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# A scoping review of decision aids for pregnant women around childbirth: Do they improve decision quality, processes, and outcomes?

Truc Phuong Nguyen, Ana Pilar Betrán, Maria Regina Torloni, Nils Chaillet, Alexandre Dumont

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## To cite this version:

Truc Phuong Nguyen, Ana Pilar Betrán, Maria Regina Torloni, Nils Chaillet, Alexandre Dumont. A scoping review of decision aids for pregnant women around childbirth: Do they improve decision quality, processes, and outcomes?. European Journal of Obstetrics & Gynecology and Reproductive Biology, 2025, 312, pp.114085. 10.1016/j.ejogrb.2025.114085. hal-05090743

HAL Id: hal-05090743

https://hal.science/hal-05090743v1

Submitted on 30 May 2025

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Review article

A scoping review of decision aids for pregnant women around childbirth:
Do they improve decision quality, processes, and outcomes?

Truc Phuong Nguyen<sup>a,*</sup>, Ana Pilar Betrán<sup>b</sup>, Maria Regina Torloni<sup>c</sup>, Nils Chaillet<sup>d</sup>,
Alexandre Dumont<sup>a</sup>

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ARTICLE INFO

Keywords:

Pregnant women

Decision-making

Decision aid

Childbirth

Peripartum

A B S T R A C T

**Background:** Meaningful engagement of women in childbirth decisions is a growing priority in maternity care. Decision aids are tools designed to improve decision quality, decision-making processes quality, care behaviours, and health outcomes (quadruple aim).

**Objective:** To map quantitative studies evaluating the effects of decision aids for women making decisions around childbirth.

**Methods:** We searched MEDLINE, Cochrane DSR and CENTRAL, CINAHL, and EMBASE (January 1975–April 2025) for reviews, randomized controlled trials and controlled before-and-after studies that assessed the effect of decision aids for childbirth decisions.

**Results:** 28 studies (11 reviews, 17 primary studies) met selection criteria. Most involved high-risk pregnant women and showed that decision aid improved the quality of decision and decision-making process. Positive impacts on care behaviour and health outcomes were more evident when decision aids were combined with other components and required discussions with healthcare providers.

**Discussion:** Although limited, evidence suggests decision aids are more effective when women are prepared to use the tool and healthcare providers are actively involved. The review identified gaps in research targeting low-risk women in low- and middle-income countries and assessing women's value and preferences for shared decision-making.

**Conclusions:** Decision aids around childbirth have the potential to meet women's needs in decision-making, appropriate use of care and perinatal health outcomes especially when they are prepared to use the tool and supported by healthcare providers. Future research should evaluate all four aim objectives to strengthen the evidence on the benefits of decision aids, especially for low-risk population and in low- and middle-income countries.

Background

Making healthcare decisions can be particularly challenging for
pregnant women because they must weigh the benefits and risks for two
individuals, themselves and their unborn child. Health decisions should
involve both provider and patients, as evidence shows that patients who
are more active in making decisions about their healthcare have better

health outcomes and care experiences than those who are less active
[1,2]. Women's engagement in healthcare decision-making during the
peripartum period has been increasingly emphasized as a priority in
maternity care, since it increases satisfaction with the childbirth expe-
rience and provides health benefits for women and newborns [3-5].

In this context, decision aids (DAs) have emerged as essential tools to
empower patients and enhance communication with healthcare

<footnote><sup>a</sup> Université Paris Cité and Université Sorbonne Paris Nord, IRD, Inserm, Ceped, 45 rue des Saints-Pères, F-75006 Paris, France</footnote>

<footnote>b Department of Sexual and Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Program of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland</footnote>

<footnote>c Obstetrics Department, Universidade Federal de São Paulo, São Paulo, Brazil, Rua Botucatu 740, sala 563. São Paulo, SP CEP 04023-062, Brazil</footnote>

<footnote>d Reproduction, mother and youth health division. CHU de Québec-Université Laval Research Center. Faculty of Medicine, Department of Obstetrics, Gynaecology and Reproduction, 2705, boul. Laurier, Bloc T3-65, G1V 4G2, Québec, QC, Canada</footnote>

