Warner Huh, MD (Host): Hello. This is Dr. Warner Huh, the Chair of Obstetrics and Gynecology at the University of Alabama Birmingham School of Medicine, and I'd like to welcome you to this monthly episode of Women's Health with Dr. Huh.

So today, we have a really unique podcast, and we're going to talk about decision aids for obstetrical care. And with me today are two true experts on this topic including Dr. Allison Shorten, who is the Professor and Department Chair in the School of Nursing including Acute, Chronic and Continuing Care here at UAB. And also, with me is Ann Peralta, who is the Founder and the CEO of Partner to Decide. So, Doctors Shorten and Peralta, welcome to the podcast.

Ann Peralta, DrPH, MPH: Thanks so much for having us.

Allison Shorten, PhD, MSc, RN: It's great to be here.

Host: So, tell me a little bit about Partner to Decide, exactly what is it, how did it come about, and how do you intend for this to be used for the obstetrical community.

Ann Peralta, DrPH, MPH: Yeah. So, Partner to Decide is a nonprofit organization that seeks to improve perinatal care experiences by improving access to shared decision-making on key decisions like we'll talk about today, like induction of labor or vaginal birth after cesarean. This really came to be from my own experience when I was pregnant for the first time. I was a public health doctoral student, and my job focused on empowered decision-making for young people, teenagers helping them think through what would be high quality decisions for them. So, that was the context in which I was pregnant for the first time and went past my due date. And I faced the decision that the tool that I later created covers, which is when there's nothing wrong-- you don't have hypertension, there's no specific reason for an induction of labor-- when do you want to consider induction? When do you want to wait for labor to start on its own?

And in my case, in my own care experiences, the choices I was given were, "Would you like an induction on Tuesday or Wednesday in the 41st week?" And for me, there was no real explanation of. What was an induction and why might I want one or not want one? And to make a really long story short, of course, I was a doctoral student and focused on empowered decision-making. So, I did my own research and came and had a conversation with my care provider about what I understood the research said and what I wanted to do, and I was really respected in my choice to wait for labor. And I went into labor on my own at 41 weeks and six days, a little longer than you might go. If I had chosen Tuesday or Wednesday, I wouldn't have gotten there. And I had a really healthy baby and a very empowering birth experience.

But I reflected on that experience and was always bothered by the fact that I felt like I was so respected in that choice, because I was talking about data from literature that I had read because I was a doctoral student. And I not only had access to those studies, but also had been taught how to read them. And it just didn't feel right that I had to be a doctoral student to access that kind of data and to be presented with a choice.

So, what ultimately I decided to focus on for my dissertation project in school to complete my doctoral studies was to make a decision aid with the goal being that you wouldn't need to be any of my identities, because I had a lot of privileged identities going for me. I was white. I was 31, so I was neither young nor old in the sort of pregnancy sphere. And I was privately insured. I was in a very liberal, progressive city. And so, I didn't want any of those to need to be true for someone to access that same information that I had and understand that there was a choice to make and that it was my choice or their choice.

So, that's how this came about. And I think the way I hope that this tool and others like it are used is I really hope that providers are using them and inviting patients to consume this information, to think about what they care about and to support them in making the choices that are right for them.

I think what makes Partner to Decide tools different from others that already exist are that they're really short. They're written at a sixth grade reading level or below, so they're pretty easy to understand and read. And whenever possible, I translate them into lots of different languages. So, the induction decision aid is currently in eight languages. And to me, patients can use them on their own. Some people find the website or find the decision aid on their own, but I have really heard so deeply and profoundly from patients how meaningful it is to get something like this from a provider. It just feels really profoundly respectful, and it ends up feeling like a really empowering experience.

Host: What are some of the common misconceptions that patients have when it comes to choosing elective induction? And I thought maybe you can comment on how can clinicians address this directly. I know you talk about the decision aid tool, but I thought maybe you could dive a little bit deeper into that topic.

