Patient and Family Preferences Strongly Influence Decisions About Trial of Labor After Cesarean

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In the U.S., the rate of vaginal birth after cesarean (VBAC) has declined over the last two decades from 28% in 1996 to 12.8% in 2017. According to a multi-institutional study, a substantial portion of this decrease is related to women foregoing trial of labor after cesarean delivery (TOLAC) even when they are appropriate candidates and this option is available to them.

When counseling women about the choice between elective repeat cesarean delivery (ERCD) and TOLAC, clinicians traditionally focus the discussion on the balance of risks and benefits of the two delivery approaches. But these may not be the most important issues to women facing this decision. Empowering women to express their preferences and engage their families in the decisionmaking process may improve decision quality and increase TOLAC rates.

Anjali J. Kaimal, MD, MAS, director of the Deborah Kelly Center for Clinical Research, and Allison Bryant, MD, MPH, specialists in the Maternal-Fetal Medicine Program at Massachusetts General Hospital, along with Miriam Kuppermann, PhD, MPH, of University of California, San Francisco, and colleagues reached this conclusion after conducting a prospective observational study published in the Journal of Perinatology.

Study Subjects and Design

The researchers identified 231 female study participants (average age of 34) at hospitals offering TOLAC in Boston, Chicago and the San Francisco Bay Area from December 1, 2014, to April 1, 2016. These women spoke English or Spanish and had a singleton gestation at 26–34 weeks, one prior cesarean delivery, no prior VBAC and no absolute contraindication to VBAC or TOLAC. Eighty-five percent were receiving their prenatal care from an obstetrician. Seventy-seven percent experienced labor in their prior pregnancy and 8% had a vaginal delivery prior to their cesarean delivery.

At the interview, the participants completed sociodemographic and attitudinal questionnaires and a series of preference elicitation exercises. When they were counseled about the delivery approach, no formal educational intervention, web tools or decision support was in place in any of the sites, but some providers used a VBAC prediction tool developed by the National Institute of Child Health and Human Development.

Participant Preferences and Actual Results

At the time of the interview, 85% of the participants stated a preference for vaginal delivery if they could be guaranteed an uncomplicated delivery of either type. Ultimately, though, only 40% of all participants underwent TOLAC; the others had ERCD. Of the participants who underwent TOLAC, 74% had a vaginal delivery.

Women who chose TOLAC and those who chose ERCD were similarly concerned about avoiding the devastating consequences associated with uterine rupture. However, the strength of preference for vaginal delivery differed significantly between these groups.

Predictors of TOLAC

On multivariable logistic regression analysis, predictors of TOLAC were:

• Stronger preference for vaginal delivery
• Desire for the experience of labor and vaginal birth
• Endorsement of TOLAC by the person (other than the provider) whom the participant thought of as most important to the decisionmaking process

Sensitivity Analysis

One of the measures in the study was the participant's perception of her provider's recommendation about the delivery approach. This was excluded from the primary multivariable analysis because it could either result from or lead to the participant's preferences.

In a sensitivity analysis, the researchers added the provider recommendation measure as one of the factors considered. It weakened the impact of the opinion of the "important other" but did not affect the relationship between TOLAC and a woman's preferences and attitudes.

Takeaway Messages

Most TOLAC-eligible women had a preference for TOLAC, but ultimately, the majority of the cohort underwent ERCD. Enhanced decision support is needed to ensure that women and their families have the data they need to participate in shared decisionmaking about the choice between TOLAC and ERCD.

The likelihood of vaginal delivery may be more important than the risk of potential complications in determining a woman's choice of approach to delivery after prior cesarean. The opinion of people other than health care providers has a key role in women's decisionmaking about the delivery approach. Educational materials and decision support tools should allow women to share reliable information outside the office visit so their partners and other important people in their lives can help them make their decision.

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Refer a patient to Maternal-Fetal Medicine at Mass General