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Trial of labour or elective repeat caesarean delivery:are women making an informed decision at Kenyatta national hospital?

ABSTRACT: Trial of labour is a safe option for most women after one previous caesarean delivery. However, the proportion of women attempting trial of labour after previous caesarean delivery (TOLAC) has been declining in many countries. In addition, women with prior caesarean delivery appear to know little regarding their mode of delivery and healthcare providers' recommendations. The doctors' preferences exert a strong influence on patient's decision whether or not to pursue TOLAC. In Kenya, it is unclear whether women who opt for trial of labour after caesarean delivery (TOLAC) or elective repeat caesarean delivery (ERCD) do that based on clear understanding of risks and benefits of both modes of delivery. This study aimed at determining whether patients with one previous caesarean delivery make an informed decision on preferred mode of delivery following their interactions with doctors.A cross-sectional descriptive study was carried out on 202 pregnant women with one previous caesarean delivery at Kenyatta National Hospital (KNH) antenatal clinic. Data was collected from both the patients' records and women were interviewed using a structured questionnaire.Out of 202 women with mean age of 30.2 years 136 (67.2%) chose Elective Repeat Caesarean Delivery (ERCD), while 66 (32.8%) opted for TOLAC. Only 61/202 (30.6%; 95% C.I: 24.4 to 37.6%) made informed decisions. Few women (65: 32.2%) knew that the chance of successful TOLAC was high (60-80%) and 97 (48%) were not aware of the chances for a successful TOLAC. More than half of the women (109: 53.9%) were unaware of the risk of uterine rupture after one previous delivery and only few patients (64: 31.7%) knew that the risk of uterine rupture in TOLAC is low (< 1%). The majority of the women (112: 55.4%) did not know that the indications for previous caesarean delivery are an important factor in determining the chance of a successful Vaginal Birth after Caesarean Delivery (VBAC). For 47(23.3%) of the women, there was no documented indication for the previous caesarean delivery. The women's mode of delivery was significantly associated with the preference of the counseling doctor (p < 0.001) and their qualification (p = 0.020). Only 23 (11.4%) women signed the consent form for ERCD while none of the women for TOLAC signed any consent form.There was an overall lack of information on both modes of delivery while doctor's preferences affected women's decisions. Only just under one third of the women made an informed decision. There is a need to develop clear standard protocols and checklists for information to be disseminated to doctors and all patients with previous caesarean deliveries in subsequent pregnancies in Kenya.

SUBMITTER: Biraboneye S P

PROVIDER: S-EPMC5558758 | biostudies-other | 2017 Aug

REPOSITORIES: biostudies-other

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Project description:BackgroundElective repeat caesarean delivery (ERCD) rates have been increasing worldwide, thus prompting obstetric discourse on the risks and benefits for the mother and infant. Yet, these increasing rates also have major economic implications for the health care system. Given the dearth of information on the cost-effectiveness related to mode of delivery, the aim of this paper was to perform an economic evaluation on the costs and short-term maternal health consequences associated with a trial of labour after one previous caesarean delivery compared with ERCD for low risk women in Ireland.MethodsUsing a decision analytic model, a cost-effectiveness analysis (CEA) was performed where the measure of health gain was quality-adjusted life years (QALYs) over a six-week time horizon. A review of international literature was conducted to derive representative estimates of adverse maternal health outcomes following a trial of labour after caesarean (TOLAC) and ERCD. Delivery/procedure costs derived from primary data collection and combined both "bottom-up" and "top-down" costing estimations.ResultsMaternal morbidities emerged in twice as many cases in the TOLAC group than the ERCD group. However, a TOLAC was found to be the most-effective method of delivery because it was substantially less expensive than ERCD (€ 1,835.06 versus € 4,039.87 per women, respectively), and QALYs were modestly higher (0.84 versus 0.70). Our findings were supported by probabilistic sensitivity analysis.ConclusionsClinicians need to be well informed of the benefits and risks of TOLAC among low risk women. Ideally, clinician-patient discourse would address differences in length of hospital stay and postpartum recovery time. While it is premature advocate a policy of TOLAC across maternity units, the results of the study prompt further analysis and repeat iterations, encouraging future studies to synthesis previous research and new and relevant evidence under a single comprehensive decision model.

