with some Asian, Black African and Mixed-race participants. Following duplicate removal 345 items remained. We grouped these into 11 broad categories/domains (i.e. indications, risks, benefits). During this process, similar items (i.e., anaesthetic options) were merged. A final 108 items, grouped into 11 domains were agreed in consultation with patient advisors before operationalising into the Phase 2 Delphi questionnaire (SF4). Phase 2: Delphi consensus process Survey We developed the Delphi survey using REDCap software. Think aloud Interviews We conducted nine think-aloud interviews with pregnant women, new parents and clinicians, resulting in a reordering of the questionnaire to reflect the degree of urgency with which decisions about caesarean births are made (planned caesarean birth, unplanned caesarean birth (within 72 hours), and emergency caesarean birth (EMCB; ≤30 minutes). The final Round 1 structure of the 11 domains/survey sections, is shown in Figure 1. There were no changes to the 108 information items within the 11 sections. Two-round Delphi Survey The Delphi survey had 360 participants between 05/04/2024-24/07/2024. Two additional respondents were excluded as non-UK residents. Table 1 lists demographic characteristics of participants in Rounds 1 and 2 (SF5). Round 1 293 participants identified as parents, 45 as professionals (21 of whom were professionals and parents), and 22 did not specify a stakeholder group. We were not able to calculate a response rate due to recruitment methods. Most participants were female, among parent and health professional participants. There were a few male health professional participants (n=5/45; 11%). Health professionals were also more ethnically diverse and had a wider age range. Most parents were aged 31-40. Many parents and professionals were educated to Bachelor’s or post-graduate degree level. Amongst parents, around a third of women had given birth within the last six months (n=91/31%). Of the 229 women who had previously given birth, 27% had had a spontaneous vaginal birth (n=80), 17% had an instrumental (n=52), 33% (n=97) had had an emergency caesarean and 23% (n=69) an elective caesarean. Most professionals were Obstetricians and Gynaecologists (n=18/46) or Midwives (n=15/46); 21/46 were professionals and a parent (all of whom were female n=21/21; most had one child n=14/21). One important difference between the parents, and the professionals who were also parents, is that more professionals had had a vaginal birth (9/19), whilst more parents had had an emergency caesarean birth (97/298). All items were retained for Round 2 (SF6), with a further three added resulting in 111 items across 12 domains. The extra items encapsulated free-text comments relating to short and long-term caesarean scar pain, and the third was about the importance of a postnatal debrief following emergency caesarean birth. Round 2 The response rate was 56% with comparable proportions of parents (n=166) and professionals (n=22) to Round 1. The attrition rate between rounds was calculated minus exclusions from Round 1 (n=22 did not specify stakeholder group) or provide an email address for Round 2 (n=5). There were few differences in the demographic profile of parents and professionals who responded to Round 1 and 2, when compared to those who only responded to Round 1. There were no professional participants from Wales or Scotland in Round 2. In Round 2, professionals rated nine information items to be of greatest importance (scored 9). All nine items were also critically important to parents, who rated an additional six of the greatest importance. These items related to unplanned caesarean birth (indications for mother; and for baby; and other options for the birth of baby), emergency caesarean birth (other options for the birth of baby; benefits of the operation to baby) and planned/unplanned caesarean birth (serious conditions with short-; and or long-term risks to baby).(SF7 7) Only one item was excluded (emergency caesarean birth: Financial cost to health), and 73 items were included. Of the 37 items that met the criteria to be discussed at the Consensus Meetings, 29 related to emergency caesarean birth, and 8 to planned/unplanned caesarean birth. The 73 items included because they scored ≥80% by either stakeholder group (critically important 7-9) and <15% from either group (limited importance 1-3) are listed in SF8. Consensus meetings We held four consensus meetings with professionals and patients (n=36) in summer 2024. All meetings were held on-line. We were aiming to have one core information set with between 15-20 information points/domains. By the end of the third meeting, anonymous voting had reached a consensus on 14 domains to be discussed with all people planning to have, or considering, a caesarean birth, but controversy remained. Consensus was reached to exclude only two items relating to the financial cost of planned/unplanned caesareans and the long-term risks to the baby of an emergency caesarean birth. As stated above, one of the additions to Round 2 of the survey