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.

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.

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. Patient(s) 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. Intervention(s) Individual semistructured (n = 12) or dyadic (n = 2) parent interviews. Main Outcome Measure(s) Directed qualitative content analysis. Result(s) 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. Conclusion(s) 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.

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Study question The objective of the study was to determine the usability, comprehensibility, and acceptability of a digital, decision-support aid prototype supporting parental disclosure of donor conception. Summary answer: This mixed methods design maximized participant feedback about the digital, decision-support aid prototype yielding rich insight about the prototype while minimizing participant and investigator burden. What is known already Although a paradigm shift is underway to remove the secrecy that has historically shrouded the practice of gamete donation, little is known about best practices that can support parents in disclosing the conceptional origins to their children. To address this gap, we created a decision-support aid prototype to facilitate parental disclosure post-treatment. In doing so, we followed the International Patient Decision Aid Standards Collaboration for developing decision-support aids, which recommends that Alpha testing (i.e., usability, comprehensibility, and acceptability) be completed to improve the quality of newly created decision-support interventions prior to Beta (i.e., real world) testing. Study design, size, duration A mixed-methods, triangulation design was used. Participants/materials, setting, methods Sixteen participants were purposefully selected based on desired characteristics and the needs of the study. Participants were asked to: (1) follow investigator prepared instructions for accessing the digital, decision-support aid; (2) complete a quantitative rating form about each slide within the decision-support aid prototype; and (3) participate in a qualitative, cognitive interview or focus group. Descriptive statistics and qualitative content analysis guided the iterative analysis. Main results and the role of chance The sample was composed of 10 parents that used donated sperm (n = 3), oocytes (n = 4), or embryos (n = 2) to conceive children and 8 clinicians; 2 participants were both donor recipient parents and clinicians. The interviews (n = 14) and one focus group (2 participants) ranged in length from 25 to 70 minutes (M = 47 minutes). Usability: Participants suggested refining the instructions for accessing the decision-support aid and upgrading the technology used to deliver the content. Common concerns were the inconsistent volume of the audio recordings and a need for higher quality images. Comprehensibility: Feedback obtained from the participants’ rating forms and in the interviews and focus group were consistently high about the ability to understand the content and the scope of the information presented. Acceptability: Participants noted the aid would resonate with parents. They recommended shortening the length of the aid, changing specific wording, modifying some of the video content, refining specific content for individual slides and the four modules. Unintended recommendations about how the aid might be used to provide clinician education or in international research were also reported. Limitations, reasons for caution Alpha testing is not designed to obtain all possible technological or content issues. Rather, it is a useful and recommended step in intervention development to mitigate existing technological bugs and key content issues prior to implementation of Beta testing of a decision-support aid. Wider implications of the findings: Other investigators that develop digital decision-support aids may consider the use of both quantitative and qualitative data collection methods during Alpha testing to refine digital interventions efficiently. The use of mixed methods not only captures rich and insightful feedback but also minimizes the burden on participants and investigators. Trial registration number Not applicable