Design, development, and evaluation of a web-based consultation system for birth after cesarean: a mixed-method study protocol

Abstract

Background

Women with a prior cesarean section frequently face challenges in choosing the mode of delivery, and limited knowledge, negative attitudes toward vaginal birth, and lack of tailored guidance often led to elective repeat cesarean sections. The main objective of this study is to design, develop, and evaluate a web-based counseling system to support and empower pregnant women in making informed decisions regarding vaginal birth after cesarean (VBAC).

Methods/design

A sequential exploratory mixed-methods study will be conducted in Mashhad, Iran. Phase 1 (qualitative) will use conventional content analysis of semi-structured interviews with 25 pregnant women and healthcare providers to identify needs, expectations, and preferences for a web-based VBAC counseling system. Phase 2 will involve iterative prototype development following the prototyping model, guided by qualitative findings, expert validation, and a systematic review. Phase 3 will evaluate system usability (System Usability Scale) and effectiveness via a two-arm randomized controlled trial with 80 eligible women. Districts will be randomized; intervention participants will access the web-based system, while controls receive routine care. Primary outcomes are VBAC intention, choices, and VBAC actual rates. Secondary outcomes include knowledge, satisfaction, and breastfeeding success. Data will be analyzed using SPSS.

Discussion

This study examines the impact of a web-based VBAC counseling system on empowering pregnant women by enhancing their knowledge of delivery options and reducing decisional conflict. The system is designed to support informed decision-making, promote shared decision-making with healthcare providers, and facilitate safer, evidence-based choices regarding vaginal birth after cesarean.

Trial registration

This trial is registered with the Iranian Registry of Clinical Trials under registration number IRCT20170607034378N3, with the registration date 2025-11-15.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-026-08694-1.

Background

Pregnancy represents one of the most critical and sensitive periods in a woman’s life, requiring comprehensive care to ensure maternal and fetal well-being [1, 2]. A key challenge for pregnant women, particularly those with a history of at least one cesarean section (CS), is selecting the mode of delivery, which can be highly complex and fraught with uncertainty [3, 4]. Globally, the World Health Organization (WHO) has noted a dramatic rise in CS rates over recent decades, transforming this surgical procedure into a major public health concern [5]. While CS is essential for reducing maternal and neonatal mortality when medically indicated potentially lowering these rates at national CS levels up to 10% rates exceeding this threshold do not yield further benefits and may expose women and infants to unnecessary short and long term risks [6, 7]. These risks include severe hemorrhage, maternal and neonatal morbidity, low Apgar scores, respiratory infections in newborns, surgical site infections, venous thromboembolism, cardiovascular complications, and increased uterine rupture in subsequent pregnancies [4, 8, 9]. Moreover, repeated CS heightens the likelihood of abnormal placental adhesion and hysterectomy [10].

CS rates have surged from approximately 7% in 1990 to over 21% today, with projections estimating nearly one-third (29%) of births worldwide by 2030, far exceeding the WHO-recommended range of 5–15% [4, 5, 11]. Regional disparities are stark, with anticipated peaks in Eastern Asia (63%), Latin America and the Caribbean (54%), Western Asia (50%), Northern Africa (48%), and Southern Europe (47%) by 2030 [4, 11]. In Iran, the rate of cesarean section has risen dramatically showing a sixfold increase from below 7% in the 1970s to more than 48% by 2018 [12]. The prevalence is considerably higher in private hospitals, ranging between 72% and 89% [13, 14]. Among 2,322,500 births, 53.6% were delivered by cesarean Sect [15]. Despite temporary reductions following health system reforms, CS rates have rebounded, underlining persistent issues like maternal requests driven by insufficient awareness of CS complications and negative attitudes toward vaginal birth after cesarean (VBAC) [9, 16]. Unnecessary CS are frequently associated with limited maternal knowledge, negative attitudes toward vaginal birth, and a history of prior CS, often resulting in elective repeat procedures [17, 18].

