 Right. So this meeting is being recorded. Today we have Courtney. Courtney Massarado. She is a certified nurse midwife at Boston Medical Center and a clinical instructor of obstetrics and gynecology at Boston University School of Medicine. She received her MPH with a focus on international maternal child health from Thuland University School of Public Health and Tropical Medicine. She completed her RN certificate and Mass of Science in Nursing with certification as both as a certified nurse midwife and family nurse practitioner at the Vanderbilt University School of Nursing. She has been providing full scope midwifery care at Boston Medical Center and an affiliated community health center since 2014. She is also one of the main providers at Boston Medical Center Refugees Women's Health Center. She has worked internationally in Africa, Asia and the Caribbean and her area of interest is global maternal health. Today Courtney will be sharing with us part of her study that she has been doing um entitled share decision making for women's choices above mode of birth about a previous caesarean section patient and provider perspective. Ladies and gentlemen, help me welcome Courtney Massarado. Thank you. Courtney, you can go ahead. Great. Well thank you Cynthia for that kind introduction. So as Cynthia said, I'm going to talk today about shared decision making from women's choices about mode of birth after a previous c-section and we're going to go over some background information about that and then get into a study that a colleague of mine and I have conducted at Boston Medical Center looking at both a patient and provider perspective of shared decision making. So I have no financial disclosures. The objectives of the talk today are include to define and review key terminology related to caesareans and mode of birth options after c-sections. Also to discuss shared decision making and decision tools and to examine new data about mode of birth about birth counseling tools and mode of birth delivering choices. So as far as the current state of delivery goes, overall caesarean deliveries have been increasing over the past 20 years. So there has been a great effort to work to decrease those rates. The World Health Organization has recently published a position statement urging providers to perform c-sections only when medically necessary and they are one of many organizations that have urged providers to do so. Globally from 1990 to 2014, 18.6% of all births were c-sections. And in the United States, in 2014, excuse me, the c-section rate was 32.2. Yesterday just told me that 2015 data came out and that the c-section rate in the United States was 32.0. And so this, although 32% is higher than I would like or many midwives I think in the United States would like and higher than many places around the world, it is a decline and it's the lowest rate since 2007. And so all of these efforts to decrease caesarean rates, all efforts to decrease caesarean rates are important. Those to decrease primary caesarean rates are vital as women who haven't had a primary c-section don't have to have any question about a mode of birth option with their next delivery. And efforts to repeat caesarean rates are important as women who are able to have a labor after c-section or have a vaginal birth after c-section then are decreasing those repeat caesarean rates. And then a little information about the vaginal birth after caesarean rates. So in the United States the VBAC rate has slowly been increasing in 2015 it was 11.9 and this is from a low of 2007 where our rate was 8.3 but unfortunately below our high of 28.3 in 1996. And this slow increase in the VBAC rate may be due in part to a 2010 NIH and ACOG recommendation that most women with a previous c-section, a previous low transfer c-section should be considered a candidate for a laboring after c-section. And these statements really help to provide to encourage providers in hospitals that more women than originally thought could actually have a vaginal birth after c-section. And so after ACOG's announcement the need for improved decision counseling in the context of shared decision making, in the context of a shared decision making framework really gained importance and it was acknowledged that women needed effective strategies to support their mode of birth decision making. While also it was acknowledged that you know many OBs, many midwives have a very busy practice and trying to work on balancing that counseling with patients but also being able to see enough patients in a day can be very difficult. So one of the ways that this adequate counseling can be done is through shared decision making and shared decision making. The ultimate goal of shared decision making is for providers and women to make an informed decision together. And shared decision making really is involves a bi-directional flow. You can see the diagram up at the top. There's the providers and the patients are working together in partnership to make decisions. And shared decision making developed largely in reaction to the paternalistic model which was used previously where providers would say this is you know the treatment that you need to have and not really involving patients in those decisions. But shared decision making really emphasizes the interaction between patients and providers and allows both to have a voice within those decisions. And shared decision making has been shown to improve health outcomes, enhance communication between patients and providers, increase patients overall satisfaction, and for pregnant women give them an increased sense of responsibility about their health and the health of their babies. And shared decision making has been shown or excuse me decision aids have been shown to be helpful with providers to help them make shared decision making decisions with their patients. So as far as shared decision making in the context of motive birth after cesarean that involves giving women balanced evidence