Making shared decisions in relation to planned caesarean sections: What are we up to?

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Making shared decisions in relation to planned caesarean sections: What are we up to? Dominiek Coatesa,b,c,* , Purshaiyna Thirukumarb , Amanda Henryb,d,e a

University of Technology Sydney, Faculty of Health, Centre for Midwifery and Child and Family Health, Sydney, Australia School of Women's and Children's Health, UNSW Medicine, UNSW, Australia Maridulu Budyari Gumal, the Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Sydney, Australia d Department of Women's and Children's Health, St George Hospital, Sydney, Australia e The George Institute for Global Health, UNSW Medicine, Australia b c

A R T I C L E I N F O

A B S T R A C T

Article history: Received 3 July 2019 Received in revised form 2 December 2019 Accepted 3 December 2019

Objective: To map the literature in relation to shared decision making (SDM) for planned caesarean section (CS), particularly women’s experiences in receiving the information they need to make informed decisions, their knowledge of the risks and benefits of CS, the experiences and attitudes of clinicians in relation to SDM, and interventions that support women to make informed decisions. Methods: Using a scoping review methodology, quantitative and qualitative evidence was systematically considered. To identify studies, PubMed, Maternity and Infant Care, MEDLINE, and Web of Science were searched for the period from 2008 to 2018. Results: 34 studies were included, with 9750 women and 3313 clinicians. Overall women reported limited SDM, and many did not have the information required to make informed decisions. Clinicians generally agreed with SDM, while recognising it often does not occur. Decision aids and educational interventions were viewed positively by women. Conclusion: Many women were not actively involved in decision-making. Decision aids show promise as a SDM-enhancing tool. Studies that included clinicians suggest uncertainty regarding SDM, although willingness to engage. Practice implications: Moving from clinician-led decision-making to SDM for CS has potential to improve patient experiences, however this will require considerable clinician training, and implementation of SDM interventions. © 2019 Elsevier B.V. All rights reserved.

Keywords: Shared decision-making Caesarean section Mode of birth Patient preferences Unwarranted variation

1. Introduction There has been a significant rise in planned caesarean sections (CS) over recent decades, particularly in high and some middle-income countries, often without clear medical reason [1–5]. While the optimal CS rate is estimated to be between 10– 15 % [6–8], the CS rate is as high as 58.1 % in the Dominican Republic [9], 50.4 % in Turkey [10], 34 % in Australia [11], 32.2 % in the United States [12], and around 26 % in the United Kingdom and Canada [12]. There is wide variation in the CS rate between countries and hospitals, which is largely unwarranted and cannot be explained by case mix or hospital factors [9,13–16]. A

* Corresponding author at: Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Level 11, Building 10, 235 Jones St. Ultimo. NSW, 2007, Australia. E-mail address: [email protected] (D. Coates).

high proportion of CS, of between 35 and 43 % in high income settings, are not medically required [4,5,17]. Despite a range of initiatives, efforts to minimise the rising rate of CS have been mostly unsuccessful [18]. This is not surprising as evidence from different areas of healthcare highlight the complexity of reducing clinical variation and unnecessary interventions [19–22]. One strategy that is sometimes put forward as having the potential to reduce clinical variation and the overuse of interventions is shared decision-making (SDM) [20,23,24]. SDM refers to a process of decision-making where women are provided with information about the risks and benefits associated with different treatment options, so that they can make informed decisions that are in line with their values and preferences [25,26]. More specifically, SDM is a dialog between the patient and clinician that includes a discussion or explanation of the problem that needs to be addressed, the presentation of options, a discussion of the pros and cons of the different options, as well as explication of patient values, preferences and self-efficacy and the clinician’s

https://doi.org/10.1016/j.pec.2019.12.001 0738-3991/© 2019 Elsevier B.V. All rights reserved.

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knowledge and recommendations [27]. The information presented throughout this process should be unbiased and informed by evidence, and understanding should be checked, and clarification provided as needed [27]. SDM is associated with improvement in patient satisfaction and health literacy [28], and is now widely recognised as an integral component of the provision of high-quality maternity care [29–31]. Maternity care guidelines increasingly stipulate that decisions about care should be informed by the woman’s preferences, and include a discussion about the risks and benefits of different treatment options [32–34]. SDM is especially relevant or important when health problems have multiple appropriate treatment options, where there is a close trade-off between harms and benefits [35–37], as is often the case for planned CS. Although CS is a relatively safe procedure, it carries the risk of maternal and neonatal complications, including an increased risk of maternal infection, the need for transfusion, infant respiratory distress and admission to the neonatal intensive care unit [15,38–40]. CS is also associated with increasing rates of iatrogenic premature birth and its associated impact on child development [41,42]. Furthermore, women who have had a CS tend to report more negative birth experiences than women who had a vaginal birth (VB) [43,44]. On the other hand, CS may moderately reduce the risk of urinary incontinence and pelvic organ prolapse [45], and when medically required, a CS can be life-saving. Even though it is well recognised that women should be informed of the risks and benefits associated with different birth options, this does not always occur [46]. A study from the Netherlands assessed the extent to which best-practice principles in relation to CS were implemented in practice, and found that only 15 % of women who had a planned CS had received adequate counselling and opportunity for SDM [46]. The aim of this study was to map the literature in relation to SDM in the context of decisions regarding planned CS (approximately 65 % of CS are planned in Australia [13]). SDM is often not appropriate in an emergency situation, and as such studies regarding emergency CS were excluded. The extent to which SDM occurs in the setting of planned CS, and whether women are provided with the information they need to make informed decisions, is unclear and has not been the focus of a review study. Related review studies focus on women’s mode of birth (MOB) preferences and the personal, social or cultural factors that influence preferences [47,48], or SDM practices or intervention to enhance women’s access to the information (e.g. the use of decision-aids) in maternity care more broadly [31,49], and do not specifically address SDM in the context of planned CS. One exception is a study by Horey et al. (2013) which reviewed interventions for supporting pregnant women's MOB decision-making, however this study was limited to MOB decision-making after a previous CS, and only included randomised controlled trials [50]. While this review identified three studies (all pre-2008), none of the interventions were designed to facilitate SDM with health professionals [50]. Furthermore, a study by Catling et al. (2011) reviewed nonclinical interventions, such as guidelines, to increase the uptake and/or the success rates of vaginal birth after CS, but did not provide insight into SDM as such [51]. To gain insight into ‘what we are up to’ in relation to SDM in the context of planned CS, this review includes qualitative, quantitative and mixed method research relevant to SDM practices from the perspective of women and clinicians. Specifically, this paper systematically maps the literature in relation to a) the experiences of women in relation to being engaged in decisions about their own care; b) women’s knowledge of the risks and benefits of CS and their sources of information; c) the experiences and attitudes of clinicians in relation to MOB decisions; and d) interventions that

