Main findings
This study has revealed that the content of readily accessed websites with information on birth options after CS reflect that contained in the RCOG patient information document ‘Birth after previous caesarean; information for you’ to a variable extent. At the extreme ends of the spectrum; from 24 key pieces of information which the RCOG recommend women are made aware of; the risk of a long operation with ERCS is discussed in only four of 48 websites assessed while uterine rupture is discussed on 45 of the 48. Less than half of the facts in support of either mode of delivery were featured on all 48 websites. Only country of origin was associated with the number of criteria supportive of ERCS with the UK reporting more supportive criterion than the US. The five most frequently returned websites contained two thirds of the facts supportive of ERCS, and less than half of those supportive of VBAC.
Strengths and limitations
The initial website searches performed on Google™ were not limited to those in the UK as it was felt unlikely the lay searcher would perform this function. As a result, more than half of the top websites originated from the USA and only 11 from the UK. For this reason, website information could have been skewed towards guidance on birth after caesarean which has been published internationally. On the other hand, no significant differences have been found between the RCOG or ACOG guidelines on birth after previous caesarean [3, 4, 20].
Another potential limitation of this internet survey is that the criteria used for the evaluation of website quality are not formally validated and the data scoring method is somewhat arbitrary. However, no consensus guideline for the evaluation of internet information exists. We therefore used criteria which have been cited as commonly used principles for this purpose [13–16]. In our analyses we have regarded all criteria as carrying equal weight in terms of importance. We cannot assume however that one website provides more reliable information than another, without first judging the individual importance of each criterion in clinical practice. This is especially important considering women are known to favour the delivery mode with least neonatal risk at the possible expense of increased maternal risk [21, 22]. Therefore websites may have scored highly despite failing to mention for example; the risk of increased neonatal mortality with VBAC, or increased risk of infant respiratory distress with ERCS.
Throughout this study, the RCOG guidelines and their supplementary patient information have been regarded as ‘gold standard’ [3, 8], with website information being scored against this. However it must be noted that the RCOG guidance has been based on best available evidence in the form of retrospective cohort studies and not randomised controlled trials. Additionally, the document was published in 2008, so there is potential for more recent research to supersede the document content. Despite this, it is the most comprehensive guidance available to date on which to base our findings, but results of future studies should prompt review of this internet survey.
It should also be noted that health information on the internet is a rapidly evolving field and the absolute results from this study will quickly become superseded by updated published guidance (e.g. NICE CG132 ‘Caesarean section’ [6]) and internet information (e.g. http://sdm.rightcare.nhs.uk/pda/birth-options-after-previous-caesarean/introduction/). In addition, there are websites available which provide good quality information on birth after caesarean that were missed using our chosen search method. Whilst acknowledging the unavoidability of such limitations, this study serves to provide a ‘snapshot’ of the nature and quality of internet information available to and accessed by women on this topic.
Interpretation
These results are amongst the first regarding the reliability of internet information on birth after previous caesarean section. Despite any potential drawbacks, this study has demonstrated that internet information on this topic is highly variable in quality and in content. A large number of unregulated and unaccountable sources are providing potentially incomplete and somewhat misleading information. This is despite efforts to improve the quality of health information available on the internet [16]. On the other hand, some websites were deemed highly reliable and balanced when compared to official guidance. Considering that the general public are notably poor in interpreting the quality of internet information [17], obstetricians should be prepared to direct pregnant women towards appropriate advice on birth after previous caesarean section. This could be done when women present to the antenatal consultation, regardless of whether or not they already have a preconceived decision on delivery mode.
This study supports what is known from previous studies about health information on the internet, in that information can often be of poor quality and contain misleading content [19, 23–30]. However it should be noted that several websites accessed in this study actually scored favourably in relation to the ‘gold standard’ and appeared to convey high quality, reliable information (Table 3). In fact, the RCOG ‘gold standard’ patient information presented itself within the overall search results, in addition to NHS patient information leaflets which closely reflected RCOG guidance. It is reassuring that women have the opportunity to access the best quality information, but they may not necessarily have the ability to contextualise this amongst less reliable sources. It is of interest that websites from the UK featured more information supportive of repeat CS than those from other countries. This may relate to the majority of such websites being owned by national health services, who are accustomed to providing comprehensive patient information regarding treatment options which plays a role in reducing risk of litigation. As failed VBAC is a major source of litigation, it is possible that greater effort is made to ensure that information on its consequences, including scar rupture, and means of avoiding these through repeat CS, is widely available to patients.
The internet is known to be a substantial resource used by pregnant women for information throughout their pregnancy and is likely to be utilised by women researching birth after previous caesarean section [11, 12]. Our study confirms that a wealth of internet information exists on birth after previous caesarean section and has identified approximately three hundred different websites addressing this topic.
Interestingly none of our top web link results were ‘blog’ or ‘social networking’ style links even though these types of internet site are known to be accessed as a valuable means of support for pregnant women with previous caesarean section [22]. Perhaps this conveys that these ‘blog’ style websites lack generalisability since they are most often written, and even accessed, by highly educated, middle class American women [22]. Nevertheless ‘blog’ style websites have been found to strongly favour VBAC as the preferred birth mode, despite our results which show both modes of delivery after caesarean as equally supported on the most popular internet sites [22].
Research and clinical implications
The findings of this study will inform care providers of the completeness of information and the most supported mode of birth to which patients may be exposed within their own home. This will enable delivery of advice regarding use of the internet for such purposes and may influence the development of future strategies to educate women on risks and benefits of modes of delivery after caesarean section via the internet.
Although this study has highlighted the availability of potentially poor quality, misleading internet information, many websites identified provided a high standard of information and balanced account of the options available. Combining this with incomplete advice often given by physicians themselves in comparison to official guidance [31, 32], then perhaps an area for further investigation is whether some internet healthcare information sources are actually more informative, accurate and balanced than that provided by healthcare professionals.