Recommendations for research
The guideline committee has made the following key recommendations for research.
As part of the 2021 update, the guideline committee removed the research recommendation on 'What are the medium- to long-term risks and benefits to women and their babies of planned caesarean birth compared with planned vaginal birth?' and replaced it with a research recommendation on the short-term and long-term risks and benefits of planned caesarean birth compared with planned vaginal birth.
1 Short-term and long-term benefits and risks of planned caesarean birth compared to planned vaginal birth
What are the benefits and risks (short term and long term) of planned caesarean birth compared with planned vaginal birth at term for women and babies/infants/children? 
Information provided to women with low-risk pregnancies in relation to the short- and long-term benefits and risks of planned caesarean birth compared with planned vaginal birth should reflect the relevant risks during the antenatal period when a woman is planning mode of birth. Studies used to inform these discussions with women should be from 'intention to treat' type analyses. However, this type of evidence is sparse for outcomes relevant to the early neonatal period and minimal for long-term outcomes and further research is needed.
For a short explanation of why the committee made the recommendation for research, see the rationale on benefits and risks of caesarean and vaginal birth.
Full details of the evidence and the committee's discussion are in evidence review A: the benefits and risks of planned caesarean birth.
What factors influence the decision-to-birth interval when there is a category 1 level of urgency for caesarean birth? 
'Crash' caesarean birth is a psychologically traumatic event for women and their partners, and is also stressful for clinical staff. Staff and resources might have to be obtained from other areas of clinical care. This should be done as efficiently and effectively as possible, minimising anxiety and ensuring the safety of the mother and her baby.
For category 1 caesarean birth there is a recognised urgency to deliver as quickly as is reasonably possible. Most research in this area is quantitative and looks at the impact of the decision-to-birth interval on various aspects of fetal and maternal outcomes rather than the interplay of factors that can affect this time period itself. Much of this evidence is retrospective. Although some work has been done in the UK to examine where the systematic delays are and how to avoid them, more work is needed to determine how to optimise the decision-to-birth interval. This work should use qualitative as well as quantitative research methods to assess which factors influence the decision-to-birth interval for a category 1 caesarean birth. Evaluation of these factors could be used to inform future NICE guidance, for example, specific guidance for management of category 1 caesarean birth. Such information could also be used by hospitals for maternity services planning, and at a team level would assist with audit and ongoing evaluation and training of the multidisciplinary team.
A large amount of NHS and other state funding is used to provide continuing care for babies who are disabled as a result of birth asphyxia and in providing lifelong support for the child and their family. In addition, large sums of public money are spent on litigation and compensation in some of these cases through the Clinical Negligence Scheme for Trusts (CNST). If research helped to reduce the incidence of birth asphyxia this would reduce the costs of continuing care to the state and the burden to the child, their family and the wider community.
More realistic and more relevant expectations for the decision-to-delivery interval based on evidence would inform debate in the legal system and could help to reduce the cost to the state of related litigation.
A prospective study to determine whether the decision-to-birth interval has an impact on maternal and neonatal outcomes when there is a category 2 level of urgency for caesarean birth. 
This research is important to inform the ongoing debate about the management of category 2 caesarean birth. The 'continuum of risk' in this setting has been recognised. However, most of the work in this area, looking at maternal and fetal outcomes, generally considers unplanned caesarean birth as a whole group without making any distinction between degrees of urgency. Furthermore, much of this work is retrospective. Most women who undergo intrapartum caesarean birth fall into the category 2 level of urgency and therefore specific information for this group could affect and benefit many women and contribute to the delivery of equity of care.
Delay in birth with a compromised fetus could result in major and long-term harm including cerebral palsy and other major long-term disability. The immediate and long-term effect on a family of the birth of a baby requiring lifelong specialised care and support is enormous. If such harm could be avoided by appropriate haste this would be an important improvement in outcome. However, if such haste is of no benefit, then any related risk of adverse maternal outcome needs to be minimised.
A large amount of NHS and other state funding is used to provide continuing care for babies who are disabled as a result of delay in birth and in providing lifelong support for the child and their family. In addition, large sums of public money are spent on litigation and compensation in some of these cases through the CNST. If research helped to reduce the incidence of delay in birth this would reduce the costs of continuing care to the state and the burden to the child, their family and the wider community.
More realistic and more relevant expectations for the decision-to-birth interval based on evidence would inform debate within the legal system and could help to reduce the cost to the state of related litigation.
What support or psychological interventions would be appropriate for women who have a fear of vaginal childbirth and request a caesarean birth? 
Fear of vaginal childbirth can stem from:
fear of damage to the maternal pelvic floor
damage to the baby during childbirth
self-doubt on the ability to physically have a vaginal birth
previous childbirth experience
unresolved issues related to the genital area.
Currently there is a wide variation in practice and limited resources lead to limited availability of effective interventions. Interventions that might be appropriate include:
antenatal clinics dedicated to providing care for women with no obstetric indications who request a caesarean birth
referral to a psychologist or a mental health professional
referral to an obstetric anaesthetist
intensive midwifery support.
Continuity of healthcare professional support from the antenatal to the intrapartum periods and 'one-to-one' midwifery care during labour are also often lacking and could make a difference to women who are anxious or afraid.
All of these interventions have different resource implications and there is no clear evidence to suggest that any are of benefit. The proposed research would compare in a randomised controlled trial 2 or more of these interventions in women requesting a caesarean birth. In the absence of any evidence, there is a case for comparing these interventions with routine antenatal care (that is, no special intervention).
This research is relevant because it would help to guide the optimal use of these limited resources and future guideline recommendations.