Learning from women: Improving experiences of respectful maternity care during unplanned caesarean birth for women with diverse ethnicity and racial backgrounds.

PROBLEM: Women from diverse ethnicity and racial backgrounds have few opportunities to share birth experiences to inform improvements in care. BACKGROUND: Respectful maternity care is recognised as a global women's health priority. Integrating that framework into diverse care systems and models may help bridge care gaps for women who had unexpected birth experiences, including unplanned caesarean birth. AIM: To describe the experiences of women who had unplanned caesarean births and use knowledge gained to inform best practice recommendations that embody respectful maternity care. METHODS: Qualitative data were analysed from focus groups involving a convenience sample of 11 English speaking women, from diverse ethnic and racial backgrounds, with prior unplanned caesarean experience. Respectful maternity care was used as the lens for interpreting women's narratives using Thorne's interpretive description. The study site was an outpatient prenatal clinic within an urban academic, tertiary-care medical centre in the United States. FINDINGS: Two predominant, contrasting themes emerged: "not feeling well cared for" and "feeling well supported". Positive experiences included sources of support and strength from the midwifery practice, group prenatal care, and a doula program. Eight domains of respectful maternity care were applied to findings, highlighting current positive institutional practices and proposing areas for future quality improvement. CONCLUSION: Key practices promoting respectful maternity care include adequate communication and information sharing between pregnancy care providers and women, and a more robust informed consent process. Further emphasis on respectful maternity care is needed to support women to make shared decisions that best fit their circumstances and preferences.

Promoting Shared Decision Making About Birth After Cesarean in Haitian Women.

This was a pilot to develop culturally appropriate group counseling sessions for shared decision making about modes of birth after cesarean for Haitian Creole speakers. The curriculum was created by incorporating information identified by women and their providers in focus groups through the lens of Health Belief Model. Ten women attended a session. There was a 50% increase in women planning to labor after cesarean; nine stated the session gave them confidence to decide about their mode of birth; all were "very satisfied" with the session and would recommend it to others. The session was accepted as a method to improve women's decision making, feasible, effective, and could be integrated to improve shared decision making discussions for other non-English speaking women.

Labour after caesarean counselling documentation: a quality improvement intervention on labour and delivery.

BACKGROUND: Most women who have had previous caesareans are eligible to have labour after caesarean (LAC), but only 11.9% do so. Studies show the majority of women have already decided about future mode of birth (FMOB) before a subsequent pregnancy. Hence, providing women with LAC counselling soon after birth may help women plan for future pregnancies. Prior to our intervention, our hospital had no method of ensuring that women received LAC counselling after caesarean section. The purpose of this QI initiative was to assess whether formal LAC documentation on labour and delivery (L&D) improves rates of LAC counselling post partum. METHODS: Our three-part intervention included: (1) surgeon's assessment of LAC feasibility in the operative note, (2) written LAC education for women in discharge paperwork and (3) documentation of LAC counselling in the discharge summary. We implemented these changes on L&D in January 2019. We conducted phone surveys of 40 women after caesarean preintervention and postintervention. Surveys included questions regarding three primary outcomes: whether or not they had received LAC counselling either in the hospital or at a postpartum visit, and whether or not they would pursue LAC as FMOB. Surveys also assessed two secondary outcomes: (1) women's understanding of the indications for surgery and (2) their involvement in the decision process. We used a χ2 analysis to assess primary outcomes and a Fisher's exact test to assess secondary outcomes. We also surveyed providers about the culture of LAC counselling at our hospital. RESULTS: After our intervention, there was a significant difference between the number of women reporting LAC postpartum counselling (30.77% vs 53.8%, p=0.04). There was also a significant difference in the number of women feeling involved in the decision-making process (68% vs 95%, p=0.03). Providers reported improved knowledge/confidence around LAC counselling (58%-100%). Providers universally stated that LAC counselling has become more ingrained in the culture on L&D. CONCLUSIONS: Documentation of LAC counselling improved the consistency with which providers incorporated LAC counselling into postpartum care. Addressing FMOB at the time of pLTCS and documenting that counselling may be an effective first step in empowering women to pursue LAC in future pregnancies.