enhance women’s access to the information they need to make informed decisions specific to CS. The aim of this review was to provide a systematic overview of the field, determine the scope and nature of the evidence and identify areas where further research and practice changes are required. 2. Method Using a systematic scoping review methodology [52–54], quantitative and qualitative studies were systematically considered to map the available evidence regarding SDM practices in the context of planned CS. The aim of a scoping review is to map the literature relevant to a broad research topic to gain insight into the nature of the evidence and identify research gaps [52–54]. While a scoping review has less depth than a traditional systematic or integrative review, it has a broader conceptual range, and allows for a diversity of relevant literature and studies using different methodologies to be considered [53,54]. The review process followed the PRISMA reporting guidelines for scoping reviews (PRISMA-ScR) (as per the review protocol, unregistered). Relevant studies were identified through a range of methods. In the first instance, the databases PubMed, Maternity and Infant Care, MEDLINE and Web of Science were searched for the period from 2008 to 2018. The databases were searched using the terms ‘caesarean section’ and ‘cesarean’ in combination with the terms shared decision-making, decision making and information needs. Following this, the reference lists of included articles and review studies were examined for further articles (See Fig. 1). References were imported into EndNote version 9 for screening. All articles were reviewed by reading the title, abstract and, if required, full text for inclusion as per the criteria outlined in Table 1. Information relevant to the research question (i.e. study aim, participants, sample size, methods, and findings) was extracted from each article by two reviewers independently using a purposely designed data charting form. Any disagreements were resolved through discussion between the two reviewers. The quality of the selected studies was assessed by two reviewers using the Mixed Method Appraisal Tool (MMAT) version 2011 [55]. This tool was selected as it is well suited to a public health context [56] and meets accepted standards in terms of validity and reliability [57,58]. MMAT consists of a checklist with 19 items to assess the quality of five different types of studies (qualitative research, randomized controlled trials, non-randomized studies, quantitative descriptive studies, and mixed method studies) [59]. An overall methodological quality score was calculated using the tool for each included study. Scores are expressed as the number of criteria met out of four, ranging from

Fig. 1. Flow of papers through review.

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Table 1 Inclusion and exclusion criteria. Inclusion criteria

Exclusion criteria

Studies relevant to:  The experiences of women in relation to SDM in the context of planned CS for any indication (e.g. breech, previous CS, maternal request).  Women’s knowledge of the risks and benefits of CS and their sources of information  The experiences and attitudes of clinicians in relation to SDM for planned CS  Interventions that enhance women’s access to the information they need to make informed decisions specific to CS (e.g. implementation of a decision aid)

Studies limited to:  Factors that influence decision-making from the perspective of clinicians, such as clinical factors and clinician attitudes and beliefs in relation to maternity care generally (not specific to SDM)  Studies limited to women’s MOB preferences and influences, that do not present findings in relation to the process of SDM or women’s information needs  Clinicians’ MOB attitudes  Quality improvement activities to reduce CS rate that do not include SDM as a core strategy (e.g. the introduction of a ‘normal birth’ guideline)  Decision-making in the context of emergency CS, i.e. where there was no opportunity for SDM

Primary qualitative, quantitative and mixed method studies (regardless of study design) Published in peer reviewed journals Published between 2008 and 2018 In English Full text available

Narrative reviews, opinion pieces, commentaries, and review articles Non-peer reviewed studies Published before 2008 Not written in English No full text available and/or not accessible

MOB = mode of birth; CS = caesarean section; SDM = shared decision-making.

25 % (one criterion met) to 100 % (all criteria met). For mixed method studies, the overall quality score is the lowest score of the study components (qualitative and quantitative). Synthesis of the extracted information was conducted to present the range of evidence [60]. We summarised the study characteristics including country in which the study was conducted, study aim, study design, participants and study setting, and grouped study findings in response to our key aims (i.e. women’s experiences of getting the information they need to make informed decisions; women’s knowledge of the risks and benefits of CS and their sources of information; the experiences and attitudes of clinicians in relation to MOB; and interventions that enhance women’s access to information). Results are reported narratively and in table format (Table 2).

3. Results 3.1. Characteristics of included studies The review identified a total of 34 studies, consisting of 10 survey studies [61–70], one cohort study [71], 16 qualitative studies [72–90], and four mixed method studies [91–94]. A total of 30 studies were set in high income countries [61–67,69–71,73– 79,81–86,88,92–94], and four from middle income countries [68,72,80,87]. Fifteen studies were set in public hospital settings [62,67,68,70–72,77,80,85,87,73–90,92,93], one study in a private hospital setting [73], and two across both public and private settings [63,81]. The setting of the remaining 16 studies was unclear or not stated [61,64–66,69,74–76,78,79,82–84,86,91,94].

Table 2 Study characteristics. Characteristic

Number of studies

Number of participants

Countries

References

10 1 19

9895 188 1378

Mixed Method Country income level High income country

4

1602

Australia, USA, UK, Canada, Trinidad, Pakistan UK Australia, USA, UK, Canada, Ireland, Netherlands, Germany, Italy, Taiwan, Turkey, Peru UK, USA, Sweden

[61,62,63,64,65,66,67,68,69,70] [71] [72,73,74,75,76,77,78,79,80,81, 82,83,84,85,86,87,88,89,90] [91,92,93,94]

30

12815

Australia, USA, UK, Canada, Sweden, Ireland, Netherlands, Germany, Italy, Taiwan, Trinidad

Middle income country Participants Pregnant women

4

248

Turkey, Peru, Pakistan, China

[61,62,63,64,65,66,67,69,70,71, 73,74,75,76,77,78,79,81,82,83, 84,85,86,88,89,90,91,92,93,94] [68,72,80,87]

15

1086

UK, USA, Canada, Netherlands, Peru, Turkey, Taiwan, Australia

Postpartum women Pregnant and postpartum women Pregnant and nonpregnant Women Health professionals Hospital Setting Public hospital

11 1

7052 150

Australia, USA, UK, Canada, China Pakistan

[62,70,72,73,75,76,80,85,86,88, 89,90,92,93,94] [61,63,67,69,71,74,77,78,79,83,87] [68]

3

1462

UK, Sweden, Trinidad

[66,84,91]

8

3313

UK, USA, Canada, Ireland, Germany, Italy, Taiwan

[64,65,73,77,78,81,82,86]

15

1508

Private hospital Both public and private Unclear/not stated

1 2 16

30 2471 9054

UK, USA, Australia, Canada, Netherlands, Turkey, China, Peru, Pakistan Taiwan USA, Ireland, Germany & Italy Australia, UK, USA, Canada, Sweden, Trinidad

[62,67,68,70,71,72,77,80,85,87,88, 89,90,92,93] [73] [63,81] [61,64,65,66,69,74,75,76,78,79,82, 83,84,86,91,94]