To mitigate these trends, the WHO recommends targeted educational interventions to facilitate informed decision-making [19]. VBAC is widely endorsed by professional bodies, including the American College of Obstetricians and Gynecologists, as an effective approach to reducing CS rates [20]. Although VBAC was historically discouraged due to concerns regarding uterine rupture, accumulating evidence since the 1970s supports its cautious implementation, which led to a 20% increase in VBAC rates between the mid-1980s and mid-1990s [21, 22]. VBAC demonstrates a success rate of 60–80% among eligible women and is associated with reduced maternal morbidity, faster postpartum recovery, enhanced maternal satisfaction, improved neonatal outcomes, and higher rates of successful breastfeeding compared to elective repeat CS [23]. Predictors of successful VBAC include younger maternal age, lower body mass index, non-vertical uterine scars, gestational age under 40 weeks, and a history of prior vaginal delivery. Optimal outcomes necessitate individualized patient assessment and the availability of facilities equipped for emergency CS [21, 22].

Despite VBAC’s benefits, decision-making is complex. Women with prior CS often lack firm preferences, seeking tailored guidance from providers, yet many express dissatisfaction with the burden of decision-making [24, 25]. In Iran, barriers include limited VBAC research, cultural resistance rooted in misconceptions about vaginal birth safety, inadequate supportive infrastructure, and poor access to specialized services, particularly in rural areas [26]. Promotional strategies, such as education via brochures, videos, shared decision-making (SDM) protocols, and digital tools, have shown promise globally [27, 28]. Digital health solutions, particularly web-based systems, enhance accessibility in resource-constrained settings by offering universal access via browsers, promoting digital equity, seamless integration with electronic health records, and cost-effective maintenance compared to mobile apps, which require downloads and platform-specific compatibility [29, 30]. Clinical decision support systems embedded in web-based platforms can mechanize expert knowledge, delivering evidence-based recommendations to improve decision-making and pregnancy outcomes [31, 32]. Studies on digital decision aids demonstrate improved knowledge, reduced decisional conflict, and enhanced shared decision-making [33, 34]. However, these studies, primarily conducted in Western contexts, focus on decision processes rather than actual VBAC uptake and often overlook cultural and psychosocial factors in non-Western settings like Iran [35, 36]. In Iran, despite mandates for third-trimester counseling on natural birth benefits, women with prior CS often receive no targeted advice and are routinely referred for elective CS [37].

Existing studies on digital decision aids for birth mode selection demonstrate improved knowledge, reduced decisional conflict, and enhanced shared decision-making [35, 38]. However, critical gaps persist: most are conducted in Western settings, overlook cultural and psychosocial determinants in non-Western contexts like Iran, and assess decision-making processes rather than actual VBAC uptake [35, 39]. This gap is particularly salient in Iran, where despite national policies requiring third-trimester counseling on vaginal birth women with a prior cesarean rarely receive individualized guidance and are instead routinely scheduled for elective repeat cesarean sections. Moreover, no comprehensive mixed-methods study has yet designed, developed, and evaluated a culturally attuned, web-based VBAC counseling system that integrates provider mapping, maternal empowerment, and real-world delivery outcomes within the Iranian healthcare context.

Objectives

This study consists of three main phases; qualitative exploration, system design and development, and system evaluation. The qualitative phase aims to identify the needs of women with previous cesarean sections in choosing VBAC through a system-based counseling approach, to explore their perceptions and experiences of receiving health services via such a system, and to understand their expectations and preferences for system-based counseling regarding birth after cesarean. Based on these findings, the design and development phase focus on creating and refining the “Birth After Cesarean Counseling System,” testing it in an experimental environment, and assessing its usability. Finally, in the evaluation phase (clinical trial), the effectiveness of the system will be examined by comparing the intention to choose, the actual choice of, and the occurrence of VBAC between the intervention and control groups.

Methods

This study protocol was developed in accordance with the SPIRIT 2025 (Standard Protocol Items: Recommendations for Interventional Trials) guidelines [40].