<footnote>* Corresponding author at: School Pierre Louis of Public health Université Paris Cité and Université Sorbonne Paris Nord, IRD, Inserm, Ceped, F-75006 Paris, France.</footnote>

<footnote>E-mail address: trucphuong.nguyen@ird.fr (T.P. Nguyen).</footnote>

<footnote>https://doi.org/10.1016/j.ejogrb.2025.114085</footnote>

<footnote>Received 9 February 2025; Received in revised form 9 May 2025; Accepted 23 May 2025</footnote>

<footnote>Available online 25 May 2025</footnote>

<footnote>0301-2115/© 2025 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).</footnote>
providers by making their decisions more explicit, providing information about options associated benefits/harms, and helping improve congruence between decisions and personal values [6]. According to The Ottawa Decision Support Framework (ODSF) [7], DAs have four objectives: (i) to help the patients make informed and value-based choices (quality of decision), (ii) to improve patient-provider communication recognizing the values-sensitive nature of the decision and the value patients place on the benefits and harms (quality of decision-making process), (iii) to facilitate the implementation of the chosen options and the appropriate use and costs of health services (care behaviour), and (iv) to improve health outcomes. Rather than replacing clinical counselling, DAs complement the clinician's guidance, enriching the patient-provider dialogue [8].

Decision-making around childbirth is especially pertinent because there is a global overuse of peripartum obstetric interventions, such as labour induction, analgesia, episiotomy, and caesarean sections, particularly for low-risk pregnancies [9–11]. Although certain interventions can be life-saving, necessary, and essential to ensure maternal or neonatal safety when certain complications arise during labour and childbirth (e.g., emergency caesarean sections for foetal distress or placental abruption), in other situations, interventions are performed without clear medical indications, raising concerns about potential harm and the unnecessary use of healthcare [9–11]. DAs are increasingly used during pregnancy to support shared decision-making [12,13] and may contribute to appropriate care behaviour by informing low-risk women on the risks and benefits of various obstetric interventions.

Up to 2023, various reviews have shown the positive effects of DA for pregnant women facing decision about antenatal screening or peripartum intervention [12–19]. There is evidence that DAs for peripartum interventions improves the match between the chosen option and the features that matter most to pregnant women, including outcomes such as knowledge, accurate risk perceptions, and value congruence with the chosen option, women’s satisfaction with the decision and decreased decisional conflict [12–19]. However, most existing reviews focused on the effectiveness of DAs to improve the quality of decision and the decision-making process but have not assessed their effect on the implementation of the chosen option, nor on maternal or perinatal outcomes. Moreover, most of the studies included in these reviews involved high-risk population such as women with previous caesarean sections [12–19].

To fill this gap, we conducted a scoping review to map quantitative studies that evaluated the effects of DAs for women facing decisions regarding peripartum obstetric interventions and to examine the effects of DAs on the four ODSF [7] objectives, i.e. improving the quality of decision, the decision-making process quality, the care behaviour and the health outcomes.

Given the breadth and heterogeneity of existing literature on decision aids for obstetric interventions, which covers a variety of populations, interventions, and outcome measures [12–19], we decided to conduct a scoping review. This was thought to be the most appropriate methodology to address this question because, differently from other types of reviews, scoping reviews allow for mapping key concepts, identifying research gaps, and summarizing a complex and emerging filed [20].

## Method

This scoping review followed the methodological recommendations of Joanna Briggs Institute handbook [20] and is reported according to the PRISMA Extension for Scoping Reviews reporting checklist [21].

## Data source and search

We searched MEDLINE, EMBASE (Supplementary Table A: search strategy for MeSH and Etree terms), CENTRAL, Cochrane DSR, ACP

Journal Club, Centre for Clinical and Translational Research, HTA database, NHS Economic Evaluation Database, CINAHL, Decision Aid Library Inventory (DALI), and PsycINFO, without language restriction. The electronic search was run from database inception to December 11th, 2023. An updated search was conducted April 30th, 2025.

