Leon-Martinez Daisy, Dehlendorf Christine, Zeme Molly, Boscardin W John, Kaimal Anjali J, Grobman William A, Kuppermann Miriam
Department of Obstetrics, Gynecology & Reproductive Sciences, University of California-San Francisco, 490 Illinois Street, Floor 10, San Francisco, CA, 94143, USA.
Department of Family and Community Medicine, University of California-San Francisco, 2540 23rd Street, #5702, San Francisco, CA, 94110, USA.
BMC Pregnancy Childbirth. 2025 Jun 3;25(1):648. doi: 10.1186/s12884-025-07788-6.
Both a trial of labor after cesarean (TOLAC) and elective repeat cesarean delivery (ERCD) are reasonable choices after a cesarean delivery, with differing risks and benefits. This study explores the impact of patient health literacy and primary language on the decision to pursue a TOLAC and on decision quality.
This is a secondary analysis of the Prior Cesarean Decision (PROCEED) trial, which examined the effect of a patient-centered decision support tool on rates of TOLAC and decision quality. Logistic regression was performed to estimate the association of limited health literacy (Newest Vital Sign score ≤4/6) and non-English primary language (NEPL) with TOLAC. Decision quality was assessed by calculating mean scores for decision-quality scales and using linear regression to estimate adjusted mean differences (aMD) by health literacy and NEPL.
Among 1455 participants, 44.6% underwent TOLAC, and 71.0% of those with a TOLAC had a vaginal birth after cesarean (VBAC). Limited health literacy was associated with lower odds of TOLAC (aOR 0.60, 95% CI [0.38, 0.93]). For decision quality, limited health literacy was associated with similar scores for decisional conflict, shared decision-making, decision self-efficacy and decision satisfaction, but lower knowledge scores (3.9 vs. 5.4; aMD -0.7, 95% CI [-1.0, -0.5]). Compared to participants whose primary language was English (n=1043), those with NEPL (n=255) had similar odds of TOLAC (aOR 1.08, 95% CI [0.69, 1.68]), but greater decisional conflict (20.9 vs. 16.7; aMD 3.9, 95% CI [1.4, 6.3]) and lower decision self-efficacy (88.6 vs. 90.9; aMD -3.3, 95% CI [-5.6, -1.1]) and decision satisfaction (4.6 vs. 4.7; aMD -0.1, 95% CI [-0.2, 0.0]).
In this study of pregnant people with a prior cesarean and no prior VBAC, those with limited health literacy had lower odds of TOLAC and lower knowledge scores about risks and benefits of TOLAC vs. ERCD. While those with NEPL had similar odds of TOLAC, they had lower decision quality scores compared to those with those with English as a primary language. These findings indicate factors that may result in less effective counseling related to delivery options after prior cesarean and may contribute to differences in approach to delivery and decision quality.
剖宫产术后试产（TOLAC）和择期再次剖宫产（ERCD）都是剖宫产术后合理的选择，两者的风险和益处各不相同。本研究探讨了患者健康素养和母语对选择TOLAC的决定以及决策质量的影响。
这是对先前剖宫产决策（PROCEED）试验的二次分析，该试验研究了以患者为中心的决策支持工具对TOLAC发生率和决策质量的影响。进行逻辑回归以估计健康素养有限（最新生命体征评分≤4/6）和非英语母语（NEPL）与TOLAC之间的关联。通过计算决策质量量表的平均得分并使用线性回归来估计按健康素养和NEPL调整后的平均差异（aMD）来评估决策质量。
在1455名参与者中，44.6%进行了TOLAC，其中71.0%的TOLAC患者剖宫产术后经阴道分娩（VBAC）。健康素养有限与TOLAC几率较低相关（调整后比值比[aOR]0.60，95%置信区间[CI][0.38，0.93]）。对于决策质量，健康素养有限与决策冲突、共同决策、决策自我效能感和决策满意度得分相似，但知识得分较低（3.9对5.4；aMD -0.7，95%CI[-1.0，-0.5]）。与以英语为母语的参与者（n = 1043）相比，非英语母语参与者（n = 255）的TOLAC几率相似（aOR 1.08，95%CI[0.69，1.68]），但决策冲突更大（20.9对16.7；aMD 3.9，95%CI[1.4，6.3]），决策自我效能感更低（88.6对90.9；aMD -3.3，95%CI[-5.6，-1.1]），决策满意度更低（4.6对4.7；aMD -0.1，95%CI[-0.2，0.0]）。
在这项针对既往有剖宫产史且无既往VBAC史的孕妇的研究中，健康素养有限的孕妇选择TOLAC的几率较低，并且对TOLAC与ERCD的风险和益处的知识得分较低。虽然非英语母语孕妇选择TOLAC的几率相似，但与以英语为母语的孕妇相比，她们的决策质量得分较低。这些发现表明了一些可能导致剖宫产术后分娩选择咨询效果较差的因素，并且可能导致分娩方式和决策质量的差异。