Study design

This study will employ a sequential exploratory mixed-methods design to develop and evaluate a web-based counseling system aimed at promoting VBAC among pregnant women with a prior cesarean delivery. System development will follow the prototyping model from software engineering, structured across three iterative phases: analysis, development, and evaluation. The flow of these phases is summarized in Fig. 1. The analysis phase will involve needs assessment and requirement analysis, drawing on qualitative findings and a systematic literature review. The development phase will focus on designing and constructing a functional prototype. Finally, the evaluation phase will assess both usability (using the System Usability Scale) and effectiveness through a two-arm randomized controlled trial (RCT).

Fig. 1.

Research flowchart illustrating the study phases

The qualitative phase will utilize conventional content analysis to explore the needs, experiences, expectations, and preferences of pregnant women and healthcare providers regarding the VBAC counseling system. The quantitative phase will consist of an RCT to evaluate the system’s impact on women’s intentions, choices, and VBAC rates.

The study will be conducted in Mashhad, Iran, from January 1, 2026 to January 1, 2028 and will be approved by the Ethics Committee of Mashhad University of Medical Sciences (approval code: IR.MUMS.NURSE.REC.1404.078). The RCT will be registered with the Iranian Registry of Clinical Trials (registration number: IRCT20170607034378N3). Written informed consent will be obtained by the researcher from all participants prior to enrollment in both the qualitative interviews and the randomized controlled trial. In the quantitative phase, consent will be obtained electronically at the first login to the web-based system, before any study-related content is accessed.

The results of this study will be disseminated through peer-reviewed publication, presentation at national and international conferences, and submission to the Iranian Registry of Clinical Trials (IRCT). A plain-language summary of findings will be shared with participating women and health centers.

Participants and sampling

Qualitative phase

The target population will include pregnant women with at least one prior cesarean delivery attending comprehensive health centers in Mashhad, as well as healthcare providers (midwives and obstetricians) affiliated with Mashhad University of Medical Sciences. Inclusion criteria for pregnant women will encompass a history of at least one cesarean delivery, proficiency in Persian, a minimum high school education, willingness to discuss the use of the VBAC counseling system, and the ability to operate a smartphone or the system. For healthcare providers, inclusion criteria will require at least one year of professional experience in obstetrics or midwifery.

Exclusion criteria will include unwillingness to participate at any stage of the study. Purposive sampling with maximum variation will be employed to ensure diversity in age, gestational age, socioeconomic status, and work experience among participants, drawn from various health centers, clinics, and hospitals across Mashhad. Sampling will continue until data saturation is achieved, with an estimated sample size of 25 participants.

Quantitative phase

The target population will comprise pregnant women with a history of at least one (and at most two) prior cesarean deliveries attending comprehensive health centers in Mashhad for prenatal care. Inclusion criteria will include: provision of informed consent, minimum secondary education, Iranian nationality and residency in Mashhad, no absolute contraindications for vaginal birth after cesarean (VBAC) (e.g., breech presentation, twins, or medical indications), access to a smartphone with internet connectivity, prior experience with electronic services, and gestational age between 28 and 38 weeks.

Exclusion criteria will include unwillingness to continue participation, pregnancy termination for medical reasons, development of cesarean indications prior to delivery, or relocation during the study period. Two health districts (Districts 1 and 3) will be selected based on their socioeconomic similarity and will be randomized to either the intervention or control group using simple randomization (e.g., coin flip performed by an independent researcher). Within each district, 10 comprehensive health centers with the highest rates of prior cesarean referrals will be randomly selected through a lottery process. Convenience sampling will then be applied within these centers until the target sample size is achieved. Because randomization was performed at the cluster level (health district), personnel enrolling participants (midwives in health centers) were aware of group allocation. However, allocation occurred prior to individual recruitment, minimizing selection bias.

Sample size was calculated based on Venkatesh et al. (2021) [35], assuming a 34% difference in trial of labor after cesarean (TOLAC) selection between intervention (60%) and control (26%) groups, with α = 0.05 and power = 80%, yielding 60 participants (30 per group). Accounting for 20% attrition, the final sample was 80 participants (40 per group).