Project description:ObjectiveThe attempt of a woman to deliver vaginally after having had a caesarean in a previous pregnancy is increasingly common in current obstetric practice. During a trial of labour after caesarean, gynaecologists consider whether continuing vaginal birth is safe or, alternately, whether a repeat caesarean is advised. There is large variation in the success rates of women with comparable medical risk factors, requiring better insight in how this assessment is made. As a window of opportunity to intervene in this unexplained variation in practice in specific, and in the globally rising caesarean rate in general, our aim was to increase understanding of gynaecologists' decision-making during trial of labour.Study designWe conducted a constructivist grounded theory study, interviewing Dutch gynaecologists. Data collection and analysis were performed concurrently. Initial convenience sampling shifted to theoretical sampling as the study progressed. Data collection continued until theoretical sufficiency was reached. We applied open and axial codes to transcripts of the interviews, and then assembled the axial codes into themes that built up to an emerging theoretical framework.ResultsNine gynaecologists were interviewed. Data indicated they continuously weighed the chance of a successful outcome of trial of labour against the likelihood of adversities. Patients' opinions, aspects of progress of labour and gynaecologists' personal stances regarding trial of labour played a role in the decision-making process; these factors are influenced by organisational affordances and culture. Variation in the assessment of individuals' chances of success and variable thresholds for a repeat caesarean added to the complexity of the decision-making.ConclusionThis study pieced together patient-, delivery-, physician- and society-related factors that result in vitally important decisions during trial of labour after caesarean; it reveals the complexity as well as the repetitive patterns involved in this process. Exposing these factors offers opportunities to incorporate the decision-making process in targeted educational interventions, with the aim of modifying the underlying assumptions and concepts in order to reduce practice variation.

Project description:BackgroundThe OptiBIRTH study incorporates a multicentre cluster randomised trial in 15 hospital sites across three European countries. The trial was designed to test a complex intervention aimed at improving vaginal birth after caesarean section (VBAC) rates through increasing women's involvement in their care. Prior to developing a robust standardised model to conduct the health economic analysis, an analysis of a hypothetical cohort was performed to estimate the costs and health effects of VBAC compared to elective repeat caesarean delivery (ERCD) for low-risk women in four European countries.MethodsA decision-analytic model was developed to estimate the costs and the health effects, measured using Quality Adjusted Life Years (QALYs), of VBAC compared with ERCD. A cost-effectiveness analysis for the period from confirmation of pregnancy to 6 weeks postpartum was performed for short-term consequences and during lifetime for long-term consequences, based on a hypothetical cohort of 100,000 pregnant women in each of four different countries; Belgium, Germany, Ireland and Italy. A societal perspective was adopted. Where possible, transition probabilities, costs and health effects were adapted from national data obtained from the respective countries. Country-specific thresholds were used to determine the cost-effectiveness of VBAC compared to ERCD. Deterministic and probabilistic sensitivity analyses were conducted to examine the uncertainty of model assumptions.ResultsWithin a 6-week time horizon, VBAC resulted in a reduction in costs, ranging from €3,334,052 (Germany) to €66,162,379 (Ireland), and gains in QALYs ranging from 6399 (Italy) to 7561 (Germany) per 100,000 women birthing in each country. Compared to ERCD, VBAC is the dominant strategy in all four countries. Applying a lifetime horizon, VBAC is dominant compared to ERCD in all countries except for Germany (probabilistic analysis, ICER: €8609/QALY). In conclusion, compared to ERCD, VBAC remains cost-effective when using a lifetime time.ConclusionsIn all four countries, VBAC was cost-effective compared to ERCD for low-risk women. This is important for health service managers, economists and policy makers concerned with maximising health benefits within limited and constrained resources.