Study design Survey study Cohort study Qualitative

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Thirty studies included a total of 9750 women [61–63,66–80, 83–87,91–94] and eight studies included 3313 clinicians [64,65,73,77,78,81,82,86] (four studies included both women and clinicians). Further study characteristics are included in Table 2. The quality of included studies was mostly high, with 23 studies rated as 100 % (meeting all quality criteria), and 11 as 75 % (meeting 3/4 criteria) (Table 3 and 4). Twenty-two studies presented findings in relation to the experiences of women in being engaged in decisions about their own care; seven investigated women’s knowledge of the risks and benefits of CS; eleven presented findings in relation to where women get their information; six presented findings in relation to the experiences and attitudes of clinicians regarding SDM; and seven regarded interventions to better engage women in decisions about their own care. 3.2. The experiences of women in relation to being engaged in decisions about their own care Of the 22 studies that investigated women’s experiences of SDM, 10 regarded mode of birth (MOB) decisions following a previous CS [62,68,73,75,76,80,88–90,92], seven regarded MOB decisions more broadly [63,67,69,72,83,93,94], and five regarded the experience of decision-making in women who requested a CS without medical reasons (referred as a Caesarean Section upon Maternal Request (CSMR)) [74,77–79,91]. 3.2.1. Planned CS more broadly (not specific to repeat CS or CSMR) In relation to women’s involvement in MOB decisions more broadly (i.e. not specific to the context of repeat CS or CSMR) studies presented mixed findings. These studies did not focus on a specific reasons for CS and included all women who had a CS, regardless of indication [63,67,69,72,83,93,94]. Three studies found that women were not engaged in the MOB decisions and did not feel that they have a choice [72,83,93], two studies found that the majority of women were engaged in decision-making and given the information they needed to make informed decisions [67,69], and a further two studies reported mixed results [63,94]. For example, specific to the US (United States), three studies reported mixed results. A survey study (N = 50) found that while the majority of women (75 %) felt they had been given a choice in relation to MOB decisions, and had been actively engaged in the decision-making process, a large minority (25 %) indicated that they had not been given a choice [94]. Another study found that 13.3 % of women who had a CS reported that they had received pressure from a clinician to do so [63]. A further study from the US (N = 101) found that the vast majority of women who had had a CS reported that they had received helpful information and been given the opportunity to ask questions, even though they would have liked more information in relation to the risks associated with CS [67]. Similarly, an Australian study with 731 women who had a CS also reported that women were engaged in decision-making, with 93 % of women reporting that they had been informed about the risks and benefits of CS and consulted in relation to their MOB options [69]. Less positive results came from two studies from the United Kingdom (UK). One UK study with 682 women who had a CS found that women were unhappy with the communication they had received and reported not being heard, listened to, or informed of their options [83]. Another study from the UK (N = 454) found that most women had not been engaged in the decision regarding MOB and not been given a choice; however this was not necessarily perceived negatively, as many reported not wanting the MOB decision to be their own choice [93]. Similarly, an interview study from Turkey (N = 29) found that only two women

had been offered information about MOB options by their obstetrician, while the remaining 27 reported that they had wanted information to make informed decisions, but that the clinicians had been unresponsive [72]. 3.2.2. CS following a previous CS Studies that investigated women’s involvement in MOB decision-making following a previous CS also presented mixed findings. While some women reported being engaged in the decision-making process, more commonly women reported not having been given a choice or being pressured towards a specific MOB. For example, a survey study from the US (N = 68) found that the majority of women (86 %) had not been provided with the information required to make an informed decision [62]. This finding is supported by interview studies from the UK, Australia and Canada, which found that women reported having little control over their MOB decisions, and that information was presented in a biased way in order to persuade them towards a particular MOB option, either attempted vaginal birth after CS (VBAC) or repeat CS depending on the clinician [75,76,88,89,92]. However, one of these studies noted that while women saw themselves as having little control over MOB, this was welcomed by many who did not wish to make the decision themselves [76]. Similar findings are presented by a study from Taiwan (N = 21) which included interviews with women as well as observations of obstetric consultations [73]. This study found that in most consultations obstetricians did not provide any counselling regarding MOB, and women seldom asked questions. While some women were informed of their MOB options, the majority were not provided with information and not given a choice [73]. Similarly, an interview study from Peru (N = 17) found that just over half of women (n = 9) had been engaged in the decisionmaking regarding MOB by their obstetrician, while the remaining were either not given any information, or only informed about one MOB option, either repeat CS or the option to attempt a VBAC [80]. More positive findings came from Pakistan, where a study found that women with a previous CS (N = 150) had been engaged in MOB decisions by the obstetrician and were overall satisfied with the information they received, even though women who had a VB were more satisfied than women who had a CS (95.9 % versus 69.0 %) [68]. 3.2.3. Maternally requested CS Studies that investigated the experiences of women who request a CS without a medical indication also presented mixed results. A mixed method qualitative study from the UK (N = 27) found that while some women felt very good about the information they received, others wanted more information in relation to the risks associated with CS to help them apply the information to them, and some perceived the information they were given as biased towards VB [77]. In another interview study from the UK (N = 15) women reported that the information provided was poor, and particularly that good quality information regarding the risks and practicalities of CS was missing [78]. The women in this study would have liked more information about the CS surgery experience and the risk and benefits of their MOB options, and also commented that they had to continually repeat and defend their decision for a CSMR [78]. Similarly, a Swedish study (N = 1066) found that adequate SDM in the context of CSMR was lacking, and that many women reported that they were not listened to and had not been given enough information to make informed decisions [91]. On the other hand, interview studies from Australia (N = 14) [74] and Canada (N = 17) [79] found that women felt supported in their decision for a CSMR, and that the decision had been informed by a process of SDM. However, some women

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Table 3 Included Quantitative Studies. Author. Publication year. Country.Quality Score

Study aim

Methods and participants

Chen & Hancock (2012) To ascertain the determinants of knowledge Cross-sectional survey study N = 33 women [61] Australia 75% regarding options for subsequent birth in who have had at least one previous CS women who have experienced a previous CS.

Folsom et al. (2016) [62] USA 100%

To identify factors influencing a woman’s decision to have an elective repeat CS versus VBAC.

Survey study N = 68 women with one previous CS and a singleton term pregnancy

Jou et al. (2015) [63] USA 75%

To determine whether perceived pressure from clinicians for IOL or CS is significantly associated with having these procedures.

Survey study N = 2400 postpartum women

Klein et al. (2009) [64] Canada 100%

To examine the attitudes of Canadian maternity care practitioners towards labour and birth.

Cross-sectional survey N = 2583 health professionals, incl. 549 obstetricians, 897 family physicians, 545 nurses, 400 midwives and 192 doulas

Klein et al. (2011) [65] Canada 100%

Survey study N = 549 obstetricians To determine if the new generation of Canadian obstetricians had attitudes differing from those of their predecessors.

