Birth Choices for Women in a 'Positive Birth After Caesarean' Clinic: Randomised Trial of Alternative Shared Decision Support Strategies

Background: Systematic approaches to information giving and decision support for women with previous caesarean sections are needed.

Aim: To evaluate decision support within a 'real-world' shared decision-making model.

Methods: A pragmatic comparative effectiveness randomised trial in the Positive Birth After Caesarean Clinic. Women with one previous caesarean and singleton pregnancy <25 weeks were randomly allocated to standard Positive Birth After Caesarean care, or standard Positive Birth After Caesarean care plus a decision aid booklet. Main outcome measure was mode of birth, with secondary measures of knowledge, decisional conflict, birth choice, adherence to birth choice, perception of decision support, and satisfaction.

Results: Of 297 participants, rate of attempted vaginal birth after caesarean increased and was similar for both groups (61% vs 57%, P = 0.5). Knowledge scores increased more for women in the additional decision aid group (2.0 vs 1.6 points, P = 0.2). Decisional conflict score reduction was similar between groups (P = 0.5). Women initially unsure of their birth preference who received the additional decision aid had greater reduction in decisional conflict score (P = 0.04) and were more likely to plan vaginal birth after caesarean (49% vs 33%, P = 0.2). Adherence to birth choice and birth satisfaction was similar between groups. Women in the additional decision aid group rated their decision support tool higher (P < 0.01).

Conclusions: In a 'real world' shared decision-making model, an additional decision aid conferred some benefits in factors associated with preparation for shared decision-making. Decision aids may provide particular benefit for women who are initially unsure and need assistance in the deliberation phase.