Schedule of enrolment, interventions, and assessments

The schedule of enrolment, interventions, and assessments is presented in Fig. 2.

Fig. 2.

Schedule of enrolment, interventions, and assessments according to the SPIRIT 2025 guideline. t₁: baseline (enrolment and randomization); t₂: 38 weeks gestation; t₃: delivery; t₄: 1 month postpartum

Data collection

Qualitative phase

Following ethics approval, a systematic review of relevant databases will be conducted to identify knowledge gaps and inform the development of interview guides. Semi-structured interviews will then be carried out in quiet, participant-preferred locations, such as health centers or clinics, to ensure a comfortable environment. Interviews will be audio-recorded with participant consent, lasting between 30 and 50 min (mean: 40 min), and will be supplemented by detailed field notes. Demographic data will be collected using structured questionnaires to provide context for participant characteristics.

Interview questions will be tailored to each participant group to address their specific perspectives. For pregnant women, questions will focus on their prior use of web-based health services, expectations from a vaginal birth after cesarean (VBAC) counseling system including functional and non-functional requirements (e.g., preferred content types such as text, video, or animation, user interface preferences, and factors influencing trust in the system). For healthcare providers, questions will explore challenges in VBAC counseling, barriers to adopting electronic systems, required information to facilitate shared decision-making, desired features for patient management, and perceived differences between in-person and electronic consultations. Probing questions (e.g., “Can you explain more?”) will be used to elicit detailed responses and ensure depth in the data collected. Interviews will conclude with open-ended prompts to encourage additional comments, and follow-up interviews will be conducted if necessary to clarify or expand on responses.

To enhance the trustworthiness of the qualitative findings, an external monitor (an independent researcher with expertise in qualitative methodology but not involved in data collection or analysis) will review the coding process, emergent themes, and analytical decisions. This external audit aligns with Lincoln and Guba’s criteria for confirmability and dependability.

Quantitative phase (RCT)

In the intervention group, participants will access the web-based system via a hyper link sent by midwives following initial registration at health centers. The system will require user authentication through SMS verification. Eligible women, without absolute contraindications for VBAC, will receive personalized content detailing VBAC benefits (maternal, neonatal, personal, and familial), estimated success probabilities, and descriptions of care during labor. Participants will indicate their VBAC intentions, and those opting for VBAC will select from a pre-approved list of VBAC-supportive obstetricians in Mashhad to book appointments. Physicians will receive SMS notifications of referrals. Women who remain undecided will access multimedia consultations (text, voice or video) and will have the option to submit queries to researchers or schedule online or in-person consultations at the midwifery clinic of Om Al-Banin Hospital. Follow-up will be conducted through physician feedback logged within the system.

Usability will be assessed post-use using the System Usability Scale (SUS), a 10-item Likert-scale questionnaire (1 = strongly disagree to 5 = strongly agree), scored from 0 to 100. The SUS is a widely used and psychometrically robust instrument, with demonstrated high internal consistency (Cronbach’s α ≈ 0.91) and strong construct validity [41]. VBAC intentions will be measured at 38 weeks gestation using a validated four-option checklist (“What is your current intention regarding delivery method?“: probably natural, probably cesarean, definitely natural, definitely cesarean). Content validity of the checklist will be confirmed by seven nursing and midwifery experts, with reliability established through test-retest methods. Post-delivery, the actual delivery mode and outcomes will be recorded through researcher follow-up.

The control group will receive routine prenatal care. Data on intentions, choices, and VBAC actual rates will be collected similarly for comparison between the intervention and control groups.