Kulkarni et al. (2014) [70] Canada 75%

Pre post design using survey N = 75 first-time To determine the potential effect of a webbased educational tool on women’s pregnant women/mothers Women were knowledge of the safety and risks of VB and CS. emailed a link to a web-based educational tool after completing a pre-test survey to assess their knowledge of the safety and risks of VB and CS. Women’s knowledge was tested again after engagement with the online material.

Mungrue et al. (2010) [66] Trinidad 100%

To determine the level of knowledge about CS Cross-sectional survey study N = 368 among women attending primary health care antenatal and postnatal women facilities in north Trinidad.

Puia et al. (2013) [67] USA 100%

Survey study N = 101 postpartum women who had CS

Summary of main findings

61 % did not know the rarity of uterine rupture, and 49 % were not aware that a CS may involve any complications for the baby. The most frequently cited sources of MOB option information women received were childbirth classes (54 %), book(s) (42 %) and leaflets (33 %). Most of the education that women received focused on pregnancy screening (67 %) and fetal growth and development (64 %). To a lesser extent, 39 % of women received information about birth interventions and 33 % of women received birth plan information. Of 68 participants, only 8 (12 %) had adequate counselling. Of those with inadequate counselling, 22 % did not recall being counselled, 63 % were not quoted a chance of success, and 60 % had more than a 20 % discrepancy between their recalled and predicted success rates. Of the 18 women who were calculated to have more than 70 % chance of successful VBAC, 16 (89 %) were not adequately counselled. 13.3 % of women perceived pressure from a clinician for CS. Compared with women who did not perceive pressure, women who perceived pressure for CS had higher odds of CS overall (adjusted OR: 5.17; 95 % CI: 3.2–8.4), without medical reason (adjusted OR: 6.13; 95% CI: 3.4–11.1), and unplanned CS (adjusted OR: 6.70; 95% CI: 4.0–11.3). In relation to the findings relevant to SDM, obstetricians had the least positive attitudes towards women’s roles in their own births, and they were the most concerned about the consequences of VB. Only 35 % of obstetricians were in favour of birth plans, compared with 59 %, 54 %, 68 %, 63 %, and 83 % of antepartum and intrapartum family physicians, nurses, midwives, and doulas, respectively. In relation to the findings relevant to SDM, younger obstetricians were less likely to appreciate the importance of maternal choice and mothers’ role in their own birth, and they appeared to be more fearful of VB, especially as a perceived cause of urinary incontinence and sexual dysfunction. Obstetricians over 40 years of age indicated a significantly higher agreement with items that supported a woman-centred model of care, including being more positive about birth plans. The mean score for knowledge about VB and CS increased significantly between the surveys, from 47 % to 76 % (p < 0. 001). The average score for the risks of CS was 45 % (95 % CI 37–52) at baseline but improved significantly post-intervention to 80% (95% CI = 73 to 88). Knowledge of the risks associated with CS made women more likely to have “very favourable” or “somewhat favourable” views of VB. The majority of women were not sufficiently knowledgeable about CS to enable them to make informed choices. Women received their information primarily from friends and family (50 %), and the mass media (28.5 %), e.g., tabloids, television, radio. Nineteen percent received information from health professionals. Persons who received information from health care professionals (OR, 1.9; CI, 1.50–2.33) were more likely to have high or adequate levels of information about CS. Whether the birth was a primary or a repeat CS, most women (94.9 %) relied on their doctor

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Table 3 (Continued) Author. Publication year. Country.Quality Score

Methods and participants

To develop an increased understanding of the women’s decision-making processes in relation to CS.

as their main source of information, although friends and relatives were also important influences. Among primary CS, women relied on the Internet (22.8 %) as an important source of information. Most women remembered having been provided with information on all aspects of their surgery. Women least remembered being provided with information about what to expect in the recovery room as well as the type of pain medication used during recovery. Most (97.0%) of the women felt they understood the information that was provided and (94.0%) felt they had the opportunity to ask questions. Overall (95.9%), study participants felt the information provided was helpful. Cross-sectional survey study N = 150 pregnant The rate of joint decision-making by doctors women who have had a previous CS and women was high, and overall women expressed satisfaction towards the information received. Women who had a VB were more satisfied with the information they received (95.9 % versus 69.0 %). When MOB decisions were made by the women alone or together with the doctor, women were more likely to have a VB than when the decision was made by the doctor alone. Cross-sectional survey study N = 3530 Specific to SDM for planned CS, 4 % of women postpartum women, of which 20.9 % (n = 731) reported not being informed of the benefits had a planned CS and risks of pre-labour CS. 93.5 % reported being both informed of the benefits and risks of the procedure and at least consulted in decision-making. Prospective cohort study N = 188 women who The intervention was a 1 -h discussion group had a single previous lower segment CS of 5–15 women, facilitated by an experienced obstetrician. Women attending the session were given written information about the risks and benefits of VBAC and repeat CS and provided with an opportunity to discuss their concerns and aspirations for their birth. Women who attended the information session were 38% more likely to opt for a VBAC than those who did not attend.

Shoaib et al. (2012) [68] To determine how women with previous CS Pakistan 75% make MOB decisions.

Thompson & Miller (2014) [69] Australia 75%

Summary of main findings

Study aim

To examine decision-making processes, specifically information provision and consumer involvement in decision-making, for nine pregnancy, labour, and birth procedures.

Wong et al. (2014) [71] To evaluate an obstetrician-led CS education UK 100% and antenatal session developed to inform and empower women in their decisionmaking following one previous CS.

VB = vaginal birth; MOB = mode of birth; CS = caesarean section; CSMR = caesarean section on maternal request; VBAC = vaginal birth after caesarean; OR = odds ratio; CI = confidence interval; SDM = shared decision-making.

commented that the informed consent discussion was not as rigorous as they had anticipated [79]. 3.3. Women’s knowledge of the risks and benefits of CS and sources of information 3.3.1. Women’s knowledge of the risks and benefits of CS Studies that investigated women’s knowledge of the risks and benefits of CS by and large support the previous observation that many women are not provided with, or at least do not recall, the information required to make informed MOB decisions. Seven studies investigated women’s knowledge of the risks and benefits of CS [61,66,67,74–76,79], and these studies found that, albeit to varying degrees, many women were not sufficiently knowledgeable about the risks associated with different MOB options [61,66,67,74–76]. For example, an Australian study with women who requested a CSMR (N = 14) found that although all women knew that bleeding, infection and epidural complications were immediate risks to themselves, only two were aware of the possible longer-term effects, and only three could identify risks to the baby [74]. Similarly, another Australian study (N = 33) regarding MOB options following a previous CS found

that 60.6 % of women did not know the rarity of uterine rupture, and 48.5 % were not aware that a CS may involve any complications for the baby [61]. This was supported by a UK study (N = 10) which found that women did not fully understand the possible implications of a previous birth by CS on an attempted VBAC or repeat CS [76]. A Canadian study (N = 17) however found that women demonstrated a detailed understanding of the range of potential risks, and prevalence of morbidities, associated with CS and VB [79]. 3.3.2. Sources of information Eleven studies presented findings in relation to where women get their information, highlighting that even though many women get some of their information from clinicians, other sources, such as family, friends, the internet and books, also play an important role [61,66,67,72,73,79,87,89,90,92,93]. While some studies identified clinicians as the primary source of information [61,67,87], other studies highlighted alternative sources, particularly friends and family and the internet, as more important [66,72,89,90,92]. For example, first-time mothers in a Turkish study (N = 29) reported that they got information in relation to MOB options from their relatives [72]. Women in a study from Trinidad (N = 368)