based information about the risks and benefits of each option. So about having a trying to have a labor after c-section or trying or having an elective repeat cesarean birth. It also involves giving women the opportunities to share personal stories, values, preferences, and the beliefs about their motive birth. And from a counseling point of view it involves for providers providing supportive, interactional, individualized counseling that allows women to weigh their options and work with their provider to decide on their preferred motive birth. And so decision aids as I just mentioned have been shown to help with shared decision making. And decision aids are materials designed to help patients make informed judgments about a treatment or procedure when there are multiple options available and when the options don't have a clear advantage or when each has risks and benefits that may be valued differently. And they're not designed to advise patients to choose one option or another nor are they meant to replace discussions with health care providers. But they seek really to prepare patients to make informed value based decisions with their providers. And as you can see in the illustration we have our patient who is trying to make a decision. Do I go straight? Do I go left? Do I go right? And the decision aid is really trying to help the patient have a better sense of how to make that decision in conjunction with discussion with their provider. So some literature review about motive birth counseling particularly in light of using decision aids. Shortens 2005 randomized control trial concluded that women who received a decision aid demonstrated a significantly higher increase in mean knowledge scores than those in the control group. And those women also had a decrease in their decisional conflict scores. Though the aids did not significantly affect their motive delivery choices. And Shortens article was kind of a landmark article for the world of VBAC counseling and VBAC decision aid research. And it was actually the first VBAC counseling tool that was accepted within the Ottawa Decision Aid group. And in 2013 there was a Cochrane review that found that decision aids reduced decisional conflict and improved women's knowledge about motive birth options. Though again they had no impact on motive birth choices. And Chinkum's 2016 study uses scripted counseling interventions and decision aids for midwives to use with patients and found that although the tools did not influence the motive birth type, they helped to follow through on their motive birth decisions. And actually Sampit Chinkum, the author of that 2016 study is a colleague of mine who works at Boston Medical Center. And so this literature or the research excuse me that I'm going to talk to you about in a couple in the next slide really builds on that study that she did and was kind of the basis of our research. So as I was saying this study that I'm going to talk to you about today it was a quantitative pilot study. And it built on Sampit Chinkum's previous study and building from it we work to develop new counseling tools. We expanded the provider scope to provide to include all prenatal providers and not just certified nurse midwives as Sampit had done. And after using the tools we asked the input of providers about their opinions of the decision aids. So the aim of our study was kind of twofold from a patient and a provider point of view. From a patient point of view we sought to determine through pre and post test surveys the effect of decision aids on women's knowledge on the risks and benefits of each mode of birth option their level of satisfaction with the decision aids and the mode of birth their mode of birth choices. And from a provider point of view we sought to explore prenatal providers opinions about the new tools and their impact on shared decision making with patients. And a little bit of background about where the study was conducted Boston Medical Center is an academic tertiary care medical center. It's the safety net hospital for the city of Boston and serves a racially and ethnically diverse population. And patients who deliver at Boston Medical Center can receive prenatal care at one of nine community health centers or at the Yaqui ambulatory care clinic. And patients can be seen prenatally by midwives, nurse practitioners, OB residents, OB attendings, family medicine residents, and family medicine attendings. So we have a wide variety of different providers who are able to see patients. So in 2016 there were 2,865 birth set BMC and our C-section rate was 31.9. So that's kind of right on par with the U.S. average of C-section rates which as I said in 2015 was 32.0. And our V-back rate was 16.6 which is slightly higher than the national average although still something that we're working on. From a success rate our V-back rate was we had a 57% success rate and Boston Medical Center has a long history of working to support laboring after C-section. In 2009 there was a quality assurance improvement project to increase lack and V-back rates. And as I already mentioned Sampit Chincom conducted her study that was from 2013 and 2012 to 2013 excuse me where she conducted her study with midwives and scripted counseling tools in hopes of trying to see about changing our or increasing our V-back rates. And so as far as methods go all patients who were English speaking and who received prenatal care at the Yaqui Clinic with midwives nurse practitioners and OB residents and attending attendings were eligible as long as they had had one or two previous C-sections and were eligible to lack. And we didn't include the family medicine OBs and family medicine residents and attendings in this section of the study due to just their small number of prenatal patients that they saw. So as far as our study interventions go at the first prenatal visit women were consented and given a pre-test questionnaire and then given the giving birth after caesarean pamphlet which