Project description:BackgroundPublic health professionals are increasingly expected to engage in evidence-informed decision making to inform practice and policy decisions. Evidence-informed decision making involves the use of research evidence along with expertise, existing public health resources, knowledge about community health issues, the local context and community, and the political climate. The National Collaborating Centre for Methods and Tools has identified a seven step process for evidence-informed decision making. Tools have been developed to support public health professionals as they work through each of these steps. This paper provides an overview of tools used in three Canadian public health departments involved in a study to develop capacity for evidence-informed decision making.MethodsAs part of a knowledge translation and exchange intervention, a Knowledge Broker worked with public health professionals to identify and apply tools for use with each of the steps of evidence-informed decision making. The Knowledge Broker maintained a reflective journal and interviews were conducted with a purposive sample of decision makers and public health professionals. This paper presents qualitative analysis of the perceived usefulness and usability of the tools.ResultsTools were used in the health departments to assist in: question identification and clarification; searching for the best available research evidence; assessing the research evidence for quality through critical appraisal; deciphering the 'actionable message(s)' from the research evidence; tailoring messages to the local context to ensure their relevance and suitability; deciding whether and planning how to implement research evidence in the local context; and evaluating the effectiveness of implementation efforts. Decision makers provided descriptions of how the tools were used within the health departments and made suggestions for improvement. Overall, the tools were perceived as valuable for advancing and sustaining evidence-informed decision making.ConclusionTools are available to support the process of evidence-informed decision making among public health professionals. The usability and usefulness of these tools for advancing and sustaining evidence-informed decision making are discussed, including recommendations for the tools' application in other public health settings beyond this study. Knowledge and awareness of these tools may assist other health professionals in their efforts to implement evidence-informed practice.

Project description:BackgroundHealth insurance enrollment is a difficult financial decision with large health impacts. Challenges such as low health insurance literacy and lack of knowledge about choosing a plan further complicate this decision-making process. Therefore, to support consumers in their choice of a health insurance plan, it is essential to understand how individuals go about making this decision.ObjectiveThis study aims to understand the sources of information used by individuals to support their employer-provided health insurance enrollment decisions. It seeks to describe how individual descriptive factors lead to choosing a particular type of information source.MethodsAn introduction was presented on health insurance plan selection and the sources of information used to support these decisions from the 1980s to the present. Subsequently, an electronic survey of 151 full-time faculty and staff members was conducted. The survey consisted of four sections: demographics, sources of information, health insurance literacy, and technology acceptance. Descriptive statistics were used to show the demographic characteristics of the 126 eligible respondents and to study the response behaviors in the remaining survey sections. Proportion data analysis was performed using the Cochran-Armitage trend test to understand the strength of the association between our variables and the types of sources used by the respondents.ResultsIn terms of demographics, most of the respondents were women (103/126, 81.7%), represented a small household (1-2 persons; 87/126, 69%), and used their insurance 3-12 times a year (52/126, 41.3%). They assessed themselves as having moderate to high health insurance literacy and high acceptance of technology. The most selected and top-ranked sources were Official employer or state websites and Official Human Resources Virtual Benefits Counselor Alex. From our data analysis, we found that the use of official primary sources was constant across age groups and health insurance use groups. Meanwhile, the use of friends or family as a primary source slightly decreased as age and use increased.ConclusionsIn this exploratory study, we identified the main sources of health insurance information among full-time employees from a large state university and found that most of the respondents needed 2-3 sources to gather all the information that they desired. We also studied and identified the relationships between individual factors (such as age, gender, and literacy) and 2 dependent variables on the types of primary sources of information. We encountered several limitations, which will be addressed in future studies.

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Trial of labour or elective repeat caesarean delivery:are women making an informed decision at Kenyatta national hospital?

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