System development

The development of the web-based counseling system for promoting vaginal birth after cesarean (VBAC) will be guided by the prototyping model, structured across three iterative phases: analysis, development, and evaluation. In the analysis phase, system requirements will be systematically elicited through qualitative data derived from interviews with pregnant women and healthcare providers, complemented by a systematic review of existing literature. These requirements will encompass content types (e.g., text, video, animation), user interface design, accessibility features, and evidence-based personalization to ensure alignment with user needs and expectations. Validation of these requirements will be conducted by a panel of experts in obstetrics, midwifery, and informatics to confirm clinical and technical appropriateness. During the development phase, a functional prototype will be designed and developed by experienced developers specialists under the supervision of an informatician and domain experts. The prototype will incorporate secure database architecture, user authentication via SMS verification, and a subset of core functionalities to facilitate iterative testing. Rigorous testing in a controlled environment will enable the collection of feedback from the research team, which will be used to refine the user interface, content delivery, and workflow processes, culminating in a finalized version of the system. In the evaluation phase, the system’s usability will be assessed using the System Usability Scale (SUS) administered to a subset of end-users, while its effectiveness will be evaluated through outcomes measured in a randomized controlled trial (RCT). This structured approach will ensure the system is both user-centered and clinically robust, addressing the needs of pregnant women with prior cesarean deliveries and their healthcare providers.

Data analysis

Qualitative phase

In the qualitative phase, conventional content analysis will be employed to analyze interview transcripts, facilitating an in-depth exploration of participants’ perspectives. Transcripts will be meticulously reviewed multiple times to identify salient segments relevant to the research objectives. Open coding will be conducted without preconceived categories, allowing codes to emerge directly from the data. These codes will subsequently be organized into themes through an iterative process of comparison and refinement, ensuring that the derived themes accurately reflect participants’ experiences, needs, and expectations. The analysis will continue until data saturation is achieved, marked by the absence of new thematic insights, thereby ensuring a comprehensive representation of the qualitative findings.

Quantitative phase

Data will be analyzed using SPSS version 25. All randomized participants will be included in the analysis according to their assigned group (intention-to-treat analysis). Participants who withdraw or are lost to follow-up will be included in the analysis using available data, and sensitivity analyses will be conducted to assess the impact of missing data. Descriptive statistics, including frequencies, percentages, means, and standard deviations, will be used to summarize variables. Independent t-tests will be employed to compare continuous variables between groups, with Mann-Whitney U tests applied for non-normal data. Chi-square or Fisher’s exact tests will be used to compare categorical variables. Paired t-tests or Wilcoxon signed-rank tests will assess pre-post changes within groups. Regression models will be utilized to adjust for potential confounders. Missing data will be handled using intention-to-treat analysis, and sensitivity analyses will be conducted to assess the impact of missingness on the primary and secondary outcomes. Statistical significance will be set at p < 0.05. No subgroup or sensitivity analyses are planned, as the study is designed to evaluate the overall effectiveness of the intervention in the target population.

Trial monitoring

The research team will conduct monthly monitoring of trial procedures, including recruitment progress, data quality, protocol adherence, and fidelity of intervention delivery. In addition, an external monitor (an independent academic with expertise in mixed-methods research) will oversee all phases of the study, including qualitative data analysis, quantitative data collection, and system implementation to ensure methodological rigor and adherence to the approved protocol.

Discussion

The implementation of SDM is widely recommended to empower pregnant women with informed choices regarding VBAC; however, the deployment of an innovative web-based VBAC counseling system in Mashhad, Iran, is likely to encounter multifaceted challenges rooted in cultural, systemic, and individual factors. Preliminary qualitative findings suggest that the proposed system will be feasible and acceptable, enhancing women’s knowledge, reducing decisional conflict, and increasing satisfaction with the decision-making process [39, 42]. However, cultural norms in Iran, where hierarchical patient-provider dynamics and deference to medical authority are prevalent, may limit women’s readiness to engage in SDM [43]. Women may lack confidence in communicating effectively with obstetricians and may perceive time constraints during consultations as a barrier, findings consistent with prior studies in similar cultural contexts [44]. These challenges highlight the need for tailored interventions to foster active participation in decision-making.

