Barriers to labor after cesarean: A survey of United States midwives.

INTRODUCTION: Despite calls for increased vaginal birth after cesarean (VBAC), <14% of candidates have VBAC. Requirements for documentation of scar type, and prohibitions on induction or augmentation of labor are not supported by evidence but may be widespread. The purpose of this study was to document midwives' perceptions of barriers to labor after cesarean (LAC) and their effects on midwives' ability to accommodate patient desires for LAC. METHODS: Midwives certified by the American Midwifery Certification Board (AMCB) were surveyed in 2019. Multiple option and open-ended text responses were analyzed using quantitative statistics and thematic content analysis. Select barriers to LAC, ability to accommodate LAC, and supportiveness of collaborators among midwives offering LAC were explored. RESULTS: Responses from 1398 midwives were analyzed. Eighty-four percent felt able to accommodate LAC "most of the time," and 39% reported one or more barriers to LAC. Barriers decreased ability to accommodate LAC by as much as 80%. Analysis of text responses revealed specific themes. CONCLUSIONS: Thirty-nine percent of midwives reported their practice was limited by one or more barriers that were inconsistent with professional guidelines. Imposition of barriers was driven primarily by collaborating physicians, and superceded supportive practices of midwives, nurses, and system administrators. Affected midwives were significantly less able to accommodate patient requests for LAC than those not affected. Midwives also reported pride in providing VBAC care, restrictions specific to midwifery scope of practice, and variation in physician support for LAC within practices affecting their ability to provide care.

A Randomized Pilot Trial of the Donor Conception Tool to Empower Parental Telling and Talking (TELL Tool) with Their Children About Their Genetic Origins.

INTRODUCTION: Parents who use donated gametes or embryos to form their families struggle with telling their children about their genetic origins. We developed the Tool to Empower Parental Telling and Talking (TELL Tool) to support parents in disclosure to their children and an eBook attention control. METHOD: A randomized parallel, two-group, attention-controlled clinical pilot trial was conducted online during COVID-19. Feasibility, acceptability, and preliminary effects among parents with children aged 1-16 years were examined. RESULTS: Over 10 months, our target of 75 parents were enrolled (85% of eligible [95% confidence interval (CI), 76% to 91%]), and 68% (95% CI: 57% to 78%) were retained at 12 weeks. At 4 and 12 weeks, positive trends were found for parental disclosure, telling confidence, and anxiety compared with attention controls. DISCUSSION: The study protocol is feasible, and the TELL Tool is acceptable to parents and demonstrates a positive effect on parents' ability to tell their children. The results support the implementation of a large efficacy trial.

Development of the Tool to Empower Parental Telling and Talking (TELL Tool): A digital decision aid intervention about children's origins from donated gametes or embryos.

Objective: This study aimed to create and develop a well-designed, theoretically driven, evidence-based, digital, decision Tool to Empower Parental Telling and Talking (TELL Tool) prototype. Methods: This developmental study used an inclusive, systematic, and iterative process to formulate a prototype TELL Tool: the first digital decision aid for parents who have children 1 to 16 years of age and used donated gametes or embryos to establish their families. Recommendations from the International Patient Decision Aids Standards Collaboration and from experts in decision aid development, digital health interventions, design thinking, and instructional design guided the process. Results: The extensive developmental process incorporated researchers, clinicians, parents, children, and other stakeholders, including donor-conceived adults. We determined the scope and target audience of the decision aid and formed a steering group. During design work, we used the decision-making process model as the guiding framework for selecting content. Parents' views and decisional needs were incorporated into the prototype through empirical research and review, appraisal, and synthesis of the literature. Clinicians' perspectives and insights were also incorporated. We used the experiential learning theory to guide the delivery of the content through a digital distribution plan. Following creation of initial content, including storyboards and scripts, an early prototype was redrafted and redesigned based on feedback from the steering group. A final TELL Tool prototype was then developed for alpha testing. Conclusions: Detailing our early developmental processes provides transparency that can benefit the donor-conceived community as well as clinicians and researchers, especially those designing digital decision aids. Future research to evaluate the efficacy of the TELL Tool is planned.

Alpha Test of the Donor Conception Tool to Empower Parental Telling and Talking.