## Eligibility criteria

We included studies that involved pregnant women facing decisions about peripartum obstetric interventions or the choice of immediate postpartum intervention during pregnancy (such as immediate postpartum family planning), regardless of their obstetric risk, and of the setting where the study was conducted. All format types of DA were included as long as they meet all three core criteria of the International Patient Decision Aid Standards (IPDAS) [6]. Randomized controlled trials (RCTs) and controlled before-and-after studies (CBAs) were eligible if they meet criteria of the Cochrane Effective Practice and Organization of Care Review Group [22]. Specifically, RCTs were included if participants were randomly assigned to alternative interventions (e.g., by random number generation). CBAs were included if they involved non-randomized intervention and control groups, with contemporaneous baseline and follow-up data collection, and if study and control sites were comparable in key characteristics (e.g., healthcare setting, reimbursement system, level of care, academic status). We also included scoping and systematic reviews if they included primary studies assessing the effects of DAs on obstetric peripartum interventions.

We excluded studies involving non-pregnant women. Existing reviews or primary studies that only assessed educational interventions, such as childbirth preparation classes, birth plans, psychoeducation, or motivational interventions, were not included.

When an included primary study was also included in an existing review, we included both the primary studies and the reviews and reported these instances where overlap occurred providing a clear distinction between the information obtained from the reviews and the primary studies.

## Outcomes

The outcomes of interest in our scoping review were categorized into four dimension as defined by the ODSF [7]: a) quality of decision, b) quality of decision-making process, c) care behaviour, and d) health outcomes. Associated outcomes of each dimension can be found in the section descriptive analysis.

## Study selection and data extraction

This process was described in the registered protocol [23]. We also extracted the score of each DA registered in the DALI [24] of The Ottawa Hospital. The score was based on the IPDAS framework [25]. This tool does not assess the methodological quality of the study but the quality of the DA.

## Data synthesis and descriptive analysis

For each review included, we summarized the information on the type of studies included in the review, participants involved, type of decisions for health treatment or screening, and the main effects of DAs.

For primary studies included, we mapped the studies' outcomes into four categories as defined as our outcomes of interests: a) Quality of decision includes outcomes such as knowledge, accurate risk perceptions, and value congruence with chosen option. b) Quality of decision-making process include decisional conflict, patient-provider communication, participation in decision making (or shared decision-making), self-efficacy and satisfaction with the decision. c) Care behaviour included the woman's preference after using the DA (option selected), the undecided woman, the actual intervention performed, and the
congruence between preferred choice and what actually happened. The
care behaviour options were categorized as 1) physiological manage-
ment of labour/ childbirth (spontaneous labour, non-pharmacological
pain control, normal vaginal birth or no treatment); or 2) the non-
physiological management of labour/ childbirth (i.e. induction of la-
bour, caesarean section, forceps/vacuum, episiotomy, external cephalic
version, artificial rupture of the membranes, neonatal intensive care,
pharmacological drugs). d) Health outcomes included major or minor
maternal and perinatal morbidity, anxiety, decisional regret, and satis-
faction about birth experience.

We reported only outcomes that aligned with the four objectives of

our study. Non reported outcomes of interest were extrapolated, when
possible, from available data in each included study.

We classified study participants broadly as low-risk or high-risk. We
defined low-risk women as a pregnant woman without significant
medical or obstetric complications in the current or past pregnancies (e.
g. single foetus in cephalic presentation at term without a previous
caesarean section). We defined high-risk women as pregnant women
with significant risk factors that may impact maternal or perinatal
outcomes (e.g. previous caesarean section, preeclampsia, multiple ges-
tations or preterm births).

We assessed the following DA characteristics: a) whether the DA

<figure><img src="image_5.png" /><figcaption>Fig. 1. Flowchart of the study identification and selection.</figcaption></figure>
required reading for use by the women (i.e. paper-based booklet) or could be used without having to read (i.e. audio or video), b) whether the DA was combined with another component and c) whether the DA required a mandatory discussion with a healthcare provider. We assessed whether each study was preceded by formative research or a baseline study to ensure that the DA was tailored to the context.