for emergency caesarean birth was that someone will come and discuss with you why you needed the operation and any important longer-term considerations. Many survey participants had an emergency caesarean birth and so had many of the consensus meeting participants. At the fourth meeting an agreement was reached for an antenatal-caesarean-birth-CIS (14 points), EMCB-CIS (5 points), and a postnatal EMCB-CIS (12 points). The content of the final Caesarean Birth Core Information Set for use as part of antenatal care and when there is time for discussion comprises 14 information points, within which there is information on 61 items relating to planned/unplanned and emergency caesarean birth. The major changes from the consensus meetings were the inclusion of information items that participants wanted to know about emergency caesarean births in this set, (so they had had information in advance should the need arise), and the ordering of information points to reflect women’s decision-making journeys and life-course. As shown in Figure 3, participants wanted a comparison of the risks and benefits of caesarean birth and vaginal birth upfront (point 5), and information about future pregnancies last (point 14). One new information point was added (How formula feeding can be supported) (SF9). To reach a consensus regarding core information that every woman should know for emergency caesarean birth (birth within ≤30 minutes) participants were asked to rank the 10 information items they most need to know to make an informed decision if their and/or their baby’s life is in jeopardy. All participants acknowledged in this scenario there is no time for discussion. The result is a short 5-information point core Information set (with 6 items) (SF10). Consensus participants felt this sufficient especially if pregnant women/birthing parents had received the above antenatal core information set and then all received a post-natal core information guided conversation. The post-natal emergency caesarean birth core information guided conversation set comprises of 12 points (SF11). Populating the core information sets The three caesarean birth information sets were populated using a pre-defined hierarchy of sources including NICE, RCOG Green Top Guidelines, and systematic reviews (with a priority for Cochrane). If the information was not available from these individual randomised or non-randomised studies were used. All sources are referenced at the end of the sets as in the companion vaginal birth 31 and induction core information sets. 32 Once populated patient involvement meetings were held to agree the final format. Patient involvement resulted in changes to length, layout, and risk communication methods. The sets (SF 12,13,14) have been designed for multiple media use following patient advisors and existing research suggesting women want paper and electronic options. 26 DISCUSSION This study aimed to develop a caesarean birth core information set to inform antenatal discussions about planning birth mode. Phase 1 identified a range of information; Phase 2 reached consensus about critical-to-know information. This study has developed three core information sets detailing the minimum information clinicians should discuss about caesarean birth in the antenatal period, the emergency setting and when an immediate postnatal debrief is taking place following an unplanned/emergency birth. Collectively, they address what information, when, and why. These three sets were driven by the needs of research participants and patient involvement contributors, who highlighted the need for these three companion caesarean birth core information sets. A third of parents who responded to the Delphi survey had had a baby in the last six months, with most experiencing an emergency caesarean birth, which reflects current trends in use in England. Nationally, amongst women aged 31-40, the proportion of caesarean (planned/unplanned/emergency) and spontaneous vaginal births is now similar. 3 In nulliparous women the emergency caesarean rate is 31%. Strengths and limitations We used a robust consensus methodology to develop three sets reconciling what women want to know when, with what professionals think women should know, to facilitate informed decision-making about and consent for planned, unplanned and emergency caesarean birth. A strength is the mean age of participants was similar to the UK birthing population. 3 The attrition between Delphi rounds is a limitation, but commensurate with similar surveys. 