Listening to Haitian Women and their Health Care Providers: Insight into Shared Decision-making After Cesarean Section.

INTRODUCTION: Haitian women in Massachusetts have high rates of cesarean section and low rates of vaginal birth after cesarean, despite evidence suggesting that many are eligible to attempt vaginal birth after a previous cesarean. This qualitative study explored the cultural impact of previous surgical birth for Haitian women to inform the development of a patient-centered decision support program. METHODS: Key stakeholders included Haitian women with previous cesarean and their obstetric care providers. Haitian women participated in focus groups; care providers participated in focus groups and in-depth interviewing. RESULTS: Four prominent themes emerged surrounding childbirth decision-making: the importance of Haitian culture and beliefs; need for more information on birthing options; influence of family/friends; and pain as a considerable factor. CONCLUSION: We hypothesize that group counseling tailored to meet cultural values and needs of Haitian women may support all stakeholders as they work towards sharing decisions about birth after cesarean.

The Perspectives of Women and Their Health-Care Providers Regarding Using an ECA to Support Mode of Birth Decisions.

This study used focus groups to assess the feasibility and acceptability of adapting an Embodied Conversational Agent (ECA) to support decision-making about mode of birth after previous cesarean. Twelve women with previous cesareans, and eight prenatal providers at an academic, tertiary-care medical center, viewed a prototype ECA and were asked to share feedback on the potential role in helping women prepare for decision-making. Both groups felt that although it was somewhat "robot-like," the ECA could provide easy access to information for patients and could augment the visit with providers. Future work is needed to improve ECA visual appeal and clarify the role and timing for utilization of decision aids using ECA technology to enhance the shared decision-making process.

A Shared Decision-Making Toolkit for Mode of Birth After Cesarean.

This study evaluated a shared decision-making (SDM) Toolkit (decision aid, counseling guide, and provider scripts) designed to prepare and engage racially diverse women in shared decision-making discussions about the mode of birth after cesarean. The pilot study, involving 27 pregnant women and 63 prenatal providers, assessed women's knowledge, preferences, and satisfaction with decision making, as well as provider perspectives on the Toolkit's acceptability. Most women experienced knowledge improvement, felt more in control and that providers listened to their concerns and supported them. Providers reported that the Toolkit helped women understand their options and supported their counseling. The SDM Toolkit could be used to help women and providers improve their SDM regarding mode of birth after cesarean.

The Effect of Evidence-Based Scripted Midwifery Counseling on Women's Choices About Mode of Birth After a Previous Cesarean.

INTRODUCTION: The purpose of this study was to evaluate how a scripted counseling intervention affected the experience of decision making and actual choice for trial of labor after cesarean (TOLAC) or elective repeat cesarean birth (ERCB) in a cohort of women receiving care from nurse-midwives. METHODS: A pilot study of scripted counseling for women who had a previous cesarean about TOLAC versus ERCB was conducted at Boston Medical Center. Candidates for a TOLAC, receiving prenatal care from nurse-midwives in 2012 and 2013, were enrolled before 28 weeks' gestation. The women received 4 scripted counseling sessions during the routine prenatal visit, evidence-based information pamphlets, and an opportunity to review the hospital TOLAC consent form. Pre and post questionnaires were completed regarding birth preference, information sources, and decision factors. A midpoint assessment of the participants' knowledge of risks and benefits of TOLAC versus ERCB was conducted, and satisfaction with the intervention and outcome were assessed after the birth. RESULTS: Twenty-two women participated in the study, and 20 completed all study questionnaires. More of the participants believed they had enough information after the intervention (95% after intervention vs 70% before the intervention). Reasons for choosing ERCB included being afraid of vaginal birth complications, having prior positive experience with cesarean, and convenience of knowing when the neonate will be born. Reasons for choosing a TOLAC included the personal importance of having a vaginal birth and that recovery is faster and easier. Few women cited concerns for their own safety and that of their newborns when choosing TOLAC. DISCUSSION: Women were satisfied with the scripted counseling and found it useful in helping them make a birth mode decision. While the scripted counseling did not appear to influence preferred mode of birth, it appeared to help women follow through with the mode of birth they chose prenatally.