We also classified each DA according to quality, based on the IPDAS score into two categories: ≥ 75 % and < 75 % or unknown score. This cut-off was chosen pragmatically, as a 75 % threshold suggests that at least three-fourths of the evaluated criteria were met, indicating a relatively high adherence to quality standards.

We also categorized the primary studies based on the type of income level of the country where they were conducted such as high-income country or low- and middle-income country (LMICs), and the type of decisions addressed by the DA, such as pain relief or mode of birth.

## Results

Our search strategy identified 5374 unique records. We excluded 5251 by screening titles and abstracts and selected 123 for full-text evaluation. The updated search (April 30, 2025) yielded 494 new citations from the same databases as the first search. Of these, only 1 study was eligible for inclusion in this review after the screening process. A total of 28 articles (11 reviews and 17 primary studies) were included (Fig. 1). Eight [26–33] of the 17 primary studies were also already included in the at least one of the reviews. We report findings from the reviews and primary studies separately.

### Main characteristics and findings of reviews

Among the 11 included reviews, 10 were systematic reviews [12,14–18,34–37] and one was scoping review [13] (Supplementary Table B1). In these reviews, DAs targeted high-risk patients, such as women with previous caesarean section (n = 2) [16,35,37], pre-existing medical conditions (n = 3) [12,15,18], or mixed obstetric population with high- and low-risk women (n = 5) [13,14,17,34,36]. None of the reviews focused exclusively on all type of peripartum obstetric interventions together. The reviews included studies involving women facing decisions not only about prenatal screening decision [12,14,15,34,36], but also about treatment during pregnancy, labour, childbirth and the postpartum period, or treatment of gynaecological issues [12–18,34–36].

DAs were found to significantly improve knowledge among pregnant women, as reported in descriptive analysis of five reviews [14,15,18,35,36] and in three meta-analyses [12,16,34], with the exception of one meta-analysis that found no significant effect [37]. DAs also reduced decisional conflict as shown in descriptive analysis of two reviews [15,35] and confirmed by three meta-analyses [12,18,37]. Evidence suggests that the use of DA does not affect the women's choices, as shown in one descriptive analysis [35] and in one meta-analysis [14]. The impact of DAs on the actual choices implemented was mixed: while no differences were reported in the descriptive analysis in three review [15,17,36], one meta-analysis [14] found an increase in choice uptake. The congruence between preferred and actual choice implemented was not significant in one meta-analysis [16]. Four reviews reported the effect of DA on health outcomes. DAs showed no impact on maternal and perinatal outcomes in the descriptive analysis of these reviews [16–18,36]. The effect on maternal anxiety was inconsistent: three reviews [13,15,36] reported no change or mixed result, while two meta-analyses [12,14] reported reduced anxiety, and one [34] found no effect. Only one review reported that 11 DAs out of 27 were appropriate to be used by low literacy population [13].