41-43 Participant demographics were comparable between rounds. Fewer professionals than parents participated in the stakeholder survey, two-round Delphi survey and consensus groups. Patient involvement was embedded into all stages of the research process and in the production of the final sets. This is a key strength, helping to balance educational and ethnicity equity considerations. During groups culturally sensitive translation, health literacy, language alongside use of illustrations and multiple formats (paper and digital) were discussed and acted upon. The emergency caesarean birth set is designed with explanatory images and words that require little or no translation. The final sets were acceptable to patients and professionals as end users. They have been designed in the context for which they are intended, where caesarean procedures are governed by national guidance. Additional development work would be required in other contexts. Pregnant women need information about caesarean birth to know what to expect to help them make decisions. Existing research shows women use sources of varying quality, for information about caesarean birth. 25;44-45 In the UK much research about caesarean birth information has focused on interventions to inform decision-making that promote vaginal birth. 4,46 However over the last decade the legal requirement for informed decision-making has been made clearer. 6-10 Irrespective of which mode of birth the information relates to the challenge is women are not homogeneous in their information requirements, 9 nor are professionals consistent in the information they provide 18,2 and pregnancy and birth are dynamic and demand fluidity in decision-making. 6 The development of three companion core information sets was unanticipated, but obvious when involving women and professionals in equitable information development. They offer a way to improve the consistency and quality of information patients receive and balance over- and under-discussion of information across antenatal, intrapartum and postnatal care tailored to what women want to know, and when. The views of participants in this study resonate with existing research reporting that women understand in an obstetric emergency there is little time for discussion. 47-48 Items excluded included the financial cost to health service of emergency and planned caesareans. These operations can be lifesaving procedures with financial considerations critical to most settings. Consensus regarding the removal of this item may be unique to the UK with its free-at-point-of-access NHS. Beyond the range of items covered in the sets, another vital dimension of information quality is the evidence underpinning materials. NICE recommends further research into the short- and long-term outcomes of caesarean birth. 11 In other contexts, there have been calls for randomised trials of planned vaginal and planned caesarean birth in low-risk populations 49-51 and national surveillance studies now exist. 52 Further research is required to address implementation considerations for information sets, short- and long-term health outcomes for women, and current drivers of caesarean use. Conclusion This study has established three caesarean birth core information sets: (1) for planned and unplanned caesareans when there is time for discussion; (2) for emergency caesareans (within 30 minutes); (3) post-emergency caesareans pre-hospital discharge. They are intended to provide a minimum set of information to support discussions between parents and professionals planning mode of birth. They are not intended to replace individualised conversations but to offer a standardised starting point. Further evaluation will be required to assess their use and whether they can contribute to more equitable care for all women across ethnic and socio-economic groups and improve their actual birth experience. Acknowledgements We thank participants in every stage of this research and Options public and patient advisors, all of whom made this study possible. We also extend our gratitude to the NIHR for funding the Options project. Funding AM, NIHR Advanced Fellow,(NIHR302530) is funded by the NIHR for this research project. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, NHS or the UK Department of Health and Social Care. For the purpose of Open Access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission. Contribution to Authorship AM produced the protocol and supporting documentation for this study with support from AD. AM,MM,JF, TJ, BG, AE undertook the systematic review, AE reviewed the patient information leaflets, FB extracted themes from the stakeholder survey, AM re-analysed the qualitative data. CK and BG performed the think-aloud interviews. GJ, EB, AH, CK, VB,AM, BG, LB undertook the Delphi and consensus meetings and analysis. MA, AM, EB, and CK populated the core information sets. CC, SH, CB, JF, EOR, WPS and MB were the site PIs for the study and recruited participants. All Options Steering Group members attended meetings to plan and disseminate the study. All authors read and approved final manuscript. AM is the guarantor for the manuscript. Terminology The words women/mother is used as a collective term in this paper, but we acknowledge those that identify by other terms. Disclosure of interests No interests to declar Options Study Collaborative Group Members: Professor Deborah Lawlor Professor of Epidemiology, MRC Investigator and BHF Chair, University of Bristol Professor Gordon Smith Professor of Obstetrics, University of Cambridge Professor Jane Norman Professor of Obstetrics and Provost and Deputy Vice Chancellor