Interventions for supporting pregnant women's decision-making about mode of birth after a caesarean.
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.
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.
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.
All published, unpublished, and ongoing randomised controlled trials (RCTs) and quasi-randomised trials with reported data of any intervention designed to support pregnant women who have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.
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.
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.
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.
Horey D
，Kealy M
，Davey MA
，Small R
，Crowther CA
... -
《Cochrane Database of Systematic Reviews》
Can We Enhance Shared Decision-making for Periacetabular Osteotomy Surgery? A Qualitative Study of Patient Experiences.
Periacetabular osteotomy (PAO) surgery presents an opportunity for shared decision-making (SDM) and may be facilitated by decision-making tools. Currently, no diagnosis or treatment-specific decision-making tools exist for this patient population. Understanding patient PAO surgery decision-making experiences and processes would enable development of a treatment-specific decision-making tool and would help hip preservation surgeons with SDM practices.
Qualitative methodology was used to address the following questions: (1) What were the information support needs of adult patients with hip dysplasia who decided to have PAO? (2) What was important to adult patients with hip dysplasia who decided to have PAO? (3) How did adult patients with hip dysplasia who have undergone PAO experience the surgical decision-making process? (4) What elements of SDM did adult patients with hip dysplasia experience with their surgeons when deciding to have PAO?
Fifteen volunteer, English-speaking patients in the United States who had been diagnosed with hip dysplasia and who had undergone PAO surgery 6 to 12 months prior to the study were recruited through five PAO surgery Facebook support groups. Individuals were excluded if they had an underlying neuromuscular condition or other diagnosis related to nondevelopmental dysplasia of the hip or if they had a previous PAO surgery > 12 months before data collection. We used purposive sampling strategies to promote sample heterogeneity based on age and preoperative activity level, as these are characteristics that may impact decision-making. Participants were categorized into three age groups: 20 to 29 years, 30 to 39 years, and ≥ 40 years. Participants were also categorized as having "low activity," "moderate activity," or "high activity" preoperatively based on self-reported University of California Los Angeles (UCLA) Activity Scale scores. Participants were enrolled consecutively if they met the inclusion criteria and fulfilled one of our sampling categories; we had plans to enroll more participants if thematic saturation was not achieved through the first 15 interviews. Participants included 14 women and one man ranging in age from 23 to 48 years, and all had undergone PAO surgery for hip dysplasia 6 to 12 months prior to the interview. One-on-one semistructured interviews were conducted with each participant by a single interviewer through Zoom video conferencing using video and audio recording. Participants answered semistructured interview questions and provided verbal responses to survey questions so researchers could gain demographic information and details about their symptoms, diagnosis, and PAO surgery between June 2021 and August 2021. Quantitative survey data were analyzed using descriptive statistics. Qualitative data were analyzed by three researchers using principles of reflexive thematic analysis. Candidate themes were iteratively defined and redefined until central themes were developed that were distinctly different, yet centrally relevant, and answered the research questions. All codes that informed category and theme development were generated within the first six transcripts that were analyzed. The team felt that thematic saturation was established with the 15 interviews.
The main information needs for adult patients with hip dysplasia included diagnosis and treatment-related information, as well as logistics related to surgery and recovery. Many patients described that their information needs were only partially met by their surgeon; most engaged in additional information-seeking from scientific research and online resources and relied on patient peers to meet information needs about the lived experience and logistics related to surgery and recovery. It was important to patients that PAO surgery could preserve their native hip or delay THA and that PAO surgery was likely to reduce their pain and improve function; decision-making was facilitated when patients were able to identify how the indications and goals of PAO surgery aligned with their own situation and goals for surgery. Patients' experiences with decision-making were more positive when information needs were met, when indications and goals for PAO surgery aligned with their personal values and goals, and when their preferred and actual decision-making roles aligned. Adult patients with hip dysplasia described high variability in the extent to which patients were invited to share personal preferences, values, and goals around PAO surgery and the extent to which preferred patient decision-making roles were assessed.
We found that elements of SDM are not consistently integrated into hip preservation practice. The knowledge gained through this work about patient PAO surgery information needs, what matters to patients when deciding to have surgery, and their experiences with PAO surgery decision-making can inform future PAO surgery decision-making tool development. Future studies are needed to validate the findings of this study and to determine whether they are generalizable to adult patients with hip dysplasia with different demographic characteristics or to patients who do not participate in social media support groups.
Surgeons should recognize that patients are likely to leave their office without their information needs being met. SDM strategies can promote more effective information exchanges in the clinic so surgeons can help patients identify their information needs, provide education and direction to accurate and reputable resources to meet those needs, and help patients appraise information they gather and apply it to their personal situation. Hip preservation surgeons can use the sample SDM script and checklist offered here to support adult patients with hip dysplasia who are making PAO surgery decisions until a future diagnosis and treatment-specific decision-making tool is available.
Muir NB
，Orlin M
，Rubertone P
，Williams G
... -
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ResearchGate
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钛学术
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