### Main characteristics and findings of primary studies

Table 1 presents the characteristics of the 17 primary studies (see

<table><caption>**Table 1**
Main characteristics of 17 primary studies.</caption><thead><tr><th>Characteristic</th><th>Number of studies (n = 17)</th><th>Reference</th></tr></thead><tbody><tr><td>Study design</td><td></td><td></td></tr><tr><td>Randomized controlled trial</td><td>14</td><td>[26-33,38-41,45,46]</td></tr><tr><td>Controlled before-after study</td><td>3</td><td>[42-44]</td></tr><tr><td>Country level of income</td><td></td><td></td></tr><tr><td>High</td><td>14</td><td>[26-32,38-43,45]</td></tr><tr><td>Low and Middle</td><td>3</td><td>[33,44,46]</td></tr><tr><td>Type of participants</td><td></td><td></td></tr><tr><td>High-risk pregnant women</td><td>13</td><td>[26-28,30-33,40-45]</td></tr><tr><td>Low-risk pregnant women</td><td>4</td><td>[29,38,39,46]</td></tr><tr><td>Type of decision</td><td></td><td></td></tr><tr><td>Planned mode of birth after previous caesarean section</td><td>10</td><td>[26,27,30-33,40-43]</td></tr><tr><td>Pain relief during labour</td><td>3</td><td>[29,38,46]</td></tr><tr><td>External cephalic version for breech presentation</td><td>1</td><td>[28]</td></tr><tr><td>Long-active reversible contraception</td><td>1</td><td>[44]</td></tr><tr><td>Neonatal care of extreme premature infants</td><td>1</td><td>[45]</td></tr><tr><td>Postnatal care of normal full-term infants</td><td>1</td><td>[39]</td></tr><tr><td>Decision aid tailored by previous research</td><td></td><td></td></tr><tr><td>Yes</td><td>14</td><td>[26-32,38,40-45]</td></tr><tr><td>No</td><td>3</td><td>[33,39,46]</td></tr><tr><td>Decision aid requires reading for use</td><td></td><td></td></tr><tr><td>Yes</td><td>9</td><td>[26,27,31,32,40-44]</td></tr><tr><td>No</td><td>8</td><td>[28-30,33,38,39,45,46]</td></tr><tr><td>Decision aid combined with other component(s)</td><td></td><td></td></tr><tr><td>Yes</td><td>5</td><td>[40-42,44,46]</td></tr><tr><td>No</td><td>12</td><td>[26-33,38,39,43,45]</td></tr><tr><td>Decision aid required discussion with the healthcare provider</td><td></td><td></td></tr><tr><td>Yes</td><td>12</td><td>[28,31-33,39-46]</td></tr><tr><td>No</td><td>5</td><td>[26,27,29,30,38]</td></tr><tr><td>Quality of decision aid</td><td></td><td></td></tr><tr><td>IPDAS score ≥ 75 %</td><td>2</td><td>[41,42]</td></tr><tr><td>IPDAS score < 75 % or unknown</td><td>15</td><td>[26-33,38-40,43-46]</td></tr><tr><td>Category of outcome</td><td></td><td></td></tr><tr><td>Quality of decision</td><td>10</td><td>[26-29,32,38,40,43-45]</td></tr><tr><td>Quality of decision-making process</td><td>15</td><td>[26-33,38-40,42-45]</td></tr><tr><td>Care behaviour</td><td>15</td><td>[26-33,39-46]</td></tr><tr><td>Health outcome</td><td>12</td><td>[26-29,31-33,38,39,41,42,46]</td></tr></tbody></table>

IPDAS, International Patient Decision Aid Standard.

Supplementary Table B2 for details). Two studies reported data from the same trial, but control groups were different in the two separate analyses and are, therefore, presented as separate studies [29,38]. Most studies (n = 14, 82 %) were RCTs conducted in high-income countries, and involved high-risk-participants (n = 13, 76 %), including women with specific obstetric conditions such as previous caesarean section, breech presentation, or extreme prematurity. Most studies (n = 14, 82 %) report that the DA was customized by previous formative research. Nine studies (53 %) used a booklet or web-based tool that required reading for use [26,27,32,39–44]. Among these studies, only one specified literacy requirements, stating that the DA was accessible to women with at least 6th-grade education [43]. In eight studies (47 %), participants could use the DA without reading, either through a video, an audio book or with guidance from a healthcare professional [28–31,33,38,45,46]. Five studies (29 %) combined the DA with another intervention component, such as women's counselling by a trained healthcare provider before the clinical encounter [40,42,44,46], or a prediction model to calculate the probability of success of the chosen option [41,42]. Twelve studies (71
%) required a mandatory discussion with healthcare providers after receiving the DA, as part of the decision-making process [28,31–33,39–46]. In almost 90 % of the studies (n = 15) the quality of the decision aid was low (IPDAS score < 75 %) or not reported by the authors.

## Decision aids' impact on outcomes

Ten studies (59 %) reported outcomes on the quality of the decision, 15 (88 %) on the quality of the decision-making process, 15 (88 %) on care behaviour, and 12 (71 %) on health outcomes. Table 2 presents the various outcomes relevant to the four objectives of the DA. See Supplementary Tables B8 and B9 for detailed outcomes related to the quality of decision and decision-making process, care behaviour and health outcomes.