The theoretical framework of the Technology Acceptance Model (TAM) provides a lens to understand the adoption of the proposed web-based system [45]. According to TAM, perceived usefulness and ease of use are critical determinants of technology acceptance. The system’s design, incorporating user-friendly interfaces, multimedia content (e.g., text, videos, animations), and a communication skills module, aims to enhance perceived ease of use, particularly for women with limited experience in SDM [46]. The communication module, positioned as the initial engagement activity, will equip women with practical strategies to interact with healthcare providers, addressing identified barriers such as low confidence in discussing VBAC options. Previous research indicates that decision aids integrated into clinical encounters can enhance patient-clinician interactions, aligning with SDM principles, compared to standalone tools focused solely on knowledge enhancement [47]. By embedding evidence-based, personalized content and secure authentication mechanisms, the system will not only support women’s decision-making but also facilitate provider engagement in SDM, potentially shifting clinical practices toward more collaborative models.

Cultural factors specific to Iran, such as the influence of family members in health-related decisions and societal expectations around childbirth, may further shape the system’s effectiveness. For instance, women’s preferences for cesarean delivery are often influenced by familial pressures or perceptions of safety and social status associated with surgical births [48, 49]. The system’s personalized content, which includes tailored VBAC success probability estimates and comprehensive benefits (maternal, neonatal, personal, and familial), aims to address these concerns by providing evidence-based information to counter misconceptions [50]. However, the success of this approach will depend on its ability to resonate with cultural values, such as trust in medical expertise and family involvement, which may require additional culturally sensitive features, such as family-oriented educational materials [51].

The system’s integration into clinical workflows supported by a secure database architecture and SMS-based notifications is anticipated to streamline shared decision-making (SDM) by aligning with existing healthcare practices in Mashhad. By providing structured, evidence-based information and facilitating direct communication between pregnant women and VBAC-supportive providers, the system aims to bridge gaps in counseling and referral pathways [52]. Nevertheless, systemic barriers such as limited internet access in underserved areas of Mashhad or varying levels of digital literacy among women may pose challenges to equitable adoption and sustained engagement with the platform [53].

Chen et al. (2023) developed an innovative web-based decision aid for VBAC in Taiwan, integrating evidence-based content, value clarification exercises, and an AI-driven VBAC success calculator. While this platform represents a significant advancement in personalized decision support, its design is deeply embedded in a high resource, technologically integrated healthcare system with established electronic health records [39]. In contrast, our study is conducted in Iran’s primary healthcare setting, where such infrastructure is limited. Rather than relying on AI or real-time data linkage, our system prioritizes accessibility through lightweight web architecture, SMS-based authentication, and offline-compatible content. Moreover, while Chen’s intervention focuses on individual empowerment, our mixed-methods approach actively engages both women and providers to address systemic barriers such as lack of VBAC-trained obstetricians and hierarchical communication patterns that are prevalent in the Iranian context.

Venkatesh et al. (2021) demonstrated the efficacy of a brief, video-based decision aid in increasing TOLAC selection among U.S. women. Their quasi experimental design showed promising results in knowledge gain and reduced decisional conflict. However, the intervention was delivered in a single clinical setting, lacked qualitative exploration of user needs, and did not assess actual VBAC uptake beyond initial choice. Crucially, the video content was developed in a Western cultural context where patient autonomy is normative unlike Iran, where family influence and deference to physician authority strongly shape delivery decisions [35]. Our study addresses these limitations by first conducting in-depth interviews with Iranian women and midwives to co-design culturally resonant content, and by evaluating not only intention but also the final delivery mode in a randomized controlled trial embedded within public health centers.

Eslami et al. (2015) proposed a computerized decision aid for childbirth mode selection in Iran, marking an early effort to localize digital health tools in the region. Although their protocol outlined a robust theoretical foundation and usability testing, the study targeted primigravid women without prior cesarean, thus excluding the high-need population of women with a CS history. Furthermore, the intervention did not include provider engagement or referral mechanisms key gaps in Iran’s VBAC ecosystem [33]. Our study specifically focuses on women with prior cesarean and integrates a “provider mapping” feature that connects users to VBAC-supportive obstetricians in Mashhad, thereby transforming information into actionable care pathways within the existing public health infrastructure.