University of Nottingham Dr Jon Heron Associate Professor in Medical Statistics, University of Bristol Professor Louise Kenny Executive Pro Vice Chancellor of the Faculty of Health and Life Sciences at the University of Liverpool Dr Michael Lawton Lecturer in Medical Statistics, University of Bristol Professor Sheelagh McGuinness Professor of Law, University of Bristol Dr Anna Davies Research Fellow in Health Psychology, Academic Women’s Health Unit, University of Bristol Professor Dame Tina Lavender Professor of Maternal and Newborn Health, Liverpool School of Tropical Medicine Dr Christy Burden Associate Professor in Obstetrics, University of Bristol Professor Jonathan Ives Professor of Empirical Bioethics, University of Bristol Mr Simon Grant Consultant in Fetal Medicine, North Bristol NHS Trust Mr Sherif Abdel-Fattah Consultant in Fetal Medicine, North Bristol NHS Trust Dr Danya Bakhbakhi Academic Clinical Lecturer in Obstetrics & Gynaecology, University of Bristol Dr Laura Bonnet Senior Lecturer in Health Data Science, University of Liverpool Dr Andrew Demetri Academic Clinical Fellow in Obstetrics & Gynaecology, University of Bristol Dr Christopher Dewhurst Medical Director, Liverpool Women’s Hospital and Consultant Neonatologist, University Hospitals of Liverpool Group Dr Mairead Black Senior Clinical Lecturer in Obstetrics, University of Aberdeen Dr Sam Finnikin GP, Sutton Coldfield Group Practice, Clinical Research Fellow at University of Birmingham Dr Amie Wilson Research Fellow in Global Maternal Health, Midwife Alexandra Freeman Executive Director, Winton Centre for Risk & Evidence Communication, University of Cambridge Professor Pete Blair Professor of Epidemiology and Statistics, University of Bristol Dr Katherine Birchenall Sub-Specialist in fetal medicine and Honorary lecturer, University of Bristol Joanne Johnson PPI Core group rep Gary Johnstone Trial/Database Manager Dr Carol Kenyon Consultant Anaesthetist, Liverpool Women’s Hospital, University Hospitals of Liverpool Group Amber Marshall PPI Core group member, Founder of BigBirthas Dr Michelle Maden Lecturer in Evidence Synthesis, University of Liverpool Dr Andy Sharp Senior Clinical Lecturer in Obstetrics, University of Liverpool Professor Andrew Weeks Professor in Obstetrics, University of Liverpool REFERENCES 1. 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Maternal mortality following caesarean section in a low-resource setting: a National Malawian Surveillance Study. BMJ Glob Health. 2024 Nov 24;9(11):e016999. doi: 10.1136/bmjgh-2024-016999. Supplementary Material File (table 1 cb cis participant characteristics.docx) Download 28.47 KB Information & Authors Information Version history V1 Version 1 02 March 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Collection BJOG: An International Journal of Obstetrics and Gynaecology Keywords delivery: caesarean section general obstetrics maternity services Authors Affiliations Carol Kingdon 0000-0002-5958-9257 University of Liverpool Department of Women's and Children's Health View all articles by this author Benjamin Greenfield University of Liverpool Department of Women's and Children's Health View all articles by this author Mahmoud Aljubeh Liverpool Women's Hospital View all articles by this author Eve Bunni 0009-0009-4991-3728 University of Liverpool Department of Women's and Children's Health View all articles by this author Alexandra Hunt University of Liverpool Department of Health Data Science View all articles by this author Vicky Bradley 0009-0002-2551-4713 University of Liverpool Department of Women's and Children's Health View all articles by this author Caroline Cunningham Liverpool Women's Hospital View all articles by this author Siobhan Holt Liverpool Women's Hospital View all articles by this author Andrew Demetri 0000-0002-2820-5919 University of Bristol View all articles by this author Christy Burden University of Bristol View all articles by this author Jo Ficquet Royal United Hospitals Bath NHS Foundation Trust View all articles by this author Elena Oteroromero Cambridge University Hospitals NHS Foundation Trust View all articles by this author William Parry-Smith Keele University Faculty of Medicine & Health Sciences View all articles by this author Mairead Black University of Aberdeen View all articles by this author Fiona Bradley Liverpool University Hospitals NHS Foundation Trust View all articles by this author Amy Elsmore Keele University Faculty of Medicine & Health Sciences View all articles by this author Jenna Frizelle Liverpool Women's Hospital View all articles by this author Tabitha Jones University of Liverpool Faculty of Health and Life Sciences View all articles by this author Abi Merriel 0000-0003-0352-2106 [email protected] University of Liverpool Department of Women's and Children's Health View all articles by this author Metrics & Citations Metrics Article Usage 498 views 367 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Carol Kingdon, Benjamin Greenfield, Mahmoud Aljubeh, et al. 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