Women's Preferences Regarding the Processes and Outcomes of Trial of Labor After Cesarean and Elective Repeat Cesarean Delivery

Abstract

Background: The decrease in trial of labor after cesarean (TOLAC) at institutions that offer this option suggests that patient preference could be a factor in the declining TOLAC rate. However, data regarding how women value the potential processes and outcomes of TOLAC and elective repeat cesarean delivery (ERCD) are limited. We sought to determine how women view the processes and outcomes of TOLAC and ERCD and identify sociodemographic and clinical factors associated with these preferences.

Materials and Methods: This is a multicenter cross-sectional study of mode of delivery preferences among TOLAC-eligible women at 26–34 weeks gestation. The time tradeoff metric was used to obtain utilities for the processes and outcomes of TOLAC and ERCD. Multivariable regression analysis was utilized to identify independent predictors of utilities.

Results: The 299 study participants constituted a geographically and racially/ethnically diverse group. Although uncomplicated TOLAC resulting in vaginal birth after cesarean and uncomplicated ERCD resulted in high utility values, any alteration in either the process or outcome resulted in substantial utility decrements. In multivariable regression analysis, race/ethnicity, insurance status, and order of scenario presentation emerged as statistically significant predictors.

Conclusions: Information regarding both maternal and infant implications is important to women in discussions about approach to delivery. Both the way in which information regarding labor interventions and potential complications is presented and the characteristics of the women contemplating this information affect its impact. These findings underscore the need for evidence-based decision support to help create realistic expectations and incorporate informed patient preferences into decision-making to optimize both clinical outcomes and individual patient experience for women with a prior cesarean delivery.

Introduction

Cesarean delivery (CD) is the most common inpatient surgery in the United States, accounting for nearly one-third of births annually.¹ Elective repeat cesarean delivery (ERCD) is a significant contributor to the cesarean rate, resulting from the combination of a rising rate of primary CD and a decreasing rate of vaginal birth after cesarean (VBAC), which declined from a high of 28.3% in 1996 to 11.9% in 2015.^2,3 A substantial portion of this decrease is related to women foregoing trial of labor after cesarean (TOLAC), even when this option is available.⁴

Although the decrease in TOLAC at institutions that offer this option suggests that patient preference could be a factor, data regarding how women value the potential processes and outcomes of TOLAC and ERCD are limited.⁵ Information from qualitative studies offers some insight, but the nongeneralizability of study populations and lack of quantitative analyses restrict their applicability.^6–11 Moreover, the quantitative data that do exist are not specific to women with prior cesareans who are eligible for TOLAC, the population that faces this decision.¹² As guidelines^13,14 have placed increasing emphasis on the central role of patient preferences in decision-making regarding delivery approach after CD, it has become clear that obtaining a better understanding of women's preferences regarding these options is an important step in optimizing patient-centered evidence-based care. Thus, we sought to obtain a detailed understanding of mode-of-delivery preferences among a diverse population of English- or Spanish-speaking TOLAC-eligible pregnant women.

Materials and Methods

We conducted a cross-sectional study from December 1, 2014, to April 1, 2016. Participants were recruited from outpatient settings associated with hospitals offering TOLAC in three geographically distinct areas of the United States: Boston (Massachusetts General Hospital); Chicago (Northwestern University Medical Center); and the San Francisco Bay Area (University of California San Francisco and California Pacific Medical Center, St. Luke's Campus in San Francisco, and Marin Community Clinic in San Rafael). Inclusion criteria included one prior CD, no prior VBAC, no contraindications to vaginal delivery, a singleton gestation at 26–34 weeks, and the ability to complete an interview in English or Spanish. Women received usual care at their institution regarding approach to decision-making regarding mode of delivery in the setting of a prior cesarean, which consisted of counseling by their provider at all participating institutions. No formal education, web tools, or decision support was in place in any of the sites. Use of the National Institute of Child Health and Human Development VBAC prediction tool was at the discretion of the prenatal provider. Study participation consisted of one face-to-face interview that included completion of a sociodemographic and attitudinal questionnaire and a series of preference elicitation exercises. Interviews were scheduled at the patient's convenience and, therefore, could coincide with a prenatal appointment; however, study procedures were separated from any clinical activities. Patient outcomes and other clinical data were abstracted from the medical record by research personnel. All participants signed written informed consent before the interview and received $50 as remuneration. The study received Institutional Review Board approval at all participating institutions.

