Implementation of a calculator to predict cesarean during labor induction: a qualitative evaluation of the patient perspective

OBJECTIVE:

Our group developed a validated risk prediction model for cesarean delivery (CD) among women under-going labor induction¹; clinical use of this calculator has been associated with reductions in maternal morbidity and CD rates and improvements in birth satisfaction.² In a qualitative study of clinician perspectives on the calculator, although there was generally positive sentiment, respondents reported concern about the patient experience.³ However, the actual patient experience concerning the CD risk calculator was previously unknown. Here, we aimed to characterize the patient experience concerning the CD risk calculator using a qualitative approach.

STUDY DESIGN:

We conducted a qualitative study using semistructured interviews, reported following the Consolidated Criteria for Reporting Qualitative Research guidelines.⁴ In 2018, the CD risk calculator was implemented as a standard of care for patients meeting the criteria⁵ in the labor unit. After obtaining the result, clinicians counseled the patient on their CD risk using standardized scripts (Supplement A).

English-speaking postpartum patients who completed labor induction at our institution with documented counseling on personalized risk were approached for inclusion in this study from November 2021 to March 2022. Enrollment occurred in each stratum (4 CD risk strata: <20%, 20.0%–39.9%, 40.0%–59.9%, and ≥60.0%) until thematic saturation was reached in each group. Purposive sampling was used for the actual mode of delivery in each CD risk stratum. Interview questions explored (1) patient understanding of personalized risk, (2) how knowledge of CD risk influenced the labor experience, and (3) how CD risk calculator utilization could be optimized.

Interviews were conducted during the postpartum stay transcribed by Datagain Transcription Services (Secaucus, NJ) and uploaded to NVivo 12. Analysis used an integrated approach.⁵ Of note, 20% of transcripts were double-coded (k=0.8), indicating high interrater reliability.

RESULTS:

A total of 40 interviews (10 per CD risk stratum) were performed (Table 1). Interview questions with exemplar quotes are shown in Table 2.

TABLE 1.

Participant characteristics, overall and by CD risk strata

Characteristics	Overall (N=20) n(%)	<20.0% CD risk (n=10) n (%)	20.0%–39.9% CD risk (n=10) n (%)	40.0%–59.9% CD risk (n=10) n (%)	≥60.0% CD risk (n=10) n (%)
Mode of delivery
Vaginal delivery	27 (67.5)	9 (90.0)	8 (80.0)	6 (60.0)	4 (40.0)
CD	13(32.5)	1 (10.0)	2 (20.0)	4 (40.0)	6 (60.0)
Race
Black	30 (75.0)	8 (80.0)	7 (70.0)	7 (70.0)	8 (80.0)
White	7(17.5)	1 (10.0)	1 (10.0)	3 (30.0)	2 (20.0)
Asian	2 (5.0)	1 (10.0)	1 (10.0)	0(0)	0(0)
Unknown	1 (2.5)	0 (0)	1 (10.0)	0 (0)	0 (0)
Parity
Nulliparous	31 (77.5)	6 (60.0)	5 (50.0)	10(100)	10(100)
Insurance status
Medicaid	24 (60.0)	8 (80.0)	5 (50.0)	7 (70.0)	4 (40.0)
Private insurance	16(40.0)	2 (20.0)	5 (50.0)	3 (30.0)	6 (60.0)

CD, cesarean delivery.

TABLE 2.

