Improving the care pathway for women who request Caesarean section: an experience-based co-design study.
Maternal request for Caesarean section is controversial and yet the NICE Caesarean section Guideline recommends that that if this is requested, following discussion of the risks and benefits, women should be supported in their choice. There was a desire to improve the pathway at Birmingham Women's NHS Foundation Trust.



Experience-based co-design methodology uses service user and clinicians experiences collected using qualitative methods to jointly re-design services. Firstly semi-structured interviews were conducted to elicit the views and experiences of health care professionals and women who requested Caesarean section (with and without medical indication). Analysis identified key themes arising from the health care professionals' interviews and 'touch points' (key moments or events related to the experience of care) arising from the interviews with women.. Separate workshops were then held with each group to ensure these resonated and to identify key areas for service improvement. At the first joint workshop a pathway using 'audio clips' demonstrating women's agreed 'touch points' prompted discussion and joint working began to change the pathway. A final second workshop was held to agree changes to the pathway.



Interviews were conducted with health care professionals (n = 22, 10 consultant obstetricians and 12 midwives) and women (n = 15). The women's 'touch points' included repetition of request, delay in the decision for Caesarean section to be made, feeling judged, and that information was poor with similar findings identified from the health care professionals. Joint working resulted in a revised pathway for women who request Caesarean section. Changes to the pathway for women as a result of the work include written information about 'The way your baby may be born' which is given to the woman followed by a discussion about mode of birth around the 16 week appointment. If the woman wishes to have a Caesarean section, referral is made to appropriate health care professionals (e.g., Consultant Midwife, counsellor) only if support and information would be useful. If Caesarean section is requested, woman is referred to a consultant obstetrician for an appointment at 20/40, with a decision by 28/40. Recording this in the notes minimises repeated challenge described by women. Final consent and timing of Caesarean section remain as recommended.



This has resulted in changes to the pathway agreed by a co-design process and which are acceptable to both health care professionals and women. Use of such methodologies should be considered more frequently when implementing service change.
Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK. s.kenyon@bham.ac.uk.
Sara L
SL
Kenyon
Birmingham Women's NHS Foundation Trust, Mindelsohn Way, Birmingham, West Midlands, B15 2TG, UK.
Nina
N
Johns
Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
Sandhya
S
Duggal
Research Fellow, Institute of Applied Health Research, University of Birmingham, 255 Walmley Road, Walmley, Sutton Coldfield, West Midlands, B76 2PN, UK.
Ruth
R
Hewston
Health Services Management Centre, University of Birmingham, Park House, 40 Edgbaston Park Road, Edgbaston, Birmingham, B15 2RT, UK.
Nicola
N
Gale
D000328:Adult; D001291:Attitude of Health Personnel; D002585:Cesarean Section; D003226:Congresses as Topic; D019091:Critical Pathways; D005260:Female; D006801:Humans; D007258:Informed Consent; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D008880:Midwifery / Q000379:methods*; D009774:Obstetrics / Q000379:methods*; D010353:Patient Education as Topic; D057240:Patient Preference; D011247:Pregnancy; D011295:Prenatal Care / Q000379:methods; D012017:Referral and Consultation
Experience based co-design; Interviews; Maternal request for Caesarean section; Qualitative methods