is a pamphlet that we developed. And at the second visit and then at a visit between 32 and 36 weeks providers use their provider counseling tool and one of two scripts to prompt shared decision-making discussions. The two scripts were slightly different based on if it was the second visit or the 32 to 36 week visit and had slightly different questions. And then after that 32 to 36 week visit the patients completed the post-test. And so this is just two pages of the giving birth after caesarean pamphlet that we gave to patients. It's a six-page pamphlet that all of the pages you know look similar to this with different information and it was given to patients at their first visit in hopes that the women would take it home, read it and help them to start think about their motive birth options. And we have it in English because our study was conducted in English with women who spoke English but given our racially diverse population at the hospital we also have the pamphlet in Spanish Haitian Creole and Portuguese Creole and women who didn't participate in the study but who had had previous C-sections have been given that pamphlet since we developed it. And then this is a just a picture of the provider counseling tool. It was a it's a single page double-sided laminated tool that is in all of the clinic rooms and the goal was for providers to have kind of a cheat sheet of shorts to help them counsel patients and it gave them not only visual representations for some statistics but also information to help them guide their conversation. And I know the text is a little bit small but if anyone's interested in in seeing more or getting more information about that I can certainly give you that information later. And then this again a very small example of the provider counseling script and this was the first script and the goal of the script was to not only help standardize provider's discussion from a study point of view so that we could standardize what our providers were counseling our patients about but also to ensure that shared decision-making discussions were occurring. I know that some providers have struggle with shared decision-making so we thought that having a script with some open-ended questions would really help providers to have the tools in order to to conduct the shared decision-making discussions, that bi-directional flow of information. And so from a methods point of view from the providers all midwives nurse practitioners and OB residents in attendings who saw prenatal patients at the Yaqui clinic were emailed about the study and were asked to watch a brief video about shared decision-making before counseling their first patients. And then before the visits where they needed to use the counseling tools in the script I contacted them to remind them about their patient's participation in the study and just remind them of their their need to counsel the patients using the script and the counseling tool. And at the end of the study all of the OB providers were asked to complete an online survey and this included the certified nurse midwives nurse practitioners OBs and the family medicine attendants family medicine providers. So that was people who had used the tools and hadn't used the tools. But those who had used the tools were asked about their impact how they valued the tools and their impact on patient care. And those who hadn't used the tools were asked about their thoughts in general about mode of birth counseling and possible the possible usage of tools. So from the results again this was a pilot study so we from a patient point of view we only had 22 women who we were able to enroll in our study. So the numbers are fairly small from an endpoint of view but nonetheless I still think are very valuable. And this study looks at the percentage of women who had correctly answered questions on the pre and the post test. And as you can see from the pre to the post test there was an increase in knowledge about the risks and benefits of the mode of about mode of birth options. And although the changes are not statistically significant they are valuable in our eyes. And this was just a small sample of the questions that we asked them. There were many more but as you can see you know women understood about had a better understanding about uterine rupture about the risks of uterine rupture and about the benefits to trying to have a vaginal birth after C-section. And then this table shows the percentage of women who created degree or strongly agree when asked about the giving birth after caesarean pamphlet and their provider counseling. And you can see that women were very positive in regards to the pamphlet and their provider counseling. And again this is a small sample of the questions that they were asked but five out of seven of the questions that I selected were a hundred percent for their patients satisfaction as far as the pamphlet and their provider counseling. And you can see that women felt that the pamphlet was useful that it should be provided to all patients that it wasn't biased and they felt like they were given enough information. And then as far as the provider counseling goes that they weren't pressured that they felt they were able to fully participate in their care and really have shared decision making with their provider. And then from a mode of birth kind of point of view the chart this chart shows women's decision about mode of birth before and after the intervention. And as you can see at the start of the study 39 percent of women were unsure about their mode of birth choice while at the end of the intervention in the third trimester women that number decreased to 13 percent. And women also became more sure of their decisions. Initially 57 percent, excuse me, initially 57 percent of women were sure or very sure but by the post test 81 percent of those women were sure or very sure. And so you know this points to there there's a decrease in the uncertainty and that the tools in the provider