Interventions for supporting pregnant women with decisions about mode of birth after previous caesarean

Caesarean birth is increasingly common but this does not mean that all subsequent births are caesareans. Pregnant women who have had a previous caesarean birth may need to decide whether to have a planned caesarean birth or commence labour with the intention of a vaginal birth (VBAC). This can be a difficult decision and decision support tools may help women with their decision making. There are three main types of decision support. Women can use some decision support tools independently, the second type are intended to be shared with the health professionals responsible for a woman's care, and others are designed for use with a third party. Some call these mediated decision supports interventions. Decision supports can include telephone decision coaching services, decision-aids, one-on-one counselling, group information or support sessions and decision protocols or algorithms. This review considered any decision support intervention intended for pregnant women making birth choices after a previous caesarean birth.

We found three studies (involving 2270 women), all from high-income countries, that were suitable for this review. The studies looked at the effectiveness of decision support tools designed to be used either independently by women or mediated through the involvement of someone not associated with their care support. No studies looked at shared decision support tools that were intended to help with shared decision making with the pregnant women and their health professionals during pregnancy care visits.

We found that the use of these decision support tools made no difference to the type of birth women planned, how women actually gave birth, or in the number of women and babies who experienced harm, although only one study reported harms. There was also no difference in the proportion of women who were unsure about what they wanted. Overall, nearly 65% of women who wanted a VBAC achieved it, while almost all women wanting a caesarean birth had one (97%). We found no difference in the proportion of women who achieved their preferred mode of birth. However, women who used decisional support interventions had less uncertainty about their decision than those that did not use them. Research is needed on the effectiveness of decision support interventions designed to be shared between women and the health professionals caring for them in pregnancy after a caesarean birth.

Authors' conclusions: 

Evidence is limited to independent and mediated decision supports. Research is needed on shared decision support interventions for women considering mode of birth in a pregnancy after a caesarean birth to use with their care providers.

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Background: 

Pregnant women who have previously had a caesarean birth and who have no contraindication for vaginal birth after caesarean (VBAC) may need to decide whether to choose between a repeat caesarean birth or to commence labour with the intention of achieving a VBAC. Women need information about their options and interventions designed to support decision-making may be helpful. Decision support interventions can be implemented independently, or shared with health professionals during clinical encounters or used in mediated social encounters with others, such as telephone decision coaching services. Decision support interventions can include decision aids, one-on-one counselling, group information or support sessions and decision protocols or algorithms. This review considers any decision support intervention for pregnant women making birth choices after a previous caesarean birth.

Objectives: 

To examine the effectiveness of interventions to support decision-making about vaginal birth after a caesarean birth.

Secondary objectives are to identify issues related to the acceptability of any interventions to parents and the feasibility of their implementation.

Search strategy: 

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2013), Current Controlled Trials (22 July 2013), the WHO International Clinical Trials Registry Platform Search Portal (ICTRP) (22 July 2013) and reference lists of retrieved articles. We also conducted citation searches of included studies to identify possible concurrent qualitative studies.

Selection criteria: 

All published, unpublished, and ongoing randomised controlled trials (RCTs) and quasi-randomised trials with reported data of any intervention designed to support pregnant women who have previously had a caesarean birth make decisions about their options for birth. Studies using a cluster-randomised design were eligible for inclusion but none were identified. Studies using a cross-over design were not eligible for inclusion. Studies published in abstract form only would have been eligible for inclusion if data were able to be extracted.

Data collection and analysis: 

Two review authors independently applied the selection criteria and carried out data extraction and quality assessment of studies. Data were checked for accuracy. We contacted authors of included trials for additional information. All included interventions were classified as independent, shared or mediated decision supports. Consensus was obtained for classifications. Verification of the final list of included studies was undertaken by three review authors.

Main results: 

Three randomised controlled trials involving 2270 women from high-income countries were eligible for inclusion in the review. Outcomes were reported for 1280 infants in one study. The interventions assessed in the trials were designed to be used either independently by women or mediated through the involvement of independent support. No studies looked at shared decision supports, that is, interventions designed to facilitate shared decision-making with health professionals during clinical encounters.

We found no difference in planned mode of birth: VBAC (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.97 to 1.10; I² = 0%) or caesarean birth (RR 0.96, 95% CI 0.84 to 1.10; I² = 0%). The proportion of women unsure about preference did not change (RR 0.87, 95% CI 0.62 to 1.20; I² = 0%).

There was no difference in adverse outcomes reported between intervention and control groups (one trial, 1275 women/1280 babies): permanent (RR 0.66, 95% CI 0.32 to 1.36); severe (RR 1.02, 95% CI 0.77 to 1.36); unclear (0.66, 95% CI 0.27, 1.61). Overall, 64.8% of those indicating preference for VBAC achieved it, while 97.1% of those planning caesarean birth achieved this mode of birth. We found no difference in the proportion of women achieving congruence between preferred and actual mode of birth (RR 1.02, 95% CI 0.96 to 1.07) (three trials, 1921 women).

More women had caesarean births (57.3%), including 535 women where it was unplanned (42.6% all caesarean deliveries and 24.4% all births). We found no difference in actual mode of birth between groups, (average RR 0.97, 95% CI 0.89 to 1.06) (three trials, 2190 women).

Decisional conflict about preferred mode of birth was lower (less uncertainty) for women with decisional support (standardised mean difference (SMD) -0.25, 95% CI -0.47 to -0.02; two trials, 787 women; I² = 48%). There was also a significant increase in knowledge among women with decision support compared with those in the control group (SMD 0.74, 95% CI 0.46 to 1.03; two trials, 787 women; I² = 65%). However, there was considerable heterogeneity between the two studies contributing to this outcome ( I² = 65%) and attrition was greater than 15 per cent and the evidence for this outcome is considered to be moderate quality only. There was no difference in satisfaction between women with decision support and those without it (SMD 0.06, 95% CI -0.09 to 0.20; two trials, 797 women; I² = 0%). No study assessed decisional regret or whether women's information needs were met.

Qualitative data gathered in interviews with women and health professionals provided information about acceptability of the decision support and its feasibility of implementation. While women liked the decision support there was concern among health professionals about their impact on their time and workload.

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