OBJECTIVE: To conduct an alpha test of the prototype of a digital decision aid to help parents disclose donor conception to their children, the Donor Conception Tool to Empower Parental Telling and Talking (TELL Tool). DESIGN: Convergent mixed-methods design. SETTING: Virtual interviews in places convenient to the participants. PARTICIPANTS: A purposeful sample (N = 16) of nine gamete-donor and embryo-recipient parents and eight clinicians, as one parent was also a clinician. METHODS: We conducted cognitive interviews to explore participants' perceptions about the TELL Tool prototype and observe patterns of use. The International Patient Decision Aid Standards (i.e., usability, comprehensibility, and acceptability) guided the development of the qualitative interview guide and directed the qualitative analysis. We also collected data about participants' perceptions and ratings of the helpfulness of each of the prototype's webpages regarding parents' decision making about disclosure. Descriptive statistics were used to analyze the helpfulness ratings before we merged the two data sets to optimize understanding. RESULTS: Participants reported that the TELL Tool was a helpful digital decision aid to help parents tell their children how they were conceived. Most (93.7%) webpage rating scores indicated that the content was very helpful or helpful. The participants identified content and technical areas that needed refinement and provided specific recommendations such as adding concise instructions (usability), tailoring adolescent language (comprehensibility), and softening verbiage (acceptability). CONCLUSION: Alpha testing guided by the International Patient Decision Aid standards was an essential step in refining and improving the TELL Tool prototype before beta testing.

Parents' experiences telling children conceived by gamete and embryo donation about their genetic origins.

OBJECTIVE: To gain an in-depth understanding of parents' experiences telling children conceived by gamete and embryo donation about their genetic origins. DESIGN: Qualitative, descriptive. SETTING: Families' homes. PATIENTS: Gamete or embryo donation recipient parents living in the United States and who told their children, from birth to 16 years, about their genetic origins. INTERVENTIONS: Individual semistructured (n = 12) or dyadic (n = 2) parent interviews. MAIN OUTCOME MEASURES: Directed qualitative content analysis. RESULTS: Fourteen families that comprised 16 gamete or embryo donation recipient parents and represented 24 donor-conceived children between the ages of 4 months and 16 years participated in the study. Single parents (n = 3) and both parents in most two-parent families (n = 9) led the initial telling conversations. Parents recounted personal short stories using language that was both developmentally and medically appropriate. Multiple strategies, including children's books, were used by parents to aid them in their telling. The oldest donor-conceived children in each family were first informed of their genetic origins at birth (n = 10 families) or at 6 months (n = 1 family; "practice runs") or from 3.5 to 12 years (n = 3 families). The telling conversations took place during routine family activities that naturally brought parents and children in close proximity, usually in the home. CONCLUSIONS: Awareness of the nuances of parents' telling conversations with their children through the age of 16 years can help guide clinical counseling and the development of tools to aid parents in their telling conversations.

Calculators Estimating the Likelihood of Vaginal Birth After Cesarean: Uses and Perceptions.

INTRODUCTION: A calculator estimating likelihood of vaginal birth after cesarean (VBAC) has been promoted by the Society for Maternal-Fetal Medicine, but little is known about how it is used and perceived in practice. Cutoffs for prohibiting labor after cesarean are discouraged by the calculator's developers, but such uses may be widespread. The purpose of this study was to determine how calculators predicting VBAC are used and perceived in midwifery practices. METHODS: Certified nurse-midwives and certified midwives currently providing care for labor after cesarean were surveyed between January 17, 2019, and February 7, 2019. Quantitative and text data were collected regarding the uses and perceptions of calculators among midwives and their colleagues. We compared these findings with midwives' perceptions of their ability to accommodate patient wishes for labor after cesarean. We used descriptive content analysis to evaluate themes occurring in text responses. RESULTS: There were 1305 valid responses. A requirement to use calculator scores for patient counseling was reported by 527 (40.4%) of responding midwives. Over 1 in 5 midwives reported that scores were used to discourage or prohibit labor after cesarean. Almost half reported some or strong disagreement with physician colleagues regarding calculator use. Interprofessional agreement and disagreement centered on how scores are used to direct clinical care or restrict patient options. Calculator scores were used in more than twice as many midwives' practices to discourage rather than encourage labor after cesarean. Descriptive analysis of text revealed 4 themes regarding calculators: inconsistent use, information counseling, informed consent, and influence patient management or options. DISCUSSION: Calculators predicting likelihood of VBAC success are widely used in midwifery settings and are more often used to discourage than to encourage labor after cesarean. Midwives reported both directive and nondirective counseling based on calculator scores.