Ann Peralta, DrPH, MPH: Sure. So, I've done lots and lots of interviews with patients facing this decision and using the induction decision aid. And I think a really common thing that people don't tend to understand about induction is that sometimes it's fast and happens quite quickly and labor goes quickly. And other times, it takes a while and can take up to one to three days. And that sometimes it doesn't actually work. So, things like that don't tend to be well understood by sort of an average patient who hasn't heard about those options and differences.

Another thing is sometimes people don't know much about that there are different options for labor inductions. Sometimes they've only heard about, say, Pitocin and don't know that a cervical balloon, for example, exists. And what that is and why that might be used. So, things like that are often unknown for patients.

And I think another thing that I hear from hospitals too is that, at some institutions, scheduling is quite complicated and patients like these where there's no medical reason like hypertension or an elevated concern for the induction, those inductions sometimes get moved around schedule-wise. And that's another thing, I would say-- the misconceptions being "It'll happen exactly when it's scheduled" and "I'll have my baby that day"-- are some of the sort of assumptions that sometimes patients make. And I think this is where clinicians spending the time to not have a, "Do you want an induction on Tuesday or Wednesday?" And really, talking about what are these options? What are the pros and cons and what you can expect if you choose one of these options or another? Like, what does that mean? If you don't have an induction by 41 weeks, for example, we'll offer extra visits to check on you and the baby. These are things that you can set up expectations so that whether they're walking into an induction or not, they're really prepared for what the plan is to go forward.

I know I talked to a lot of labor and delivery nurses who are very eager for this decision aid to be used, because they often find people coming in for inductions, but they don't really have a sense of what that means and what's going to happen.

Host: Your answer is so spot on. Although I don't do Obstetrics anymore, I think one of our greatest dissatisfiers are when the induction gets delayed or rescheduled entirely because of resource issues, space issues, we don't have enough nursing staff, et cetera. And I think that there's a lot of breakdown in terms of the understanding of that elective induction. And so, like what you say, it's like something that we deal with almost on a very regular basis. I think a lot of education goes a long way. And I know, like you said, our labor and delivery nurses would very much embrace this kind of tool.

 So Dr. Shorten, I don't know if you have any additional thoughts on that, but I just could be curious to hear what you think about how this engages both the patient as well as the obstetrician in terms of deciding when and if to do elective induction and just that overall decision-making process. I just didn't know if you had additional thoughts on that.

Allison Shorten, PhD, MSc, RN: Yeah, the decision aids are really about helping get everyone on the same page. We want to make sure that everyone has access to the same, up-to-date and balanced facts. And decision aids are a way of preparing patients for those discussions and also guiding that discussion with their provider. So, it helps both the patient and the provider to go over those facts. They're based on current research, and they're presented in a way that is easy for everyone to understand.

So for the clinician, it's really the best way to provide that consistent information about decision options, and to ensure that that decision discussion is a really high-quality decision discussion. But it also improves the opportunity for patients to talk about what's important for them and to process that information about the pros and cons of their different options and for them to come together and to make a decision together. Because really, the decision aids are about shared decision-making, so that means everyone's on the same team. And preparing someone to have the knowledge at their fingertips, to be able to have that discussion with their provider and to feel confident that they understand what the induction will mean for them personally and for the provider to understand what's important for the patient and how a positive experience would take place if an induction does take place. Whereas Anne had said, you know what, if things don't go exactly as planned and how's that going to work out? So, the decision aids set really important point of guidance so that everyone is walked through that decision in a way that they're confident that the decision is what's best for everybody.

Host: Dr. Peralta, I don't know if you have anything further you want to add to that?

Ann Peralta, DrPH, MPH: Sure. I would just add that we know really clearly from some really high quality recent studies that the vast majority of pregnant women and other birthing people in the U.S. want to lead decisions about their bodies and their babies, but they're also eager for partnership and support from trusted care providers.