Shorten et al. (2004) pioneered one of the earliest decision aids for VBAC a printed booklet tested in Australia. Their work highlighted the value of value clarification exercises and balanced risk communication. However, as a paper-based, pilot-scale intervention, it lacked scalability, digital interactivity, and integration into clinical workflows. More importantly, it did not evaluate whether stated preferences translated into actual VBAC deliveries [54]. In response, our study leverages a web-based platform to ensure broader reach and dynamic content delivery, embeds the tool within routine prenatal care in urban health centers, and tracks real world VBAC outcomes. Additionally, by grounding system design in qualitative insights from both patients and providers, we ensure the intervention reflects the sociocultural realities of Iranian women something a static booklet cannot achieve.

This study examines the impact of a web-based VBAC counseling system on empowering pregnant women by enhancing their knowledge of delivery options and reducing decisional conflict. The system is designed to support informed decision-making, promote shared decision-making with healthcare providers, and facilitate safer, evidence-based choices regarding vaginal birth after cesarean.

Trial status

Participant recruitment will commence on February 1, 2026, based on protocol version 1.0. The estimated primary completion date is February 1, 2028.

Any important modifications to the study protocol will be communicated to the Ethics Committee of Mashhad University of Medical Sciences, the Iranian Registry of Clinical Trials (IRCT), and, if applicable, to enrolled participants. Protocol amendments will also be documented in the final trial report and, if relevant, in any resulting publications.

Abbreviations

ACOG

American College of Obstetricians and Gynecologists

CS

Cesarean Section

ERCS

Elective Repeat Cesarean Section

IRCT

Iranian Registry of Clinical Trials

RCT

Randomized Controlled Trial

SDM

Shared Decision-Making

SPIRIT

Standard Protocol Items: Recommendations for Interventional Trials

SPSS

Statistical Package for the Social Sciences

SUS

System Usability Scale

TAM

Technology Acceptance Model

TOLAC

Trial of Labor After Cesarean

VBAC

Vaginal Birth After Cesarean

WHO

World Health Organization

Biographies

FJM

is a PhD candidate in Reproductive Health at Mashhad University of Medical Sciences, with a research focus on digital health interventions to promote evidence-based maternity care in Iran.

FHT

is an Associate Professor in Reproductive Health with expertise in shared decision-making, health behavior theories, and qualitative research in women’s reproductive health.

SMT

is an Associate Professor in Medical Informatics and specializes in the design and evaluation of web-based clinical decision support systems for maternal and child health in low-resource settings.

MF

is an Assistant Professor of Midwifery and a practicing midwife with over 15 years of clinical experience in maternal care and VBAC counseling in the Iranian public health system.

Authors’ contributions

FJM: PhD student in Reproductive Health; conceived the study, drafted the protocol, coordinated data collection, and wrote the initial manuscript. FHT: Associate Professor in Reproductive Health; contributed to theoretical framework, outcome measures, and intervention content development. FHT: Associate Professor in Reproductive Health; contributed to theoretical framework, outcome measures, and intervention content development.SMT: PhD in Medical Informatics; led system architecture, technical development, database design, and digital platform implementation. MF: Assistant Professor of Midwifery; supervised the clinical and qualitative components, contributed to study design, and critically revised the manuscript. All authors read and approved the final manuscript.

Funding

This study is funded by the Mashhad University of Medical Sciences, Iran (Grant No. 4040618). The funding body had no role in the design of the study, data collection, analysis, interpretation of data, or manuscript writing.

Data availability

The final anonymized dataset will be available to the research team and may be shared upon reasonable request after publication, subject to ethical and institutional restrictions. The web-based counseling system will not be publicly released but may be made available to collaborating institutions under a formal data-sharing agreement.

Declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Mashhad University of Medical Sciences (approval code: IR.MUMS.NURSE.REC.1404.078). Written informed consent will be obtained from all participants prior to enrollment in both the qualitative interviews and the randomized controlled trial.

Consent for publication

Not applicable. This study protocol contains no individual person’s data, images, or videos.

Competing interests

The authors declare no competing interests.