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Table 4 Included Qualitative and Mixed-Method Studies. Author. Publication year. Country. Quality Score

Study aim

Methods and participants

Summary of main findings

Boz et al. (2016) [72] Turkey 75%

To identify first-time mothers’ experiences of decision-making in relation to MOB.

Interview study informed by phenomenology N = 29 first-time mothers, of which 9 had a CS

Chen at al. (2018) [73] Taiwan 100%

To explore women’s decision-making processes Mixed method qualitative study informed by and the influences on their MOB following a grounded theory, consisting of naturalistic previous CS. observation of obstetric consultations and interviews with women during the antenatal and postnatal period. N = 21 women and 9 obstetricians (9 consultations were observed)

David et al. (2010) [90] Australia 75%

To gain insight into the information needs of women who had had a previous CS

Only two women were offered information about MOB options by health professionals, a midwife and a doctor, and they made their decisions accordingly. The rest of the women reported that they wanted to receive information and support, but that health professionals were indifferent, unresponsive and even unconcerned. The women explained how they needed more information and knowledge. Women sought relevant information regarding MOB from obstetricians, significant others or the internet and then discussed the options with obstetricians to confirm the MOB. Some (4/21) women did not receive information regarding VBAC from obstetricians. In communicating with obstetricians, while some women complied with obstetricians’ recommendations for repeat CS without being informed of alternatives, others were more actively engaged in decision-making. During the consultation, women seldom asked questions and obstetricians did not provide any counselling regarding MOB. Some women expressed fear about asking questions of their obstetrician because the obstetrician had many patients waiting for consultation. Many women called the service to seek clarification as to the accuracy of information they had received from a health care professional, and some women reported feeling pressured by their health professional into having a repeat CS. A large majority of callers articulated using the internet to source information. Several women commented that the information leaflet provided by the hospital and/ or the study DVD was the only information they had been given. Some women felt that this was the only information that they needed, but many other women sought out additional information from a variety of different sources including television, the internet, and other people (including health professionals). A number of women reported not knowing what their role was in the decision-making and reported not being given a choice or that the choice was presented to them in a biased way which meant that they would have had to ‘fight’ to choose the alternative. The decision-making intervention was welcomed by the participants and findings suggest that the intervention improved SDM. Information and support gave women confidence in their decision. Women recalled various discussions with their doctor about the risks of a CS. Although all women knew that bleeding, infection and epidural complications were immediate risks to themselves, only two were aware of possible longer-term effects, and only three could identify risks to the baby. Women who had a CSMR perceived that medical discourses supported and reinforced their decision as a ‘safe’ and ‘responsible’ choice. The information program included a face to face information session with the researcher as well as access to a website, and gave information only, including the risks and benefits of attempted VBAC versus repeat CS. The decision analysis program recommended a MOB recommended 'preferred option' based on the individual woman’s risk factors. In relation to the information program, women who received the information program suggested that the quality

Farnworth et al. To examine the experiences of women with a (2008) [92] UK previous CS in relation to MOB decision making 75% as well as the impact of a decision support intervention comprising of an informational DVD/video and a home visit by a midwife.

Fenwick et al. (2010) [74] Australia 75%

Content analysis of telephone calls made to women to a next birth after CS clinic over a 16 month period N = 170 telephone calls

Mixed method study using surveys and interviews. N = 32 women with a history of one previous CS completed surveys and 18 also participated in an interviews 16 women received the intervention which comprised of an informational DVD or video, and a home visit by a research midwife.

To describe first-time pregnant women’s request Qualitative interview study N = 14 (Women who for a CS in the absence of medical reasons. requested a CS in their first pregnancy in the absence of medical indications)

To obtain the views of women on their Frost et al. (2009) [75] UK experiences of decision making about the MOB 100% following a previous CS and the role of decision aids in this process.

Interview study N = 30 women with one previous CS, of which 14 participated in an information program, 14 in a decision analysis program, and 2 received normal care

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Table 4 (Continued) Author. Publication year. Country. Quality Score

Study aim

Methods and participants

Summary of main findings

and the depth of the information provided facilitated informed decision-making and reduced their uncertainty. Women who received the decision analysis program reported mixed responses, with some observing that the program added to their uncertainty and did not consider their individual circumstances. However, women in this group were better able to identify specific risks associated with MOB options than the women who received the information program. Overall both decisions aid were perceived as helpful and increased women’s understanding of the decision to be made. Goodall et al. To explore women’s perceptions of the role of Interview study informed by phenomenology Women expressed a lack of personal knowledge (2009) [76] UK health professionals in their decisions regarding N = 10 pregnant women with their second child of the risks associated with CS versus VB. They 100% the birth of a second child, following previous following a previous CS did not fully understand the possible CS. implications of a previous birth by CS on subsequent VBAC or repeat CS. Although they did receive information, the women considered such information to be too probabilistic to be useful to them as individuals. Overall women saw themselves as having little control over MOB, but for many this was welcomed. Giving control to others resolved difficult personal emotions that they experienced in attempting to make an individual choice. Women felt unprepared to make individual decisions without knowing the likelihood of personal success. Hogberg et al. To examine public attitudes about CSMR and its Cross-sectional population survey with closed Many respondents felt that that they were not (2008) [91] association with health care and birth and open ended questions N = a representative given enough information and the staff were too Sweden 100% experiences. community sample of 1066 women aged 20-80 stressed to be helpful. While the majority of women reported positive experiences, many respondents felt physicians abused their power: they felt they did not listen to their fears and anxiety and were unkind, nonchalant or disrespectful. To explore the complexities of women’s and Kennedy et al. In relation to women’s experiences of SDM, Mixed method qualitative study including (2013) [77] UK clinicians’ choices around elective CS. interviews, observation and document review some women indicated that they felt very good 100% N = 27 postpartum women and 34 clinicians about the information they received, whereas others were confused by an overwhelming amount of data and varying perceptions of helpfulness of their consultations. Women talked about the difficulties of personalising the risks they were given by health professionals. One woman who had already had successful VBACs could not quite see that the risk could be very significant for her at all. Others wanted more information about where the evidence on risks came from, to try to understand how it applied to them. The confusing and conflicting nature of information from various sources was also considered a source of concern for women. Some women described that they perceived a bias towards VB. Findings in relation to clinicians’ experience of SDM mostly regard SDM in the context of repeat CS versus attempted VBAC. Clinicians had a commitment to counselling women about the benefits and risks of MOB options. Women as well as health professionals reported To map the experiences of women and health Kenyon et al. Mixed method study with non-participant (2016) [78] UK professionals for women who request a CS observation, semi structured interviews and co- that the information provided was poor. The 100% without medical indication. design workshops N = 22 health professionals women felt that good quality information on the (10 obstetricians and 12 midwives) and 15 risks and practicalities was missing and this women who had a CSMR included both short and long-term risks and benefits of elective CS (written information was related to CS generally and not specifically for women requesting CS and verbal information from midwives and consultants varied). It was also agreed that there was a lack of information about what the CS surgery experience is like and of the risk information comparing VB emergency and elective CS and that these areas. Women felt