To measure preferences, we used “ELICIT,” a computerized preference elicitation tool previously developed by one of the investigators (M.K.).¹⁵ After asking each participant “If you could be guaranteed an uncomplicated delivery of either type, which delivery would you prefer?” with response options of “vaginal delivery” or “cesarean delivery,” we assessed the strength of their preference for the potential outcomes of ERCD and TOLAC, using the time tradeoff (TTO) metric.^16,17 The TTO, which generates values ranging from 0 to 1, where 0 indicates death (or the worst outcome) and 1 indicates ideal health (or the “ideal” outcome), has been used to evaluate patient preferences for myriad health care decisions.^18–20 For this study, participants were presented with a choice between the less-than-ideal outcome being evaluated (Choice 1) and a hypothetical “ideal” outcome (Choice 2, determined by their stated mode of delivery preference) that they could experience in exchange for giving up a certain number of years of life. The number of years that Choice 2 requires giving up to achieve the ideal outcome is varied until the participant is indifferent between living her full life expectancy having experienced the less preferred outcome versus a reduced life expectancy with the ideal outcome. TTO utility values for both modes of delivery were obtained on a 0-to-1 scale for all women, regardless of their stated preferred delivery mode. Preferences for the other potential outcomes of TOLAC and ERCD were also measured using the TTO.

To minimize potential bias due to the order in which scenarios were assessed,²¹ participants were randomly assigned to evaluate scenarios in different sequences. To avoid either starting or ending the preference assessments with a scenario involving potentially devastating outcomes, uterine rupture outcomes were always presented in the middle of the list. Group 1 first assessed scenarios describing VBAC with a variety of interventions or complications during labor, followed by TOLAC resulting in CD, and the three rupture outcomes. These scenarios were followed by outcomes of ERCD. In contrast, Group 2 started by assessing the scenarios related to ERCD, then assessed the TOLAC scenarios resulting in CD, followed by the three rupture outcomes, and ended by assessing the scenarios describing VBAC. The narratives were developed based on the literature regarding the most common clinical scenarios encountered in the setting of TOLAC and ERCD^{2,5–9,11,13} as well as our group's prior work regarding which events are most relevant to the women facing this specific decision²²; the narratives then underwent an iterative process of feedback and revision based on participant responses to develop the final set of scenarios. (See Table 1 for outcome descriptions and order of presentation.) A standardized script was used to explain the TTO procedure to all participants, who completed a test scenario and had the opportunity to ask questions before responding to the study scenarios.

Table 1.

