# Implementation of a decision aid to promote shared decision-making on mode of birth in low-risk pregnant women: a cross-sectional study within the QUALI-DEC hybrid trial

## TL;DR

A decision aid tool helped low-risk pregnant women make informed choices about their mode of birth, improving communication and satisfaction in four low- and middle-income countries.

## Contribution

Demonstrates the effectiveness of a decision aid in promoting shared decision-making in maternity care in low- and middle-income settings.

## Key findings

- DAT users were more likely to identify risks/benefits of each mode of birth and communicate their preferences.
- DAT users were less likely to prefer caesarean section and reported higher satisfaction with their birth experience.
- Use of the DAT was associated with improved knowledge and no adverse outcomes.

## Abstract

Implementing shared decision-making (SDM) in maternity care remains challenging in low-income and middle-income countries (LMICs). Decision aids can support SDM, but evidence on their effectiveness in such settings is limited. We assessed the impact of a decision analysis tool (DAT) for pregnant women on mode of birth (MOB) within the QUALIty DECision-making project, a multisite, multicountry pragmatic trial to reduce unnecessary caesarean sections.

We conducted a cross-sectional survey among postpartum women considered at low risk for caesarean section in early pregnancy and who delivered in 32 hospitals across Argentina, Burkina Faso, Thailand and Viet Nam. Associations between DAT exposure and selected outcomes were analysed using multilevel, multivariate regression models adjusting for confounders and cluster effects.

Of 2368 women included, 249 (11%) had used it outside antenatal care visits, 212 (9%) had heard of but not used it, and 1907 (80%) had never heard of the DAT. Compared with women who had never heard of the DAT, users were more likely to identify at least three risks/benefits of each MOB (adjusted OR (aOR) 1.9; 95% CI 1.3 to 2.8; p=0.001) and to communicate their preferred MOB to providers (aOR 2.3; 95% CI 1.5 to 3.6; p<0.001). DAT users were less likely to prefer caesarean section in late pregnancy (aOR 0.4; 95% CI 0.2 to 0.8; p=0.006) and reported higher birth experience and satisfaction scores (adjusted β=1.9; 95% CI 0.5 to 3.3; p=0.006).

The use of the DAT was associated with improved knowledge, communication of birth preferences, lower caesarean preference and greater satisfaction, without adverse outcomes. Findings suggest that decision aids can strengthen SDM and promote respectful, women-centred maternity care in LMICs.

ISRCTN67214403