Objectives: The objective of this Future Research Needs project is to identify top-priority research needs in the area of strategies to reduce cesarean birth in low-risk women. The research needs identified in this report include knowledge gaps related to the effectiveness of specific strategies for reducing use of cesarean birth compared with usual care, knowledge gaps about factors that drive patient and provider preferences and attitudes, and recommendations for methodologic improvements. This project builds on the evidence gaps and methodologic issues identified in the Comparative Effectiveness Review (CER) Strategies To Reduce Cesarean Birth in Low-Risk Women.
Data sources: In Phase 1, stakeholders participated in a teleconference and then a Web-based survey to build a comprehensive list of research questions and methodologic recommendations. In Phase 2, stakeholders participated in one conference call and completed three Web-based surveys to prioritize research questions and recommendations. We identified currently funded and recently completed research between February 2012 and June 2012. To identify currently funded or recently completed randomized controlled trials intended to reduce use of cesarean delivery, we conducted searches of U.S. government resources (i.e., ClinicalTrials.gov, NIH Reporter), international trial registries (e.g., Current Controlled Trials), and other potential funding sources such as relevant associations and organizations (e.g., American College of Nurse-Midwives, American Congress of Obstetricians and Gynecologists).
Results: Thirteen stakeholders representing the perspective of patient advocacy groups, academic researchers, obstetrician-gynecologists, nursing and nurse-midwifery professional organizations, payers, and national foundations and societies agreed to participate in one or more of the stages of ranking and prioritization. The group included five Key Informants/Technical Expert Panel members from the draft CER. In Phase 1, stakeholders generated a “snowballed” list of 47 research questions and 17 methodologic recommendations. In Phase 2, stakeholders worked from the snowballed list to prioritize research needs. In Phase 3, the Evidence-based Practice Center investigators developed recommendations for optimal study design.
Conclusions: Our multistep process for identifying, multiplying, and prioritizing research questions to advance research in the area of strategies to reduce cesarean birth in low-risk women resulted in an actionable list of research topics to fill specific knowledge gaps. The top-tier research questions reflect a focus on standardization strategies for induction and arrest of labor (three of the top five research questions), systems-level strategies (one of five), and novel staffing models (one of five). For strategies that standardize induction and definitions of arrest of labor, we recommend cluster randomized controlled trials with randomization of entire labor and delivery units. For trials of systems-level strategies and staffing models, we recommend multisite studies to improve power and generalizability. The top-tier methodologic improvements focused on improving the capture of short- and long-term birth outcomes.