Scenario Descriptions and Order of Presentation

Brief description	Full scenario presented to participants	Group 1 order	Group 2 order
TOLAC common outcomes
TOLAC, VBAC, no interventions or complications (given 1 when TOLAC is preferred)	You choose to have a trial of labor.	1	9
	You go into labor and at the hospital your labor progresses as expected.
	You have a vaginal birth.
	You and your baby go home 2 days later.
	Full physical recovery takes 1–2 weeks.
TOLAC, oxytocin augmentation, VBAC	You choose to have a trial of labor.	2	10
	You go into labor but at the hospital your labor stops progressing.
	You get an intravenous medicine (Pitocin)a to make your contractions stronger and more frequent.
	You have a vaginal birth.
	You and your baby go home 2 days later.
	Full physical recovery takes 1–2 weeks.
TOLAC, chorioamnionitis, VBAC	You choose to have a trial of labor.	3	11
	During labor, you develop a fever and are given antibiotics.
	You have a vaginal birth.
	Because of the fever, your baby needs antibiotics after the delivery.
	You and your baby go home 2 days later.
	Full physical recovery takes 1–2 weeks.
TOLAC, VBAC, third or fourth degree laceration	You choose to have a trial of labor.	4	12
	You have a vaginal birth.
	During the delivery, a tear occurs in the vagina and muscles around the anus, which is repaired with stitches.
	You and your baby go home 2 days later.
	You have discomfort from the tear for the first 1–2 weeks.
	You have an increased chance of losing stool beyond your control in the future.
TOLAC, CD, no complications	You choose to have a trial of labor.	5	5
	While you are in labor, your provider determines that you need a C-section.
	You have a C-section without complications.
	You and your baby go home 4 days later.
	Full physical recovery takes about 6 weeks.
TOLAC rupture outcomes
TOLAC, rupture, CD with rupture easily repaired	You choose to have a trial of labor.	6	6
	While you are in labor, your provider determines that you need a C-section.
	During the delivery, the doctor sees that the uterine scar from your previous C-section has opened.
	The opening is easily repaired and your baby does not have any complications.
	You and your baby go home 4 days later.
	Full physical recovery takes about 6 weeks.
TOLAC, rupture, CD, hysterectomy (no infant complications)	You choose to have a trial of labor.	7	7
	While you are in labor, your provider determines that you need a C-section.
	During the delivery the doctor sees that the uterine scar from your previous C-section has opened.
	The opening cannot be repaired, and a hysterectomy is necessary.
	This means that you will not be able to get pregnant in the future.
	Your baby does not have any complications.
	You and your baby go home 4 days later.
	Full physical recovery takes about 6 weeks.
TOLAC, rupture, CD, severe infant complication (HIE or death)	You choose to have a trial of labor.	8	8
	While you are in labor, your provider determines that you need a C-section.
	During the delivery your doctor sees that the uterine scar from your previous C-section has opened.
	The opening is repaired.
	However, your baby has serious complications related to the delivery and has to stay in the hospital.
	In some cases, your baby may die; if he or she survives, he or she will have serious, lifelong medical problems.
ERCD outcomes
ERCD, no complications (given 1 when CD is preferred)	You choose to have a scheduled C-section.	9	1
	You have a C-section without complications.
	You and your baby go home 4 days later.
	Full physical recovery takes about 6 weeks.
ERCD, minor surgical complications (surgical site infection/wound dehiscence)	You choose to have a scheduled C-section.	10	2
	Three days after surgery, your surgical incision becomes infected and the skin opens up.
	Your baby does not have any complications.
	You and your baby go home 6 days later.
	You have to get daily wound care at home for 2–4 weeks.
	Full physical recovery takes about 6 weeks.
ERCD, transient neonatal complications (transient tachypnea of the newborn)	You choose to have a scheduled C-section.	11	3
	Your baby has difficulty breathing and is admitted to the neonatal intensive care unit for 24 hours.
	Your baby recovers well and you both go home 4 days later.
	Full physical recovery takes about 6 weeks.
ERCD, CD, future complications (accreta with late preterm birth)	You choose to have a scheduled C-section.	12	4
	You and your baby go home 4 days later.
	Full physical recovery takes about 6 weeks.
	Two years later, you decide to have another baby.
	During that pregnancy, you are told that your placenta is covering the birth canal and appears to have grown too deeply into the uterus as a result of your prior C-sections.
	You are told that you are at increased risk of having a premature baby.
	You deliver about 5 weeks before your due date.
	Your baby stays in the hospital for 3 weeks.
	You have a hysterectomy at the time of your delivery because of the placental problem.
	This means that you will not be able to get pregnant in the future.

^a“Pitocin” was used rather than oxytocin as during the development/pretesting of these materials, participants were not all familiar with the generic term.

TOLAC, trial of labor after cesarean; VBAC, vaginal birth after cesarean; CD, cesarean delivery; HIE, hypoxic ischemic encephalopathy.

