BACKGROUND AND PURPOSE:

• Kuppermann et al. (JAMA, 2020) examined the effects of a patient-centered decision support tool on TOLAC rates and decision quality

METHODS:

• Multicenter, randomized, parallel-group clinical trial (RCT)
  • Prior Cesarean Decision (PROCEED) trial
• Participants
  • English- or Spanish-speaking women
  • 1 prior cesarean
  • No contraindication to trial of labor
• Randomized 1:1 to 2 groups
  • Intervention: Tablet-based decision support tool <25 weeks | Purpose of tool is to assist women in choosing between TOLAC or repeat cesarean
  • Control: Usual care
• Decision tool included
  • Published outcomes data related to TOLAC vs repeat cesarean
  • Preference-based predictors of TOLAC
  • Interactive multimedia decision tools
  • Integration into clinician and patient discussions to encourage shared decision-making
• Primary outcome
  • Trial of labor
• Secondary outcome
  • Vaginal birth
  • Maternal and neonatal outcomes
  • Decision quality

RESULTS:

• 1470 women
  • Decision support tool: 735 women
  • Control: 735 women
  • Mean (SD) age: 34.0 (4.5) years
• TOLAC rates did not differ significantly between groups
  • Decision support tool: 43.3%
  • Control: 46.2%
  • Adjusted absolute risk difference –2.78% (95% CI, –7.80% to 2.25%)
  • Adjusted relative risk (RR) 0.94 (95% CI, 0.84 to 1.05)
• Vaginal birth rates did not differ significantly between intervention and control groups
  • Decision support tool: 31.8%
  • Control: 31.8%
  • Adjusted absolute risk difference –0.04% (95% CI, –4.80% to 4.71%)
  • Adjusted RR 1.00 (95% CI, 0.86 to 1.16)
• Other clinical maternal or neonatal outcomes did not differ significantly between groups
• There were also were no significant differences found for the 5 decision quality measures
  • Decisional conflict | Knowledge | Shared decision-making | Decision efficacy | Decision satisfaction

CONCLUSION:

• The decision support tool, investigated in this RCT, did not appear to alter TOLAC or vaginal delivery rates
• Authors note that

Given the high rates of trial of labor and vaginal birth and good decision quality, further increasing the trial-of-labor rate in the study population may not be appropriate or desirable, as it may already reflect the true informed preference-based demand for this delivery approach

Learn More – Primary Sources:

Effect of a Patient-Centered Decision Support Tool on Rates of Trial of Labor After Previous Cesarean Delivey – The PROCEED Randomized Clinical Trial

Related ObG Topics:

VBAC Guidelines: Who is a Candidate for a Trial of Labor after Cesarean Delivery?

Trial of Labor After Cesarean for Twins and Risks for Adverse Outcomes

Three Previous Cesarean Deliveries: When to Deliver?