Birth choices after caesarean in Taiwan: A mixed methods pilot study of a decision aid for shared decision making.

Background: Taiwan has a high national caesarean rate coupled with a low vaginal birth after caesarean (VBAC) rate. Studies suggest that women do not receive sufficient information about birth choices after caesarean in Taiwan and shared decision making (SDM) is not an expectation. This pilot study aimed to test the feasibility of using a birth choices decision aid to improve women's opportunity for engagement in SDM about birth after cesarean.

Methods: A two-phase sequential mixed methods pilot study was conducted in a regional hospital in northern Taiwan. Phase I involved a randomized pre-test and post-test experimental design. Participants with one previous caesarean section (CS) were recruited at 14-24 weeks. A total of 65 women completed a baseline survey and were randomly allocated to either the intervention (birth choice decision aid booklet) or usual care (general maternal health booklet) group. A follow up survey at 37-38 weeks measured change in decisional conflict, knowledge, and birth mode preference. Birth outcomes and satisfaction were assessed one month after birth. Phase II consisted of postnatal interviews with women at one month after birth, to explore women's decision making experiences, using a constant comparative analytic technique and thematic analysis.

Results: Decisional conflict was relatively low at baseline for all women. Although there were reductions in decisional conflict at follow up, differences between groups were not statistically significant. Women's early preferences regarding mode of birth influenced their knowledge-seeking behaviors and expectations or intention for engaging in SDM during pregnancy. Improvements in knowledge for the decision aid group were larger than for the usual care group, although differences between groups were not statistically significant. Four themes related to key factors in decision making were clarity, safety and risk, consistency, and support.

Conclusion: A cultural shift is needed to align expectations and relationships towards SDM for birth in Taiwan. Simulation-based strategies and tailored communication skills should be explored to enhance skills in decision coaching for providers. Use of interactive multimedia technology may provide opportunities to increase engagement with tools and support women during decision consultations. Midwife-led continuity of care models may also be beneficial in empowering women to actively share decisions and achieve the birth that is best for them.