And I think decision aids really support that actually happening. So in all of our national guidelines from the American College of Obstetricians and Gynecologists, from the American Certified Nurse Midwives Association from all of these entities, all of them call for shared decision-making on this topic. But there's sort of a gap between what the guidelines call for and all of, I believe, everyone's really good intentions to be doing this. But it's hard in 15-minute visits to cover complex information about options in a really digestible and easy to understand way. And as Allison said, to get everyone on the same page, it feels really different. It was my good experience to end up feeling supported and respected in the choice that I made not to get an induction for gestational timing. But other people without these decision aids sometimes feel like, when they don't want an induction, sometimes they feel like they're being told, "Well, you're risking the life of your baby." And sometimes when they do want an induction, they feel judged or not on the same page with their provider, right? We have all kinds of providers with different ideas, views, and biases around induction timing. And similarly, we have really diverse ideas, preferences, wishes on patients. So, the decision aid really gets you on the same page talking about the same data including the data of what's important to this person in addition to why would we even do this intervention, what do we know from studies and research and best practice.

Host: Okay. So, I want to pivot to a different topic that is complicated and that the topic is on vaginal birth after cesarean delivery. And so, for our listeners, we're talking about the scenario in which a patient who's had a prior cesarean section is now pregnant again, and they're entertaining the possibility of having a vaginal birth after having a prior cesarean delivery. We call it VBAC for short in the medical world. And the decision to do that is literally quite complex. And it involves thinking about multiple different scenarios, and sometimes those scenarios can be difficult to explain.

Can one of you just talk about the considerations patients typically face when they're making this choice? And what role does advanced planning play in helping decide whether patients do VBAC and how to providers guide patients through these hypothetical situations? I would love to hear from one or both of you your thoughts on that.

Allison Shorten, PhD, MSc, RN: Well, firstly, it's important to consider that most women who plan a VBAC with their providers and are well-supported in that plan can achieve a vaginal birth. And in fact, the research tells us around 70% or seven out of 10 women who try VBAC will be successful with that. But it is a complex decision, and there are many things that patients will be thinking about.

Of course, there are the medical risks and benefits of each choice. But often, there are many other considerations too. So, for example, some people will feel like a planned repeat cesarean is a plan where they know exactly what to expect. They like the ability to know the date the baby will be born and when that will happen, and maybe they don't plan to have more children after this.

 So for some, those possible risks of having multiple cesareans aren't really something they're thinking about. But others will want to actually experience the vaginal birth, perhaps they want a faster recovery after the birth, and maybe they do want to have more children after this, and to reduce those possible risks of multiple cesareans. So, thinking through those different elements and considering recovery time, impact on the future pregnancies, and that ability to plan in advance and figuring out which ones are the most important, which can help women and their providers make high quality decisions that are right for them.

And women also want to know about what each choice will be like. So, they want to know about what their options would be for pain relief in a planned VBAC and whether they can move around in labor and the chance of complications that might happen, and if they might need a cesarean during the labor. So, they're going to want to know how clinicians will monitor the labor to identify if things are not going to plan. So, it's important to go over all of those elements depending on which of those is most important to the person making that choice.

And research tells us that although there can be serious complications, the chances of those really serious complications in VBAC or in a planned repeat cesarean, and they're generally small, but there's a chance of complications in any birth. So, it is important that women and clinicians go over the facts. They share this decision and plan the birth together. And decision aids really help walk patients and providers through those possibilities and help them to understand those options and weigh up those pros and cons and some of the what-ifs and have a conversation about the chance of success for them to ultimately make a decision, because that's another part as well. There's the, "I can say around seven out of 10 I would be successful." But of course, the person's thinking, "What's my chance of success? What will my experience be like?" And so, the decision aids are an opportunity to go over the common things that could occur, but then to have a conversation about what's important to the person having that experience.

Host: So, I have to ask when I hear about these decision aids and some of the complexity related to decisions that are made between the patient and the provider, this issue of health literacy. And to our listeners, what I mean by that is their understanding of the medical information that's being provided and whether that clicks for them. I'd be very curious to kind of hear your thoughts on the element of health literacy as it relates to these decision aids.

Ann Peralta, DrPH, MPH: The Partner to Decide tools, the induction one that already exists and the one Allison and I are working on, a version of other decision aids she's already made, it is specifically designed so that you don't have to have high health literacy in order to understand these options and the risks and benefits. And I would argue it's way better than any, like, consent form I've ever seen.