## Quality of decision and decision-making process

Among the ten studies (8 RCTs and 2 CBAs) that evaluated the quality of decision, seven (70 %) studies reported significant improvements, mainly increased patient knowledge regarding the risks and benefits of chosen options (Table 2). Among the 15 studies (12 RCTs and 3 CBAs) that evaluated the quality of decision-making process, 11 (73 %) studies reported significant improvements, mainly decreased decisional conflict and improved satisfaction with the decision (Table 2). There is no marked variations in the proportion of studies with at least one positive effect for both outcome categories according to DA characteristics (Supplementary Table B3), type of country (Supplementary Table B4), type of participants (Supplementary Table B5), type of decision (Supplementary Table B6) and study design (Supplementary Table B7).

<table><caption>**Table 2**
Decision aids outcome by objective.</caption><thead><tr><th>DA objective</th><th>Outcome</th><th>Number of studies measuring the outcome</th><th>Number of studies reporting significant improvement* (%)</th></tr></thead><tbody><tr><td rowspan="2">Quality of decision<br>N = 10 studies</td><td>Knowledge</td><td>10<br>[26-29,32,38,40,43-45]</td><td>7 (70)<br>[26-29,43-45]</td></tr><tr><td>Values</td><td>2<br>[28,43]</td><td>1 (50)<br>[28]</td></tr><tr><td rowspan="6">Quality of decision-making process<br>N = 15 studies</td><td>Decisional conflict</td><td>13<br>[26-33,38-40,44,45]</td><td>7 (54)<br>[26-28,30,33,39,44]</td></tr><tr><td>Informed, patient-centred decision</td><td>3<br>[28,29,43]</td><td>3 (100)<br>[28,29,43]</td></tr><tr><td>Choice/risk information discussed</td><td>1<br>[42]</td><td>1 (100)<br>[42]</td></tr><tr><td>Self-efficacy</td><td>3<br>[31,32,45]</td><td>1 (33)<br>[32]</td></tr><tr><td>Shared decision-making</td><td>5<br>[29,31,39,42,43]</td><td>1 (20)<br>[42]</td></tr><tr><td>Satisfaction with the decision</td><td>8<br>[27-29,31,32,40,43,44]</td><td>4 (50)<br>[27,28,43,44]</td></tr><tr><td rowspan="3">Care behaviour<br>N = 15 studies</td><td>Preference/intention/final choice</td><td>6<br>[26,28,32,39,40,44]</td><td>2 (33)<br>[28,44]</td></tr><tr><td>Use of peripartum intervention</td><td>10<br>[27-33,41,42,46]</td><td>3 (30)<br>[33,42,46]</td></tr><tr><td>Congruence between preferred and actual peripartum intervention</td><td>1<br>[43]</td><td>none</td></tr><tr><td rowspan="6">Health outcome<br>N = 12 studies</td><td>Maternal morbidity</td><td>4<br>[28,31,41,42]</td><td>1 (25)<br>[41]</td></tr><tr><td>Perinatal morbidity</td><td>5<br>[28,29,31,41,42]</td><td>1 (20)<br>[41]</td></tr><tr><td>Anxiety</td><td>4<br>[27-29,38]</td><td>1 (25)<br>[27]</td></tr><tr><td>Decisional regret</td><td>2<br>[33,39]</td><td>1 (50)<br>[33]</td></tr><tr><td>Satisfaction about birth experience</td><td>3<br>[26,32,46]</td><td>1 (33)<br>[46]</td></tr></tbody></table>

## Care behaviour

Five of the 15 studies (33 %) that evaluated care behaviour reported significant improvement, mainly through increasing selection or use of physiological option (e.g. spontaneous labour, non-pharmacological pain control) or long-active contraception uptake in the immediate postpartum period. There is a marked variation in care behaviour improvement depending on whether the DA is used alone or in combination with another intervention (e.g. women's counselling and training of healthcare providers), requires a mandatory discussion with a healthcare provider of not, and depending on the type of country. Three out of five studies (60 %) combining the DA with another intervention component had at least one positive outcome, compared with two out 10 (20 %) studies with DA alone (Fig. 2). Five out of 11 (45 %) studies with a mandatory discussion also reported at least one positive care behaviour outcome compared to none out of four studies without a mandatory discussion (Fig. 3). This suggests that the active participation of healthcare providers in implementing the DA is required to change care behaviour. For example, Mushy et al. evaluated a family planning DA in Tanzania [44], compared to routine post-partum care. They reported that DA provided to pregnant adolescents during antenatal care visits, combined with individual face-to-face counselling education by trained healthcare providers, not only lowered decisional conflict, improved knowledge and satisfaction with decision making, but also enhanced contraception uptake in the immediate postpartum period.