After calculating the mean TTO utilities for the various scenarios, we used multivariable regression to identify sociodemographic and clinical factors associated with these utilities. Candidate clinical covariates were identified a priori based on the literature^2,13 and our prior study.²² We analyzed factors associated with utility scores by Poisson regression,²³ with one utility as the outcome and with robust standard errors. This approach was used to account for the left-skewed distribution and interpretation of utility scores (clustered near 1.0 for many outcomes). Univariable and multivariable models, therefore, estimated fold effects of candidate covariates on how far less than 1.0, the ideal, the utility tended to fall. A fold effect of 2, for example, indicates a mean utility score that is twice as far from 1 and, therefore, is lower than the value to which it is being compared (e.g., 0.90 vs. 0.95), whereas a fold effect of 0.5 indicates that a mean utility is half as far from 1 and, therefore, has a higher value (e.g., 0.96 vs. 0.92).

We selected a primary multipredictor model by backward selection using a criterion of p ≤ 0.2 for retention and used multiple imputation to handle missing values.²⁴ Statistical significance was set at a p-value ≤0.05. All analyses were performed with SAS version 9.4 (SAS Institute, Cary, NC).

Results

A total of 299 women, with a mean age of 33.2 years (standard deviation ±5.9), enrolled in our study (Table 2). Together, they constituted a geographically (40.0% San Francisco Bay Area, 36.8% Chicago, 22.7% Boston) and racially/ethnically (46.5% white, 10.7% black, 13.4% Asian/Asian American, and 23.1% Latina) diverse sample, mostly married/living with partners (90.2%), receiving prenatal care from an obstetrician (85.8%) and mixed with regard to educational background and insurance status (67.9% were college graduates and 73.8% were privately insured). Regarding their pregnancy histories, as expected based upon the inclusion criteria for the study, most had only one prior delivery, their primary cesarean. A total of 73.7% had labored in the past, and 7.6% had a vaginal delivery before their CD. Indications for prior CD were varied (Table 2).

Table 2.

Sociodemographic and Clinical Characteristics of Study Participants (n = 299)

	N (%) or Mean (±SD)
Recruitment site
San Francisco Bay Area
University of California, San Francisco	61 (20.4%)
California Pacific Medical Center/St. Luke's Hospital, San Francisco	50 (16.7%)
Marin Community Clinic, San Rafael	10 (3.3%)
Chicago
Northwestern University Medical Center	110 (36.8%)
Boston
Massachusetts General Hospital	68 (22.7%)
Age (continuous)
Mean (±SD)	33.2 (±5.9)
Race
White	139 (46.5%)
Latina	69 (23.1%)
Asian/Pacific Islander	40 (13.4%)
Black	32 (10.7%)
Mixed/other/missing	19 (6.4%)
Education
High school graduate or less	49 (16.4%)
Some college	47 (15.7%)
College graduate	203 (67.9%)
Health insurance type
Public insurance	78 (26.2%)
Private insurance/Other	220 (73.8%)
Primary obstetric care provider
Obstetrician	254 (85.8%)
Midwife or family practice physician	42 (14.2%)
Current relationship status
Married or living with a partner	267 (90.2%)
Significantly involved with a partner, but not living together	17 (5.7%)
Single/not significantly involved	12 (4.1%)
Income
≤$50K	75 (26.3%)
>$50K–<$100K	49 (17.2%)
$100K+	161 (56.5%)
Indications for prior cesareana
Active phase arrest	100 (33.4%)
Arrest of descent	69 (23.1%)
Breech	62 (20.7%)
Cesarean delivery on maternal request	3 (1.0%)
Fetal intolerance of labor	101 (33.7%)
Macrosomia	9 (3.0%)
Multiple gestation	7 (2.3%)
Previa	14 (4.7%)
Other	3 (1.0%)
Not sure/do not remember	1 (0.3%)

^aSums to >100% as participants were asked to check all that applied.

SD, standard deviation.

