Intended for healthcare professionals


Two decision aids for mode of delivery among women with previous caesarean section: randomised controlled trial

BMJ 2007; 334 doi: (Published 21 June 2007) Cite this as: BMJ 2007;334:1305
  1. Alan A Montgomery, senior lecturer in primary care research1,
  2. Clare L Emmett, trial coordinator1,
  3. Tom Fahey, professor of general practice2,
  4. Claire Jones, research assistant3,
  5. Ian Ricketts, professor of assistive systems and healthcare computing3,
  6. Roshni R Patel, specialist registrar in obstetrics and gynaecology4,
  7. Tim J Peters, professor of primary care health services research1,
  8. Deirdre J Murphy, professor of obstetrics5
  9. DiAMOND Study Group
  1. 1Department of Community Based Medicine, University of Bristol, Bristol BS8 2AA
  2. 2Department of General Practice, Royal College of Surgeons in Ireland, Mercer's Medical Centre, Dublin 2, Republic of Ireland, and Tayside Centre for General Practice, University of Dundee, Dundee
  3. 3School of Computing, University of Dundee, Queen Mother Building, Dundee
  4. 4Academic Unit of Obstetrics and Gynaecology, University of Bristol, St Michael's Hospital, Bristol
  5. 5Academic Department of Obstetrics and Gynaecology, Trinity College Dublin, Coombe Women's Hospital, Dublin 8, Republic of Ireland, and Department of Obstetrics and Gynaecology, University of Dundee, Ninewells Hospital, Dundee
  1. Correspondence to: A Montgomery alan.a.montgomery{at}
  • Accepted 18 April 2007


Objectives To determine the effects of two computer based decision aids on decisional conflict and mode of delivery among pregnant women with a previous caesarean section.

Design Randomised trial, conducted from May 2004 to August 2006.

Setting Four maternity units in south west England, and Scotland.

Participants 742 pregnant women with one previous lower segment caesarean section and delivery expected at ≥37 weeks. Non-English speakers were excluded.

Interventions Usual care: standard care given by obstetric and midwifery staff. Information programme: women navigated through descriptions and probabilities of clinical outcomes for mother and baby associated with planned vaginal birth, elective caesarean section, and emergency caesarean section. Decision analysis: mode of delivery was recommended based on utility assessments performed by the woman combined with probabilities of clinical outcomes within a concealed decision tree. Both interventions were delivered via a laptop computer after brief instructions from a researcher.

Main outcome measures Total score on decisional conflict scale, and mode of delivery.

Results Women in the information programme (adjusted difference −6.2, 95% confidence interval −8.7 to −3.7) and the decision analysis (−4.0, −6.5 to −1.5) groups had reduced decisional conflict compared with women in the usual care group. The rate of vaginal birth was higher for women in the decision analysis group compared with the usual care group (37% v 30%, adjusted odds ratio 1.42, 0.94 to 2.14), but the rates were similar in the information programme and usual care groups.

Conclusions Decision aids can help women who have had a previous caesarean section to decide on mode of delivery in a subsequent pregnancy. The decision analysis approach might substantially affect national rates of caesarean section.

Trial Registration Current Controlled Trials ISRCTN84367722.


  • We thank the women who took part in the study. Other members of the Decision Aids for Mode Of Next Delivery (DiAMOND) Study Group are as follows: Julia Frost, Alison Shaw (qualitative study); Peter Gregor (applied computing); Sandra Hollinghurst (economic evaluation); Beverley Lovering, Anne Schlegelmilch, Kate Warren (recruitment); Maureen Macleod, Irene Munro (recruitment, delivery of interventions, data collection); Helen Watson (data collection); and Kav Vedhara (health psychology)

  • Contributors: AAM (guarantor), TF, and DJM had the original idea for the study and, with TJP, carried out the design. AAM, TF, RRP, TJP, and DJM obtained funding. AAM, CLE, TF, CJ, RRP, IR, TJP, DJM developed the interventions, and CLE was also responsible for data collection. AAM, CLE, and TJP carried out the analysis. AAM and CLE drafted the manuscript, which was revised by TF, CJ, IR, RRP, TJP, and DJM.

  • Funding: BUPA Foundation. AAM was part supported by a postdoctoral fellowship from the UK Department of Health National Coordinating Centre for Research Capacity Development.

  • Competing interests: None declared.

  • Ethical approval: South west multicentre research ethics committee.

  • Accepted 18 April 2007
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