There's also the issue we could talk about of not everyone is an oral learner, right? So even if you have a really great verbal conversation in a prenatal care visit, personally, I am not much of a verbal-only learner. So, I might remember some of that, but I'm not going to be able to tell my husband when I get home exact, like, every single thing that you told me. So, I think, for me, yes there is data in here, but there is a accompanying charts and we use best practices on how you portray data so that it's most easily understood by the most people.

Allison Shorten, PhD, MSc, RN: I would agree with that. It's important when designing decision aids and we spend a lot of time in our design of decision aids to get input from the people that are going to be using them. And so, we do make sure that the language is at a level that is really easy to understand. We're translating from research findings sometimes, or statistics and studies, and we're packaging that information in a way that's easy to go through sequentially.

As Anne said, we have pictographs and visual representation of outcomes, and we spend a lot of time figuring out what the best pictographs are, and which ones help patients understand the information we're trying to convey. And also, if you're moving beyond paper-based tools, and there are electronic decision aids out there, we have audio recordings and some have videos of course, too. So, we understand that everyone learns differently. So, there's options according to how people learn best built into decision aids when we develop them. And that's so important to have that as a resource. And as Anne mentioned, her decision aids have been translated into other languages, and I've had some of my decision aids translated into other languages as well to increase the access to these tools, and that's another important part in our health literacy.

Host: So, can you guys share any specific success stories or data demonstrating how these decision aids have improved patient outcomes or satisfaction? And I just am curious, and I'm not trying to be a naysayer here, are you sure that this doesn't make it just simply harder for patients and providers to make decisions and engage in this process of shared decision-making?

Allison Shorten, PhD, MSc, RN: It's a great question. And it makes it much easier. I will say that it makes much easier for patients and providers to work through these decisions, because knowing what our patients need and really want to experience with the birth and supporting them to put those plans in place can really improve the birth experience and satisfaction, which also helps how women feel after the baby's born. And we know that decision aids can help us to achieve those things, and we have found consistently that decision aids improve knowledge about options and can significantly reduce what we call decision conflict, which is when we have someone struggling to make a choice because they don't feel informed enough or they don't feel supported in their choice.

So, decision aids can reduce that decision conflict and increase confidence in the decision. And in my work, I've had patients say, "Thank you. This decision aid helped me explain to my doctor exactly what I wanted," and that they felt at peace with their decision. And that word feeling at peace comes up quite a bit, and their decision aid empowered them to have a voice and express to their provider what type of birth they really wanted.

So, patients who use decision aids will recommend them to others. And when we ask them that question, they consistently say, "Yes. I know someone with a similar decision point that they would recommended the decision aid because it improved their satisfaction," as long as the patients are able to follow through with the decisions they make and feel supported once their plans are in place. And so when it comes to birth after cesarean and if someone's choosing to plan a VBAC and they actually get the experience they were hoping for, they will be happy with that. But if someone wants a planned cesarean and they have a positive cesarean experience, they'll be happy with that choice. So, it's not really surprising because we all like things to go as planned.

So, that's an important element that, as long as patients are able to follow through with the plan, that will increase the chances that they'll feel satisfied with that. And ultimately, when decision aids are a regular part of pregnancy care and they're integrated into the flow of care, it also supports providers because they can talk through those important decisions together. It's just a part of how care is provided, and it helps them to be more consistent with the information they're providing to all of their patients. They can share up-to-date evidence, weigh up things as they make those plans. And that's why we use the term shared decision-making, because it's really about patients and providers working together as a team.

And the decision aids help the patient feel informed, but also to know that someone's listening to them and hearing the things they value and what's important to them. And it helps providers share important data from their perspective and information about the options and what that might be, and then invite the patients to make a decision about a topic that's really important with their support together. So, the shared decision-making part of it is really high quality care, and that's what we all want for our patients.

Host: Excellent. All right. Before we close out the podcast, Dr. Shorten and Dr. Peralta, I don't know if you have any closing comments or thoughts.