Although a majority (83.6%) of the participants had a stated preference for vaginal delivery if they could be guaranteed an uncomplicated delivery of either type, only 37.8% underwent TOLAC. In general, participants assigned high preference scores (utilities) to scenarios involving an uncomplicated VBAC or ERCD (Table 3). Consistent with the high rate of having a stated preference for vaginal delivery, TOLAC without any interventions or complications received the highest mean utility score (0.984). However, TOLAC augmented by oxytocin resulting in vaginal delivery and TOLAC complicated by uterine rupture without maternal or infant sequelae received lower scores (0.927 and 0.930, respectively), which were similar to the mean score for ERCD without complications (0.931). Both TOLAC complicated by chorioamnionitis requiring antibiotic administration and ending with vaginal delivery (0.918) and TOLAC ending in an uncomplicated CD (0.917) had similarly lower mean values. ERCD with minor surgical complications (0.894) or transient neonatal complications (0.880) were next in order, followed by TOLAC ending in vaginal delivery with a severe perineal laceration (0.851) and ERCD resulting in a future delivery complicated by abnormal placentation (0.831). Not surprisingly, the scenario describing uterine rupture resulting in severe infant complications (hypoxic ischemic encephalopathy [HIE] or infant death) received a substantially lower mean utility score (0.448) than any of the other outcomes.

Table 3.

Time Tradeoff Utilities for the Potential Outcomes of Trial of Labor After Cesarean and Elective Repeat Cesarean Delivery

Outcome	Mean (±SD)
TOLAC outcomes
TOLAC, VBAC, no interventions or complications (assigned a value of 1 when TOLAC is preferred)	0.984 (±0.089)
TOLAC, oxytocin augmentation, VBAC	0.927 (±0.170)
TOLAC, chorioamnionitis, VBAC	0.918 (±0.178)
TOLAC, VBAC, third or fourth degree laceration	0.851 (±0.228)
TOLAC, CD, no complications	0.917 (±0.161)
TOLAC rupture outcomes
TOLAC, rupture, CD with rupture easily repaired	0.930 (±0.135)
TOLAC, rupture, CD, hysterectomy (no infant complications)	0.869 (±0.200)
TOLAC, rupture, CD, severe infant complication (HIE or death)	0.448 (±0.319)
ERCD outcomes
ERCD, no complications (assigned a value of 1 when CD is preferred)	0.931 (±0.145)
ERCD, minor surgical complications (wound complication)	0.894 (±0.184)
ERCD, transient neonatal complications (TTN)	0.880 (±0.199)
ERCD, CD, future complications (accreta with preterm birth)	0.831 (±0.242)

ERCD, elective repeat cesarean delivery.

In multivariable analysis, Latina and Asian race/ethnicity were associated with lower utility scores for oxytocin augmentation and complications related to a future cesarean, and Asian and black race/ethnicity were associated with lower utility scores for severe perineal laceration (Table 4). For example, the adjusted fold effect for Asian race/ethnicity was 2.36 (95% confidence interval [CI] 1.09–5.11), indicating that the mean utility score for oxytocin augmentation among Asian women was about twice as far from 1, the ideal, than the mean utility score obtained from white women. Public insurance was associated with lower utilities for chorioamnionitis during TOLAC and ERCD with minor surgical complications. As might be expected, a stronger preference for TOLAC was associated with a lower utility score for TOLAC resulting in CD and ERCD with minor neonatal complications. Women who did not plan to have additional children assigned a higher utility score to TOLAC resulting in a hysterectomy (adjusted fold effect 0.56 [95% CI 0.37–0.84]), indicating a mean utility about half as far from 1, the ideal, in comparison with women who did plan additional pregnancies. Recruitment site was retained in most of the models and was associated with differences in utilities for the receiving antibiotics during labor and severe neonatal complications, although the site associated with a lower utility differed.

Table 4.

Multivariable Predictors of Utilities for the Outcomes of Trial of Labor After Cesarean and Elective Repeat Cesarean Delivery