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Table 4 (Continued) Author. Publication year. Country. Quality Score

Study aim

To explore whether women view decisionKingdon et al. (2009) [93] UK making surrounding VB or CS as their choice. 100%

Kornelsen et al. (2010) [79] Canada 100%

To explore women’s experiences of the decisionmaking process leading to a CSMR.

Lazo et al. (2017) To explore the perspectives, decision-making [80] Peru 100% process, and final MOB among pregnant women with a previous CS.

Lundgren et al. (2015) [81] Ireland, Germany and Italy 75%

To explore the views of clinicians from countries with low VBAC rates on factors of importance for improving VBAC rates.

to explore, from the mothers' perspective, the McGrath et al. (2010) [88] decision-making experience with regard to Australia 100% subsequent birth choice for women who had a previous CS

Munro et al. (2017) [89] Canada 100%

To explore attitudes towards and experiences with decision-making for MOB after previous CS

Methods and participants

Summary of main findings

they had to continually repeat and defend their decision to each different health professional they saw and that ‘no-one was listening’. They also felt that long term risk information was used to ‘ram home risks”. Women felt that those health care professionals were at all stages, judging or stereotyping them, when in fact their decision was a carefully thought through, and sometimes very difficult, decision. Mixed-method study N = 454 pregnant women Information was received from multiple sources completed a survey, and 55 participated in an (family, friends, media, health professionals), interview at 24 weeks pregnant, 34 at 36 weeks, with varying degrees of influence at different and 64 semi-structured postnatally. 94 women time-points. Women did not feel they had an had a CS autonomous choice over their actual MOB, but neither did they necessarily want it. At the same time as many women supported the principle of ‘a woman’s right to choose’, all women were uncomfortable with the application of this rhetoric to decision-making surrounding VB or CS. Ultimately, women felt health concerns should take precedence in decision-making and entrusted health professionals to act appropriately. Interview study informed by grounded theory For most women the process of decision-making N = 17 first-time mothers who had a CSMR was marked by informed consent discussions with their care provider(s). Many talked of the clarity with which their obstetricians explained the risks and benefits and their willingness to answer questions in a straightforward and supportive way. For some respondents the informed consent process was less rigorous then they anticipated. Women demonstrated detailed knowledge of the range of potential risks and prevalence of morbidities associated with CS and VB. This information often came from nonmedical sources, including the Internet, popular books on childbirth, and television programs. Interview study N = 17 pregnant women Many participants affirmed that they made the decision about their MOB. About half (9) of women stated that the physician explained that they had two approaches for birth, a trial of labour after CS or repeat CS. Two women stated that their respective providers explained only one option, either a trial of labour or repeat CS. Six women did not receive any information from their providers about their birth options. Focus group study N = 71 clinicians across 9 This study identified four main themes as focus groups important to improving VBAC rates, of which one regarded SDM. All clinicians agreed that women should be made aware that both attempted VBAC and a repeat CS are options and be made aware of the risks and benefits of both options. There was much debate within the focus groups as to whether the woman should ultimately have a choice, with an ultimate agreement that SDM was critical. Interview study informed by phenomenology Women reported that the health professionals' N = 20 women who had all had a previous CS, attitude to birth, and thus the support they offer and which 16 had a repeat CS, two had a VBAC to mothers, is predominantly pro-CS, with VBAC and two attempted a VBAC. positioned as risky. Medical recommendations, especially during the birth, were experienced as powerful and difficult to go against. While some doctors were perceived as supportive of VBAC, it was not possible to remain exclusively under their care. Interview study informed by grounded theory Women reported not fully understanding why N = 23 women who were eligible for VBAC they had needed a primary CS, and noted that they had not been given enough information following their primary CS. Women reported that discussions with physicians were brief where they not included in a discussion. Many described feeling rushed and others feared that by asking too many questions. Few women told they physician about their MOB preferences.

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Table 4 (Continued) Author. Publication year. Country. Quality Score