counseling has really helped women make informed decisions that they can be confident in. And so from a provider this is from a provider point of view and though it's very busy it shows providers opinions on the counseling tool and script. And I know it's really busy and I worked really hard to try and find a different way to present this but this is kind of how it ended up. And it's busy because I wanted to be able to compare in one table the answers of providers who had used the script but also those who hadn't used the script to be able to visually compare those. And so on the left hand side there's so much text because the providers who had used the text and those who hadn't used the text had slightly different questions. And so the data shows that providers who used the text, used the tools and scripts were more likely to agree and strongly disagree, agree and strongly agree, excuse me, with the different statements regarding shared decision making and the usage of the tools. You can see that you know overall most providers even if they hadn't used the tools felt that shared decision making was important but that there were more differences in the percentage of providers who had used the tools who thought that the patients who thought that the tools were useful and or would be useful and thought that the patients were comfortable asking questions. And in the last, the last value on the table is statistically significant and looked at providers opinions about if the tools helped patients understand the different mode of birth options and the fact that that's statistically significant points to the fact that providers who used the tool really saw the value in those and that those who hadn't been exposed to the tools maybe didn't appreciate quite as much what they could be used for. And so from a conclusion point of view, patients had an increased knowledge, had increased knowledge on the risks and benefits of each mode of birth option. They had a high level of satisfaction with the decision aids and with their prenatal providers. They had increased confidence in their decision regarding mode of birth choices after exposure to the decision aids and shared decision making counseling. And from a provider point of view, overall there was a high level of satisfaction with decision with the study decision aids and with shared decision making. And as I just mentioned, there was a statistically significant difference in providers opinions about the values of the counseling tools for those who had used it and those who hadn't. And so I hope that this presentation has given you a better sense about the mode of birth counseling, shared decision making and decision aids, and that this new data that we have collected regarding the use of shared decision, the use of decision aids and provider counseling scripts has helped you to appreciate the value of using them and their value in helping women make decisions regarding mode of birth choices. So I just wanted to give a thank you to Sampo Chigam, who is my co-PI with this study, who's actually on an airplane on her way to vacation, which is why she's not presenting with me, and Karla, who did all the data collection and analysis and then all the patients and providers at Boston Medical Center. And if there are questions, I would love to try and answer some questions. All right. Thank you, Courtney. So Courtney has presented. So we, Courtney, Becky is asking, asking you to define decisional conflict. Sure. Decisional conflict is just the idea of having, is the idea that sometimes there's not a right or wrong answer and so there's some conflict between making decisions for providers and for patients. So it's basically the individual making, deciding or uncertain about a course of action to be taken when a particular choice is to be made, for example, if a risk or if it's a challenging situation. So thank you for that. Do we have any more questions? Celine is asking, Courtney, what was the reactions of the providers when the woman wanted a VBA scene? Well, it was actually very interesting. Because we included all different providers in this study, rather than just midwives as Samped had done in our previous study, we had actually the majority of patients had physicians for their primary providers. And we have a number of physicians who feel that feedbacking is not always the best for patients, but they really embrace this counseling. And they were very good about using the counseling tools, using the scripts and really giving patients that opportunity to voice their opinions and voice what they wanted to do, even if they didn't necessarily believe that it was kind of best. So overall, I think the midwives are very supportive of vaginal burst after C-section. But as I said, I was delighted that all of the providers embraced the shared decision-making model and really worked towards that bidirectional flow of information with the patients and providers and kind of put away their own biases for the good of the patient's choices and really embracing what they wanted within the safety of ensuring that having a vaginal burst was not unsafe for the patient. All right. Thank you, Courtney. Our DM in Denmark is asking, would you do a water birth for VBAC? So at Boston Medical Center, we don't do water births. We are, so that's unfortunately not an option for us. Becky's asking, did the health care providers, that's the certified nurse midwives and medical doctors, have concern about liability in shared decision-making? Not as far as anyone expressed to me. So not to my knowledge, no. Thank you. Eva is asking, how much does the tool discuss other topics than a risk? Example the postnatal period, breastfeeding, et cetera. Do you mean in regards to having a vaginal burst or having a C-section? I mean a C-section, I assume. Okay. Yeah, so yeah, so in with the giving birth after caesarean pamphlet and the provider counseling tool is a small amount of discussion about the post, well, not small, there