Utility	Predictors included in multivariable modela	Type 3 p-value	Multivariable fold effect (95% CI)b
TOLAC, oxytocin augmentation, VBAC	Recruitment site	0.16
	Northwestern		Reference
	UCSF		0.70 (0.31–1.55)
	Massachusetts General		1.19 (0.64–2.22)
	St. Luke's Hospital		1.66 (0.79–3.46)
	Prefer TOLACc	0.16	1.11 (0.96–1.28)
	Race/ethnicity	0.0073
	White		Reference
	Black		1.55 (0.74–3.26)
	Asian		2.36 (1.09–5.11)
	Latina		3.62 (1.89–6.91)
	Mixed/other/missing		0.58 (0.22–1.53)
	Order of presentation—this scenario presented before any other complications of TOLAC or ERCD	0.13	0.69-(0.43–1.09)
TOLAC, chorioamnionitis, VBAC	Recruitment site	0.020
	Northwestern		Reference
	UCSF		0.90 (0.47–1.72)
	Massachusetts General		1.27 (0.72–2.26)
	St. Luke's Hospital		2.67 (1.37–5.19)
	Public Insurance	0.0039	2.35 (1.38–4.01)
TOLAC, VBAC, third or fourth degree laceration	Recruitment site	0.18
	Northwestern		Reference
	UCSF		0.75 (0.44–1.26)
	Massachusetts General		1.29 (0.86–1.92)
	St. Luke's Hospital		1.06 (0.58–1.91)
	Race/ethnicity	0.033
	White		Reference
	Black		1.82 (1.12–2.95)
	Asian		2.55 (1.54–4.21)
	Latina		1.57 (0.89–2.77)
	Mixed/other/missing		1.06 (0.47–2.39)
	Public insurance	0.052	1.67 (1.04–2.69)
	Order of presentation—this scenario presented before uterine rupture or ERCD complications	0.051	0.73 (0.53–1.00)
TOLAC, CD, no complications	Recruitment site	0.055
	Northwestern		Reference
	UCSF		1.05 (0.54–2.05)
	Massachusetts General		1.19 (0.70–2.02)
	St. Luke's Hospital		2.56 (1.33–4.93)
	Prefer TOLAC	0.0059	1.20 (1.06–1.36)
	Race/ethnicity	0.16
	White		Reference
	Black		1.71 (0.90–3.23)
	Asian		2.17 (1.18–4.00)
	Latina		1.67 (0.90–3.11)
	Mixed/other/missing		1.78 (0.79–3.99)
TOLAC, rupture, CD with rupture easily repaired	Recruitment site	0.13
	Northwestern		Reference
	UCSF		1.45 (0.82–2.57)
	Massachusetts General		1.18 (0.72–1.95)
	St. Luke's Hospital		2.61 (1.32–5.16)
	Public insurance	0.14	1.51 (0.89–2.54)
	Order of presentation—this scenario assessed after severe perineal laceration	0.0062	0.55 (0.37–0.81)
TOLAC, rupture, CD, hysterectomy (no infant complications)	Race/ethnicity	0.11
	White		Reference
	Black		0.94 (0.56–1.59)
	Asian		1.88 (1.12–3.16)
	Latina		1.58 (0.95–2.64)
	Mixed/other/missing		0.74 (0.35–1.57)
	Public insurance	0.054	1.58 (0.99–2.53)
	Do not plan to give birth in the future	0.018	0.56 (0.37–0.84)
	Order of presentation—this scenario assessed after severe perineal laceration	0.11	0.77 (0.56–1.06)
TOLAC, rupture, severe infant injury or death	Recruitment site	0.0080
	Northwestern		Reference
	UCSF		1.19 (0.99–1.42)
	Massachusetts General		1.33 (1.13–1.56)
	St. Luke's Hospital		1.11 (0.88–1.39)
ERCD, minor surgical complications	Recruitment site	0.15
	Northwestern		Reference
	UCSF		1.31 (0.73–2.36)
	Massachusetts General		1.46 (0.88–2.44
	St. Luke's Hospital		2.01 (1.08–3.74)
	Prefer TOLAC	0.17	1.07 (0.97–1.18)
	Race/ethnicity	0.17
	White		Reference
	Black		1.60 (0.91–2.83)
	Asian		2.00 (1.18–3.39)
	Latina		1.97 (1.19–3.28)
	Mixed/other/missing		1.81 (0.89–3.68)
	Public insurance	0.050	1.57 (1.02–2.42)
	Order of presentation—this scenario assessed after hysterectomy/severe infant complications	0.0003	0.51 (0.35–0.73)
ERCD, transient neonatal complications	Prefer TOLAC	0.019	1.13 (1.02–1.24)
	Race/ethnicity	0.039
	White		Reference
	Black		1.33 (0.82–2.17)
	Asian		1.91 (1.15–3.18)
	Latina		2.30 (1.39–3.82)
	Mixed/other/missing		0.92 (0.41–2.08)
	Education	0.12
	College graduate/postgraduate		Reference
	Up to high school		1.37 (0.81–2.31)
	Some college		1.69 (1.07–2.66)
	Experienced labor in prior delivery	0.12	1.38 (0.90–2.10)
	Order of presentation—this scenario assessed after hysterectomy/severe infant complications	0.042	0.70 (0.49–0.99)
ERCD, CD, future complications	Age (continuous)	0.048	0.97 (0.93–1.00)
	Prefer TOLAC	0.065	1.09 (0.99–1.19)
	Race/ethnicity	0.0014
	White		Reference
	Black		1.17 (0.64–2.15)
	Asian		2.11 (1.39–3.19)
	Latina		2.12 (1.46–3.07)
	Mixed/other/missing		0.83 (0.40–1.74)
	Order of presentation—this scenario assessed after hysterectomy/severe infant complications	0.016	0.69 (0.50–0.94)