## Health outcomes

Four (30 %) of the twelve studies that included health outcomes measures reported a positive impact on one or more maternal and/or perinatal outcomes. There is a marked variation in health improvement

<footnote>*Quality of decision: increasing knowledge, value congruence; Quality of decision-making process: increasing self-efficacy, patient-centred decision, shared decision-making, satisfaction with decision, decision conflict; Care behaviour: increasing selection or use of physiological option, congruence between preferred and actual peripartum intervention; Health outcomes: decreasing anxiety, decision regret, maternal or perinatal morbidity.</footnote>
<figure><img src="image_6.png" /><figcaption>Fig. 2. Effect of decision aids according to combination with other components.</figcaption></figure>

<figure><img src="image_7.png" /><figcaption>Fig. 3. Effect of decision aid according to requirement of discussion with a healthcare provider.</figcaption></figure>

depending on whether the DA is used alone or in combination with another intervention (e.g. prediction model and training of healthcare providers). Two studies out of three (67 %) combining the DA with another intervention component had at least one positive health outcome, as compared with two out of nine (22 %) studies with DA alone (Fig. 2). For example, Shahveisi et al. [46] evaluated a DA about pain control provided to low-risk women combined with individual counselling and mandatory discussion with healthcare providers during the latent phase of labour, compared with usual care (where providers

decided for the women). The authors report that significantly more women in the DA group chose non-pharmacological pain relief methods and had better childbirth experience than those in the usual care group.

In addition, all three studies conducted in LMICs show improvements in care behaviours and health outcomes, compared with between 17 % and 20 % of studies conducted in high-income countries (Fig. 4).
<figure><img src="image_8.png" /><figcaption>Fig. 4. Effect of decision aids according to country income level.</figcaption></figure>

Discussion

This scoping review identified 11 reviews and 17 primary studies on the effect of DAs for women facing peripartum obstetric interventions. The 11 reviews provide valuable insights from aggregated data but also highlight a significant gap in the literature regarding DAs specifically designed for obstetric interventions around childbirth. Our analysis of 17 primary studies provided additional information to help fill this gap. We identified several studies that showed positive effects of DAs on the four categories of outcomes using the Ottawa Decision Support Framework: quality of decision, quality of decision-making process, care behaviour, and health outcomes.

DAs combined with other intervention seem to be an important factor to improve care behaviour and health outcomes of women by preparing them to use the tool (counselling activities and prediction model) or involving healthcare professionals more closely in its implementation (training). Women's counselling may enhance their choice, while prediction models help women understand the likelihood of success of their chosen options. These models seem to not only guide women toward informed decisions but also enable providers deliver tailored advice.

Studies implementing DAs that included a mandatory discussion with healthcare provider also showed more consistently positive effects on the four categories of outcome [28,32,33,39,41-44,46]. This discussion between the patient and her provider is an important opportunity to clarify complex information, share her preference and actively engage in the decision [47,48]. If this discussion is not mandatory, the provider may not be aware that the women has used a DA, or the woman herself might feel hesitant to communicate her preferences with her caregiver. Additionally, healthcare provider discussions allow for direct communication of information and clarification of doubts and ensuring comprehension of options, even for women who face literacy challenges. This is particularly important in LMICs where most of women may have low literacy level [49].