Munro et al. (2017) [82] Canada 100%

Redshaw & Hockley (2010) [83] UK 100%

Rees et al. (2009) [84] UK 100%

Schoorel et al. (2014) [85] Netherlands 100%

Shorten et al. (2015) [86] USA 75%

Wittmann-Price et al. (2011) [94] USA 100%

Wang & Hesketh (2017) [87] China 100%

Study aim

Methods and participants

Summary of main findings

Women wished for more information. Pamphlets and materials written for the general population were considered “impersonal” and not useful for making a decision. Midwifery clients had more opportunities for deliberation. To gain confidence in their preference, participants actively sought statistics on the risks and benefits of attributes of VBAC and repeat CS that were important to them by googling information. Women were referred to an obstetrician around the 36th week for an informed consent consultation. Rather than assist in their decision, the obstetric consult caused these women to question their choice. To explore health professionals’ decision making Interview study informed by grounded theory Clinicians acted as information providers of processes in relation to birth after previous CS. N = 35 family physicians, midwives, primary and clinical risks and benefits, with limited consultant obstetricians, nurses, anaesthetists, discussion of women’s preferences. While administrators, managers, and directors clinicians explained that women were engaged in ‘informed choice discussions’, they explained that these discussions were often persuasive (towards attempted VBAC). Physicians opened the discussion with women by first asking about their preference for MOB, and then responding by giving a standard “pitch” for planned VBAC. To gain a better understanding of individual Qualitative survey study N = 682 postpartum In relation to the findings relevant to decisionwomen’s recent experiences with CS. women who had a CS making, a key theme reported by women who had a CS was a lack of appropriate communication from health professionals. They reported not being heard or listened to, and not being informed. Communication was an issue at all stages of care. Participants were generally positive about the Focus group study N = 28 health professionals To explore health professionals’ views about decision aids for women choosing MOB after a including midwives, obstetricians and general decision aids, and believed they should be previous CS. practitioners implemented during early pregnancy, but should be accessible throughout pregnancy, with any arising questions discussed with an obstetrician nearer to term. To develop a decision aid for MOB after CS that Interview study informed by co-design The decision aid included a booklet with integrates personalised prediction of VBAC with principles N = 25 (pregnant women with a information on MOB after CS, a preference the elicitation of patient preferences and history of one previous CS) elicitation exercise, and tailored risk evidence-based information. information, including a prediction model for successful VBAC. Women reported that the decision-aid was clear and informative and helped their decision-making process. To seek recommendations from key Women recommended that features and Focus group and interview study informed by stakeholders to inform the development of a participatory action research N = 19 pregnant functions of the decision aid should include decision aid to better support women making women, 9 medical residents, 8 obstetricians, 2 individualised information, trustworthy decisions about birth after previous CS. gynaecologists evidence, a secure and private site, quizzes to check knowledge, and a way to share values and preferences with their providers. Providers recommended individualised information for women, a process for women to share and document values and preferences with providers, and balanced, straight-forward and complete information about the risks and benefits of each option. To investigate if women were making active In general women were using an Emancipated Survey study with closed and open ended decisions about their MOB choices. questions N = 50 pregnant women of which 15 Decision Making process overall. They perceived had a CS The survey included the validated that their decision was done in a flexible emancipated decision making-r scale. environment, using personal knowledge, and that they were aware of the social norms influencing their decision. Thirty-seven women indicated they had a choice in MOB, whereas 13 reported that they had no choice. While some reported they had received adequate information to make an informed choice, others did not. To explore the experiences of MOB decisionIn relation to the findings relevant information Interview study Postpartum women = 45 making among Chinese women. access, most received their information about childbirth from friends, family, the internet, and most importantly, the doctor or hospital.

VB = vaginal birth; MOB = mode of birth; CS = caesarean section; CSMR = caesarean section on maternal request; VBAC = vaginal birth after caesarean; OR = odds ratio; CI = confidence interval; SDM = shared decision-making.

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reported that they received their information primarily from friends and family (50 %) and the mass media (28.5 %); only 19 % received information from clinicians [66]. Women in an Australian study (N = 33) reported that they predominantly got their information from childbirth classes (54.4 %), book(s) (42.4 %) and leaflets (33.34 %) [61]. 3.4. The experiences and attitudes of clinicians in relation to SDM Six studies investigated the experiences and attitudes of clinicians in relation to SDM [64,65,77,78,81,82]. Of these, two studies evaluated the attitudes of clinicians towards SDM [64,65], two investigated clinicians’ experiences of SDM in the context of birth following previous CS [81,82], and two studies regarded decision-making in relation to CSMR [77,78]. The evidence in relation to the attitudes of clinicians towards SDM comes from two Canadian studies [64,65]. One study compared the attitudes of different clinicians (N = 2583, including 549 obstetricians, 897 family physicians, 545 nurses, 400 midwives and 192 doulas) in a 43-question Likert scale survey covering a range of labour and birth topics. It found that obstetricians had the least positive attitudes towards a woman’s role in her own birth, with only 35 % of obstetricians agreeing with the statement “women should be encouraged to develop a birth plan” [64]. However, none of the questions directly asked about SDM. Another study by the same authors compared the attitudes of younger versus older (>40 years of age) Canadian obstetricians and found that older obstetricians were significantly more likely to appreciate the importance of maternal choice and mothers’ role in their own birth (N = 549) [65]. A further Canadian study examined clinician decision-making processes in relation to birth after previous CS, and included family physicians, midwives, primary and consultant obstetricians, nurses, anaesthetists, administrators, managers, and directors (N = 35) [82]. This study found that while clinicians provided women with information about clinical risks and benefits, there was generally limited discussion regarding women’s MOB preferences. While clinicians explained that women were engaged in ‘informed choice discussions’, they described these discussions as persuasive towards attempted VBAC [82]. A focus group study (N = 71 clinicians across 9 focus groups) from Europe (Ireland, Germany and Italy) also regarded SDM in the context of birth after previous CS and found the majority of clinicians agreed that women should be provided with unbiased information about their options and supported to make an informed decision [81]. In relation to clinicians’ attitudes towards SDM in the context of CSMR, evidence comes from two qualitative studies from the UK [77,78]. While the clinicians (N = 22) who participated in one study described the process of SDM and the quality of the information provided as ‘poor’ [78], findings from the other study suggest that even though in practice SDM does not always occur, clinicians demonstrated a commitment to SDM and counselling women about the benefits and risks of MOB options [77]. 3.5. Interventions to enhance SDM, and better engage women in decisions about their own care Seven studies regarded interventions to enhance SDM, and better engage women in decisions about their own care. To empower women with the knowledge they need to make informed MOB decisions, one study tested a web-based educational tool [70], one tested an obstetrician-led CS education and antenatal session [71], one tested a SDM intervention that included an educational video and home-visit by a midwife [92], and four studies regarded the use or development of decision aids [75,84–86].

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A study from Canada assessed the impact of a web-based educational tool on women’s knowledge of the safety and risks of VB and CS (N = 75 first-time pregnant women/mothers) [70]. Using a pre-test post-test design, this study found that women’s knowledge in relation to MOB options improved following engagement with the resources [70]. A study from the UK evaluated an obstetrician-led CS education and antenatal session regarding MOB options for women with one previous CS (N = 188) [71]. The intervention was a one-hour discussion group of 5–15 women, facilitated by an experienced obstetrician. Women attending the session were given written information about the risks and benefits of VBAC and repeat CS, and provided with an opportunity to discuss their concerns and aspirations for their birth. Women who attended the information session were 38 % more likely to opt for a VBAC than those who did not attend [71]. Another study from the UK evaluated the impact of a decision support intervention that comprised of an informational DVD/ video and a home visit by a midwife (N = 32) [92]. This SDM intervention was welcomed by the women and the information provided improved their confidence in making decisions [92]. Four studies regarded decisions aids to guide MOB decisionmaking following a previous CS, two from the UK [75,84], one from the Netherlands [85], and one from the US [86]. A UK study compared the experiences of women with two different decisions aids (N = 28), an information program and a decision analysis program [75]. The ‘information program’ included a face-to-face information session with the researcher as well as access to a website and provided information only, including the risks and benefits of VBAC versus repeat CS. The ‘decision analysis program’ provided information and also generated a MOB recommendation based on the individual woman’s risk factors. Women who received the information program (N = 14) suggested that the quality and depth of the information provided facilitated informed decision-making and reduced their uncertainty. Women who received the decision analysis program (N = 14) reported mixed responses. While for some women the program added to their uncertainty, women in this group were better able to identify specific risks associated with MOB options than the women who received the information program. Overall both decisions aid were perceived as helpful and increased women’s understanding of the decision to be made. A second study from the UK evaluated a decision aid from the perspective of midwives, obstetricians and general practitioners (N = 28), and found that clinicians were generally positive about the decision aids [84]. There was an agreement that the tool should be widely implemented during early pregnancy, and remain accessible throughout pregnancy [84]. A study from the Netherlands regarded the development and evaluation of a decision aid for MOB after CS [85]. The decision aid included a booklet with information about MOB options after CS, a preference elicitation exercise, and tailored risk information, including a prediction model for successful VBAC. Feedback from women (N = 25) indicated that the decision-aid was clear and informative and helped their decision-making process. A study from the US regarded the development of decision aid and sought feedback from stakeholders (19 pregnant women, 9 medical residents, 8 obstetricians, 2 gynaecologists) to inform the design [86]. Women recommended that the decision aid should include features such as individualised information, trustworthy evidence, a secure and private site, quizzes to check knowledge, and a way to share values and preferences with their providers. Providers recommended individualised information for women, a process for women to share and document values and preferences with providers, and balanced, straight-forward and complete information about the risks and benefits of each MOB option.