^aCandidate predictors evaluated included recruitment site, age, preferred delivery approach, race/ethnicity, education, health insurance type, prior experience of labor, primary prenatal care provider type, plans for future childbearing, and order of presentation. Primary multipredictor model was chosen by backward selection using a criterion of p ≤ 0.2 for retention. Predictors with p ≤ 0.05 are bolded.

^bFold effect >1 indicates lower utility, farther <1. Fold effect <1 indicates higher utility, closer to 1.

^c1–5 scale, 1 indicates definitely ERCD, 5 indicates definitely TOLAC. Fold effect >1 indicates lower utility, farther <1, per 1 point increase in preference.

CI, confidence interval; UCSF, University of California San Francisco.

We also observed ordering effects for some of the utility scores. Specifically, women who were randomized to assess the scenario describing uterine rupture without complications after the scenario regarding severe perineal laceration (Group 1) scored the former more favorably. Women who assessed the short-term neonatal complications and future complications related to abnormal placentation after the severe maternal and infant complications of uterine rupture (hysterectomy, HIE, or death) scored the short-term neonatal and future delivery complications more favorably (Table 3).

Discussion

Among this group of TOLAC-eligible women, although most would prefer an uncomplicated vaginal delivery if that could be guaranteed, only a minority opted for TOLAC. This discordance can be explained by considering the utilities that women assigned to the scenarios involving minor and major complications of both delivery options: although uncomplicated TOLAC resulting in VBAC and uncomplicated ERCD resulted in high utility values, any alteration in either the process or outcome resulted in substantial utility decrements.

The finding that some scenarios yielded similar utilities despite their seemingly significant clinical differences is also informative, as it appears that women attribute utilities similar to events that may be superficially dissimilar but have other more deeply shared elements. For example, ERCD without complications, TOLAC augmented by oxytocin resulting in vaginal delivery and TOLAC complicated by uterine rupture without maternal or infant sequelae elicited similar utilities (0.931, 0.927, and 0.930, respectively). Although these scenarios are quite different, they all deviate from the hypothetical “ideal” of an uncomplicated vaginal delivery without any interventions, and all result in a healthy mother and infant. The fact that labor augmentation with oxytocin resulting in vaginal delivery is viewed similarly to uncomplicated ERCD or TOLAC complicated by uterine rupture without maternal or infant effects suggests that this group of women who mostly prefer vaginal delivery nonetheless has a negative view of oxytocin, an intervention that might be considered by obstetric providers to be reasonable and consistent with the goal of vaginal birth. Although, as expected, severe infant complications resulted in the most significant utility decrement, scenarios involving even short-term neonatal sequelae (e.g., short-term antibiotics or short-term neonatal respiratory complications) resulted in large utility decrements as well, underscoring the importance of neonatal complications in both counseling and decision-making regarding obstetric care.²⁵ These findings highlight the critical importance of including information regarding both maternal and infant implications in discussions about approach to delivery, and placing both labor interventions and potential complications in context.