is a discussion about the postnatal period about recovery times, breastfeeding, so that certainly is addressed, was addressed using the decision aids. Thank you, Courtney. Ginger, I assume, correctly, is asking, did the number of ladies wanting V-Back increase or decrease? Yeah, so the number of women who wanted to V-Back increased, it went from 43% in the pre-test to 58% in the post-test. Celine is asking, are providers really ready to offer V-Back? I think so. I mean, as I said, the midwives have been on board at our hospital for many, many years about vaginal, having V-Backing, and I think the physician, our physician colleagues are really on board as well. I mean, we have institutional support from the hospital to really work to increase the V-Back rates and decrease caesarean rates, both from a primary and a repeat point of view. So I do genuinely think that they want to offer women vaginal births as much as possible. Thank you. I have a question. You find that women in some parts of the world are not empowered to make decisions. I don't know much about your demographic characteristics of your clients, but do you think that your women are that empowered to make decisions? Do they have to involve their spouses to make the decision? So that's a great question, and it's a hard answer. I would like to hope that my patients are empowered enough to make the decisions and that they feel comfortable having discussions with their providers and that through these discussions with their providers they feel like they're getting enough information. But I do know that there were a number of women in the study whose partners felt very strongly one way or another, and that certainly did influence their decision. And that's tough, but I think that from a provider point of view, especially here in the States, all we can do or what I hope to do is give mom enough information that she feels comfortable kind of debating with her partner if her partner feels strongly one way or another. And also what I've done in the past is just encourage the provider, encourage, excuse me, the partner to come and to be able to have discussions with them, because sometimes just having a one-on-one discussion and hearing why someone may have reservations about having another C-section or having, trying to labor after C-section, sometimes just having that one-on, having that in-person discussion can really help resolve any sort of conflicts and have a resolution. But it is an issue that is present in the States and is present globally, as you've mentioned, that I don't know if there's an easy fix or an easy way to make sure that the woman feels confident in her decision and is able to make the decision all on her own without any kind of outside influence. Thank you so much. We have one person raised in hand. I think it's Emily. You can go ahead and turn on your microphone. Amy, you should be able to see a microphone icon in the top bar now. And if you click on that, you can ask your question. Thank you, Annie. I think we might have lost Amy. She doesn't seem to appear in the list. Catherine in USA is saying, popular culture and the media have a huge influence on the woman's decision making here in the US as well. Thank you for that, Catherine. Yeah, I completely agree. Another part of the study that we did that is not in this talk was focus group discussions about women who've had C-sections who were pregnant or who were planning to be pregnant. And it was very interesting to hear what influenced them and why they thought that if they got pregnant again, if they were thinking about having a vaginal birth or having a repeat C-section and you're right, a lot of it comes from the media and from pop culture. And evidently we have a session on that very shortly. When a decision is made for VBAC, is there a special schedule for antenatal visit? Do you stick to the traditional schedule or do you modify the schedule? Is there a need for that? No, I mean here at where I work, it's just the traditional schedule. After 36 weeks, they're seen every week. But that there's no difference in visits if someone wants to have a vaginal birth after a seren. Okay, thank you so much. If we don't have any more questions for Courtney, Annette, could we conclude? Yeah, people are typing still. I also want to say that if someone wants to ask Courtney a question and speak, you still have the possibility to get the microphone right. Then you just need to raise your hand or by using the man with the hand and here in the top bar. And then we will give you a microphone right and you can ask questions directly to Courtney if you want to. And it seems like there are still comments and questions in the chat. So we'll just see if there's... Catherine, I totally agree with your comment about the impact of the decision related to post-tates. That is something that is in both the provider counseling tool and the pamphlet that we gave patients of ways to help increase their rate of having a vaginal birth after c-section if that's what they wanted to do. And one of them was to try and avoid being post-tates and trying to avoid an induction. So we do offer membrane stripping and talk about non-pharmacological ways that women can encourage labor to start if that's something that they're interested in. Thank you Courtney. Eva is saying that if any person is interested in making a tool, you said I can recommend the IPDAS decision making tool and some other good examples from the Queensland Australia. A question is asked, what gestation is post-tate though? Here it is 41 plus 5 gestation. That's a year in UK 41 plus 5. Yeah, I mean that's a good point. In Boston Medical Center we consider post-tates after 41 and 0. So there is some variation in what different hospitals and different kind of countries consider post-tates. Thank you. Okay, if we do not have more questions coming up we will like to thank Courtney for a very interesting presentation and I'll just go through the ending slide because