Ann Peralta, DrPH, MPH: Additional things that we didn't cover in other questions, I think one is that my experience is that without a decision aid on something like induction of labor options, that patients just don't generally understand the full range of options, and it also focuses them on specific pros and cons and evidence, right? Otherwise, it's pretty overwhelming to look up these things on the internet, right? There's major rabbit holes you can go down on the internet, reading information and wondering what information is really valid and true and what information isn't. So, patients really appreciate that too, getting really trusted information from their provider.

And then, the other thing I'll say about the benefits to providers is two things. One is what I heard loud and clear from providers implementing this decision aid was that it increased the consistency and quality of their care. So, they really started reflecting on the fact that without a consistent process for when to have this conversation and using a tool like this to have the same type of conversation with the same content in the same way with all of their patients, they realized that before they were doing that, there were really wide variations in how they were having that conversation with some people. Some people were bringing it up, other people were not. And things like that were affecting whether they even talked about it with someone, whether something was a choice for someone because they brought it up and asked about it and thought it was a choice, or if they were just ending up with a situation, like my own experience of, you know, here we are at the induction due on Tuesday or Wednesday.

And then, the second thing is that when you properly inform and engage a patient in a decision like VBAC or induction and any other major decision like this, you then get a prepared and engaged patient, right? We gave that example of you don't have patients showing up on the Labor and Delivery floor for an induction having no idea what the process looks like, right? You don't have them learning for the first time as they sign an informed consent form about any of these major interventions, the pros and cons, the risks that they have to now sign that they understand. When you've had that conversation before, you save a lot of time in the long run. So, someone might say, "Ugh, if I just schedule Tuesday or Wednesday, that's a very quick conversation. My colleagues that I work with that I know used the decision aid. They say they can use it in two minutes." That's not very much time. Of course, it took them more time than that when they started using it. But it gets very efficient, and then you save lots of time when you don't have to have a much longer conversation when someone comes in for, say, an induction of labor, not knowing what to expect, and then you have to have the conversation then.

Allison Shorten, PhD, MSc, RN: Following on from that, it's important that when our patients make decisions and make plans that it's a shared decision, that we're able to follow through with that within reason. If there's other complications and things come into play, we know that things can change. So that's another part of it, depending on when the decision aid is used and when a decision is made. And that it is documented in the record that this is the preference or this is the choice, but it's important to be prepared to support the choice and follow through with that. And when someone has made the decision, for example, to plan a VBAC goes into labor, that the providers are aware of what's important to that person in that experience, that that's documented in the medical record, that is a genuine opportunity to try to achieve a VBAC if that's what has been decided.

And in the same way, if someone has decided for a planned cesarean, to make that the most positive experience it can be. Because when you have a scenario such as making choices for birth after previous cesarean, you have that previous birth experience there to consider. So, this next birth after previous cesarean is really important for the health and wellbeing of mothers and families going forward.

So when I mentioned satisfaction and having the experience someone was hoping for, it's important for providers to be aware of the reasons behind the decision, what's expected in that experience, and to do everything they can to support that choice.

Host: Thank you. I really appreciate the response from both of you. Again, for someone that doesn't practice obstetrics actively, this is a highly enlightening conversation. And I'm actually thinking about-- I know this goes well beyond the scope of the podcast-- but how these decision aids can be extended to other aspects of women's health, including in gynecology and GYN-oncology. But maybe you guys can take that conversation offline at some point.

 Anyway, I want to thank both of you for participating in this and talking about decision aids for obstetrical care. It. This was an amazing podcast. And again, to our listeners as always, please rate this podcast and we welcome any comments, particularly on topics that you are interested in. And for more information on women's health services, particularly as obstetrical services at UAB Medicine, please check out uabmedicine.org. But until next time, thank you again. My gratitude to both Dr. Shorten and Dr. Peralta for their expertise. And I hope you all have a great day. Take care and peace out.

Ann Peralta, DrPH, MPH: Thank you so much for having us.

Allison Shorten, PhD, MSc, RN: Thanks so much for the opportunity to talk about decision aids.