Using Health Information Technology to Reduce Disparities in Shared Decision Making About Birth After Cesarean

Purpose: Decision aids are central to shared decision making (SDM) and recommended for value-sensitive healthcare decisions. Effective strategies for widespread implementation of decision aids to reduce disparities in decision making experiences, including use of interactive web-based platforms, are lacking. The purpose of this research was to evaluate the feasibility and acceptability of implementing a web-based decision aid designed to support shared decision making about birth after previous cesarean, for women receiving care in high volume, urban, ethnically diverse outpatient clinic settings. We hypothesized that an interactive decision aid implemented into routine practice using health information technology (IT) would increase opportunities for shared decision making for women through effective decision preparation and communication of women’s preferences and values with providers.

Methods: A before and after study design was used to assess the feasibility and acceptability of the decision aid for women's preparation for shared decision making. This included assessing changes in women's knowledge about their birth options, levels of decisional conflict, preferences for mode of birth and actual birth outcomes. Decision aid users rated acceptability of the content, features, and function of the decision aid. Documentation of women's birth preferences and actual birth outcomes were compared.

Results: Participants included 68 pregnant women from diverse background with mean age 29.3 years; black, 46.2%; Hispanic 35.4%; White 13.8%; Asian/Other 4.6%. All had experienced one previous cesarean section. Knowledge of birth options test scores increased by 2.58 points out of 15 (p<0.001; d=0.87) for women participating in the study. Decisional conflict scores also reduced by 0.45 points out of five points (p<.001; d = 0.69). Forty-four women (65.9%) attempted VBAC, of whom 29 (65.7%) succeeded. Most participants used the decision aid during pregnancy and rated the decision aid content, features and functions as good/excellent. All women who rated the decision aid indicated they would recommend the decision aid to other women.

Conclusion: It is feasible to implement web-based decision aids within ethnically diverse pregnancy care settings to address disparities in decision preparation. Strategies to improve timely decision aid access and promote consistent utilization of decision support for all women are needed. Seamless integration into workflow, including use of the electronic medical record, is an important next step for future dissemination and implementation.