In examining factors associated with these utilities, several patterns emerged that also have implications for counseling. First, Asian and Latina race/ethnicity were both associated with lower utilities for oxytocin and for complications related to future cesarean, whereas Asian and black race/ethnicity were associated with lower utilities for severe perineal laceration. Second, public insurance was associated with lower utilities for complications of both TOLAC and ERCD. Although the underlying reasons for these differences are not yet clear, these findings highlight the importance of ensuring opportunities for patients of varying backgrounds to receive patient-centered information regarding processes and outcomes of TOLAC or ERCD. Depending on the population, the shared decision-making process may require more support to ensure the ultimate goal of creating realistic expectations and empowering women to express informed patient preferences.

The impact of the order of presentation of the scenarios also deserves particular attention. We found that participants who evaluated the scenario describing severe infant complications before the short- and long-term neonatal complications of ERCD assessed the latter more favorably than those who assessed these complications first. Although severe infant injury is a devastating outcome that both providers and patients want to avoid, it is also very unlikely; the absolute risk of term neonatal HIE is ∼1 per 1000 women undergoing TOLAC.²⁶ “Safety,” whether conceived as desire for a healthy baby or fear of a bad outcome, is a central issue that has emerged in qualitative studies as determinative of preferred delivery approach; women who have chosen a TOLAC or an ERCD each see their choice as the safer option.^27–30 Our results suggest that if the risk of severe neonatal injury with TOLAC is presented before consideration of other outcomes, women give less weight to the more common potential short- and long-term complications of ERCD.

Several limitations deserve comment. Although the study participants were geographically and racially/ethnically diverse, they reported higher educational attainment and income than the general U.S. population, were primarily partnered, and received prenatal care by obstetricians at academic medical centers. This may have implications for generalizability to all populations. Preferences are known to vary through the course of gestation; we chose to constrain the gestational age of participants to 26–34 weeks to target a timeframe in which preferences should approximate those at delivery, but still before acute peripartum events occur. However, this limits our ability to assess the variation in preferences according to gestational age. Despite these limitations, a significant strength of this study is the large sample size and the focus on TOLAC-eligible women. The participants had a variety of clinical experiences at the time of their prior cesarean, and although most expressed a preference for an uncomplicated vaginal birth, the proportion that ultimately opted for TOLAC, although high in comparison with the national rate, is consistent with the TOLAC rates at the participating institutions. The use of the TTO method of preference elicitation allowed nuanced exploration of women's values for birth processes and outcomes, and the detailed sociodemographic information allowed us to examine factors associated with these preferences.

Conclusions

Although most women who are eligible for TOLAC highly value uncomplicated vaginal birth, common labor interventions or alterations to the hypothetical ideal dampen enthusiasm for this approach. Scenarios that resulted in a healthy mother and baby received similar scores regardless of which processes or outcomes were altered. Scenarios involving neonatal adverse outcomes, whether minor or more severe, generally were assigned lower utility scores, highlighting the importance of placing neonatal and maternal outcomes in context. Race/ethnicity, insurance status, and order of presentation were predictive of several utilities, indicating that these factors may be important to consider when contemplating how best to counsel a diverse population of women regarding approach to delivery after cesarean.

In the course of clinical care, discussion of the risks and benefits of delivery approach after CD is often improvised and driven by the health care provider. As a result, the information exchanged may be highly variable. This study provides important information about how women view the different processes and outcomes of TOLAC and ERCD, as well as the association of sociodemographic characteristics and the way that information is presented with these values. Gaining understanding about what information matters most to women considering TOLAC and ERCD and how this information can be communicated most effectively is an important first step toward designing decision support to optimize patient-centered evidence-based care in the setting of prior CD. These findings underscore the need for evidence-based decision support to help create realistic expectations and incorporate informed patient preferences into decision-making to optimize both clinical outcomes and individual patient experience for women with a prior CD.

Author Disclosure Statement

No competing financial interests exist.