Sample interview questions with exemplar quotes

Domain	Interview questions	Exemplar quotes
General questions	Did you think about how you would deliver the baby, either by VD or by CD, before you came in?	“Yes, I thought that I was going to deliver vaginally. That was in my brain.” (40.0% –59.9% CD risk; actual mode CD) “I thought only about delivering vaginally.” (20.0%–39.9% CD risk; actual mode VD) “I just figured it would be vaginally.” (≥60.0% CD risk; actual mode CD)
	How did you feel about the possibility of having a CD? Do you remember ever talking about CDs with your doctors or midwives?	“We didn’t really talk about [it] because it was assumed that I wasn’t going to need one. Even up into the last appointment,… I think they were going to give me a [cesarean] care pack or something. And I remember my doctor saying, no, she’s not going to need that, that’s not the plan. So I did feel as if I was going to have a vaginal delivery.” (≥60.0% CD risk; actual mode CD) “Yeah, we had a couple conversations just in event anything didn’t go well. She was like that’s always on the table. That’s always going to be an option, just preparing me.” (40.0%–59.9% CD risk; actual mode VD)
Understanding of the personalized percentage risk	How did that conversation go for you? How did it make you feel? What went well? Not well?	“It was very positive, she pretty much really reassured me that I’ll be able to give birth vaginally, and that’s something that I wanted to do.” (<20.0% CD risk; actual mode VD) “You now told me that while I was being induced, that I had a higher chance of having a [CD], which is not comforting at all.” (40.0%–59.9% CD risk; actual mode VD) “I feel like that [conversation is] very helpful, rather than just being blindsided and you have no other choice.” (≥60.0% Cd risk; actual mode CD)
	Did your provider mention any reasons why your risk of CD was low or high? If yes, do you remember what they are and how they were explained to you?	“I believe it was my gestational hypertension because I know if my blood pressure had risen too high or whatever, it could have turned into preeclampsia, which it would be harmful for me and the baby. So I think that was what was part of [it].” (≥60.0% CD risk; actual mode VD)
How knowledge of CD risk influenced the experience of labor and delivery	After that conversation, as you went on in labor, did you think about your risk of CD again? If so, when? How did it make you feel in those moments? If not, why do you think it did not come up again?	“I think because I felt like the percentage was so low that it took my worries away about maybe having to have a [CD], so I didn’t concentrate on that.” (<20.0% CD risk; actual mode VD) “I think it impacted my mindset because as things didn’t go smoothly as everyone had anticipated, I always was saying, “You told me there’s a 66.0% chance of [CD], why am I suffering? Why are you giving me this? What’s going on?” And then they just kept on saying like, oh, there’s still a chance and we want you to deliver vaginally… But when we got into the next day and I had basically had contractions and been laboring … [I] just always wondered like, why aren’t they using this information of the 66.0% chance? Why were they pushing the vaginal birth so much?” (≥60.0% CD risk; actual mode CD)
How CD risk calculator utilization could be optimized	What could have made that conversation about risk of CD better for you? How would you change the process about discussing the CD risk calculator for other women in the future?	“I feel like it all was based off of was my weight and my height and the gestational age, which was known when I scheduled my induction more than a week prior. That could have been talked about much earlier than when I’m already hooked up in an induction room expecting to deliver vaginally.” (≥60.0% CD risk; actual mode CD) “I just think that doctors should just be as transparent and as open as possible with women when it comes to their bodies. So that way, when you make a decision to do something medically, you can make it based off of knowledge and not off of fear.” (≥60.0% CD risk; actual mode VD)

CD, cesarean delivery; VD, vaginal delivery.

When asked about whether patients had thought about delivery mode before presenting for labor, most birthing people, regardless of CD risk, stated that they believed that they would deliver vaginally. Many participants did not recall discussing CD at all during prenatal care, whereas others stated CD was only brought up “just in case.”

In addition, despite documented counseling, nearly a quarter of participants did not recall a conversation about personalized CD risk taking place on admission. When counseling was recalled, many perceived that they were counseled at lower risk than their actual result, and most could not identify reasons why their risk was high or low.

As height and body mass index are 2 calculator variables and possibly sensitive topics, the participants were specifically asked if they recalled discussing height and/or weight as components of CD risk. As the vast majority did not, participants were asked how they would feel if these topics had been brought up. Participants expressed a lack of surprise that these variables affect CD risk and that they would “not have been offended” if clinicians had discussed them.

In discussing how counseling about CD risk made patients feel, sentiment varied by CD risk group. Patients with low risk of CD (<20.0% and 20.0%–39.9%) expressed either little influence on their labor or a sense of comfort from the counseling. After initial counseling, those with low CD risk primarily stated that they did not think about their CD risk again. For those at higher risk of CD (40.0%–59.9% and ≥60.0%), sentiment toward counseling followed 2 major themes. Some felt the conversation increased stress during induction, especially if elective. Others believed that the conversation helped prepare for the possibility of CD. Those of higher risk were more likely to report recalling their counseling later in labor induction and that knowledge of cesarean risk influenced how they felt about how labor was progressing.

To improve counseling, participants, especially those at the highest risk, recommended starting the conversation prenatally, even if the calculator result changes with the admission examination.

CONCLUSION:

This qualitative study characterized the patient experience of a CD risk calculator during labor induction using rigorous qualitative methods with sufficient samples to obtain thematic saturation in each stratum (4 risk strata). However, our findings may have limited generalizability beyond our unit. In addition, although standardized scripts regarding counseling were recommended for use, we did not assess what counseling was actually given or how well it was delivered to the patient as a part of this work. These data may reassure clinicians with concerns regarding the CD risk calculator and thereby aid sites in the implementation of this clinically effective tool.