This review identified several research gaps, starting with the limited number of studies that assessed the effects of DAs in low-risk obstetric populations. We identified only four studies involving exclusively low-

low-risk women, mainly to assist informed decision-making for labour analgesia (Table B5). One of these studies showed a significant change in behaviour, namely more frequent use of non-pharmacological methods to control labour pain [46]. Additional research is needed to assess the impacts of DA in low-risk women, particularly for those facing decisions such as induction of labour [50] and mode of birth [51]. Moreover, this research gap needs to be bridged even more urgently in LMICs, where overuse of peripartum obstetric intervention in low-risk women leads to inequity and excess morbidity [4,52].

An additional research gap identified by this review was the dearth of studies that analysed the effects of DAs on women's values [28,43] and preferences [26,28,32,39,40,44]. As DAs are designed to help women identify and prioritize their personal values, enabling them to make informed decisions aligned with what matters most to them is particularly important [7]. There is also a paucity of evidence about the impact of DAs on shared decision-making. This gap reflects a wider issue highlighted in the literature, namely that women often report that healthcare professionals do not seek consent for interventions during childbirth [53] and women's expectations are not in accordance with what they actually experience [54]. Despite the importance of shared decision-making in maternity care, only one of the five trials included in this review that assessed it as an outcome reported a significant improvement (Table 2). This raises concerns about whether women were adequately supported or empowered to participate actively in decision-making. Strengthening shared decision-making requires not only providing DAs but also fostering an environment where women feel confident and supported in voicing their preferences or concerns. Most of the included studies failed to report their IPDAS scoring to assess the DA quality. Most studies (15 out of 17) reported developing their DAs using the IPDAS framework, the ODSF, or an existing DA derived from these sources, with or without adaptation to the local context. However, only five DAs from these studies were listed in the DALI for IPDAS scoring. This indicates that the evaluation of DAs through IPDAS scoring may be limited in its scope or application.
## Strengths and limitations

Our scoping review updates the existing literature combining systematic reviews and primary studies. We strived to categorize the main characteristics of the population, interventions, and outcomes measured. Moreover, we designed a sensitive search strategy that was run in several electronic databases without date or language restrictions, and we conducted study selection and data extraction in duplicate.

Our review has several limitations. First, by restricting our review of primary studies to RCTs and controlled observational studies, our findings represent only a portion of relevant research pertaining to DA and their implementation [26-33,38-46]. We took this decision in an effort to synthesize the evidence on DA effectiveness across studies with similar designs and with designs that are more appropriate to assess effects. However, future research could gain valuable insight from qualitative comparative analyses [55]. Second, since very few studies assessed all four categories of outcomes, we were not able to directly assess the association between the characteristics of individual studies of DAs with all outcomes. Future research might benefit from taking a more comprehensive approach to evaluate the impacts of DAs in women facing important decision around childbirth. Third, since we did not include dissertations, theses, or other grey literature sources in this review, we may have missed relevant unpublished findings. While the inclusion of such sources could have captured additional data, we prioritized peer-reviewed and published studies to ensure a consistent level of methodological quality and completeness in reporting.

## Conclusion

This scoping review provides a comprehensive overview of the evidence on the impact of DAs across ODSF's quadruple outcomes. Findings suggest that DAs are more effective when they are associated with a mandatory discussion with a healthcare provider and are combined with additional components, such as women's counselling, prediction models or healthcare provider training. The few studies from LMICs show potentially positive effect. While evidence for low-risk women is limited, DAs show promise in supporting informed and value-based choices. Conversations with healthcare providers remain essential to achieve shared decision-making, empowering women to actively voice their preferences on matters directly affecting their health and well-being. Future research should focus on evaluating all four aim outcomes to strengthen the evidence on the benefits of DAs in peripartum care.

## CRediT authorship contribution statement

**Truc Phuong Nguyen:** Writing – review & editing, Writing – original draft, Methodology, Investigation, Formal analysis, Data curation.
**Ana Pilar Betrán:** Writing – review & editing, Validation, Resources, Data curation.
**Maria Regina Torloni:** Writing – review & editing, Methodology, Data curation.
**Nils Chaillet:** Writing – review & editing, Methodology, Data curation.
**Alexandre Dumont:** Writing – review & editing, Validation, Methodology, Data curation, Conceptualization.

## Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

## Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.ejogrb.2025.114085.

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