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4. Discussion and conclusion 4.1. Discussion The review identified a total of 34 studies, including 9750 women and 3313 clinicians, presenting findings in relation to the experiences of women in being engaged in decisions about their own care; women’s knowledge of the risks and benefits of CS; where women get their information; the experiences and attitudes of clinicians regarding SDM; and interventions to better engage women in decisions about their own care. Our major findings in these areas were, firstly, that women reported limited CS SDM, with many not having the information required to make informed decisions. Regarding clinicians, they generally agreed with SDM, while recognising it often does not occur. In terms of potential SDM interventions, decision aids and educational interventions were viewed positively by women. Synthesis of study findings indicates that many women continue not to be actively engaged in MOB decision-making and are not provided with the information required to make informed choices. While a number of studies demonstrated that some women felt able to make informed choices, many did not. Two studies suggested that not being involved in decision-making is not necessarily a bad thing, and that some women welcomed it [76,92]; while this may be true for some women, it does not appear to apply to the majority. Most women, regardless of why they had a CS, wished they had been more actively engaged in making decisions about their own birth [62,72,78,83,93]. SDM is particularly important when there are multiple reasonable treatment options [35–37,95,96], as is often the case for MOB decisions, both broadly and following a previous CS specifically. While decisions in relation to planned birth are driven by a range of interconnected factors, including medical considerations, the influence of clinician preferences is increasingly recognised [15,97]. A systematic review by Panda et al. (2018) in relation to the factors that influence decision-making in relation to CS highlighted the role of clinicians’ personal beliefs as playing an important role [97]. Given the value-based nature of decisionmaking in this context the widespread implementation of SDM in this space is critical. However, despite considerable efforts, the implementation of SDM is faced with a large number of well-documented barriers, including resistance from clinicians [24,36,98–107]. As identified in this review, some clinicians hold views on labour and birth that suggest they do not believe women should be actively engaged in decision-making [64,65]. However, while some clinicians may be resistant, a number of studies found that many clinicians had a positive attitude towards SDM and demonstrated a commitment to change practice [77]. Furthermore, this review identified seven interventions designed to better engage women in decisions about their own care [70,71,75,84–86,92], with encouraging results. While modest in terms of their evaluation, these interventions were wellreceived by women and clinicians. However, only a minority of the identified studies involved clinicians. Given the influence of clinician preference on MOB decisions, future research involving both clinicians and women, particularly regarding design and implementation of SDM interventions in this space, is required. To support the widespread implementation of SDM in relation to MOB decisions, clinicians need to be supported with SDM training and mentoring. SDM relies on the ability to tailor information to each patient’s individual needs and identifying and clarifying patient values and preferences, however many clinicians may not have had the opportunity to develop the relational and communication skills required for this [36,103,108–113]. SDM also requires a level of selfawareness and reflective practice that many clinicians may not have

[37]. To move from a model of clinician-led decision-making towards SDM, clinicians need training to develop the knowledge, awareness and communication skills required, as well as institutional support [36,108,111,114]. Furthermore, clinical guidelines should be updated or developed to include more detail in relation to SDM. A number of studies have either identified a lack of guidelines or insufficient detail in the existing guidelines as key contributing factors to the rising CS rate [115–119]. This is supported by a recent review of CS guidelines which found that overall, few guidelines provide direction in relation SDM [120]. SDM is associated with improved patient experiences and knowledge about their options [28], and is increasingly accepted as paramount to high quality care. In addition, it has been put forward that SDM may also have the potential to reduce clinical variation and reduce the overuse of interventions [20,23,24,121]; this should be tested in the context of MOB decision-making. While there is some evidence that indicates that women who have access to the information and knowledge required to make informed choices are less likely to prefer or request a CS [122–124], the potential of SDM to reduce clinical variation should be formally tested. A strength of this review is that it provides an up-to-date overview of the field, systematically searched for and analysed by two reviewers for both content and quality. Limitations include that only full-text articles published in English were included. There may have been valuable insights into SDM for planned CS published in non-English journals. However, although the majority of included studies were from the USA, UK, Australia, and Canada, there were several studies from non-English speaking countries and non-Western settings such as Taiwan, Turkey, Peru, and Pakistan, so a diverse international perspective is not entirely missing. Another limitation is the time restriction to articles published from 2008 onwards. However, work published in 2008 is likely to have been performed up to five years earlier, and given the evolution of maternity care services, including changing attitudes and expectations regarding CS and SDM, it is likely that the more recent research covered in this review is most relevant to informing current care. Lastly, because of the heterogeneity of included studies, this study was also limited in its ability to conduct subgroup comparisons, for example by reasons for CS, or type of SDM intervention. 4.2. Conclusion This review found that in the setting of MOB and planned CS, many women are not actively engaged in decision-making about their own care, across a variety of international settings. The reasons for this appeared multi-factorial, including insufficient information about the risks and benefits of CS versus vaginal birth, presentation of information by clinicians biased towards a particular MOB option, or not being offered a choice at all. From the few studies that examined interventions to enhance SDM, decision aids show promise and were viewed positively by both women and clinicians. The minority of studies that included clinicians suggest uncertainty regarding SDM practice, although willingness to engage. Future research priorities are to include both women and clinicians in the development and implementation of SDM interventions in this space. 4.3. Practice implications Moving from clinician-led decision-making to SDM regarding MOB decisions and planned CS has potential to improve patient experience and reduce variation. To do so, clinicians need training to develop the knowledge, awareness and communication skills required, and women need to be supported in acquiring and

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processing sufficient structured and unbiased knowledge about risks and benefits of CS to fully participate in SDM.

[30]

Funding [31]

The work was supported by the Maridulu Budyari Gumal, the Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Australia.

[32] [33]

Declaration of Competing Interest

[34]

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