Grant: Travel Awards - Institute Community Support

Repeat caesarean accounts for one-third of all caesareans in Canada. Nonetheless, vaginal birth after caesarean (VBAC) is a safe and healthy option for low-risk women and among those who attempt VBAC approximately 70% will have a vaginal birth as planned. High rates of repeat caesarean may not reflect patients' desire to attempt planned VBAC, due in part to care provider 'misdiagnosis' of patient preferences. One potential solution to promote patients' informed choice is shared decision-making (SDM) with the use of patient decision aids. We sought to identify perceived barriers and facilitators to implementing SDM and a patient decision aid into routine practice for choice of next birth after a caesarean section (NBAC). An online survey was administered in fall 2016 with primary maternity care providers in a health authority in western Canada that has the highest regional caesarean section rate in the country (36.6%, 2014-15). The study was completed in partnership with decision makers conducting a regional quality improvement initiative to implement SDM for NBAC. Respondents (n=93) perceived the key barrier to patient decision aid implementation was health system resources: having limited surgical and anaesthesia services for emergency caesarean to support the option of VBAC. Key facilitators were present included having strong agreement with the appropriateness of SDM for patients considering NBAC (80.6%) and having adequate time to engage in SDM (79.6%). Respondents perceived that the optimal time to begin SDM for NBAC was the early postpartum after the caesarean (66.7%) to facilitate information exchange before women form a preference for NBAC. Our findings suggest that resource and medico-legal concerns may negatively impact the feasibility and acceptability of implementing a decision aid for NBAC in routine workflow. These factors require interventions to support patient decision aid implementation at the provider and and organizational levels.