A team of prenatal care providers (two midwives, an obstetrician, and a family medicine physician) from Boston Medical Center and a public health expert from the Boston University School of Public Health collaborated to create the initial prototype in alignment with International Patient Decision Aid Standards. We then used a quality improvement process to test and refine the decision aid and made changes to it based on feedback from a diverse group of pregnant people and medical providers.

From the prototype to the final product we designed for equity. This looked like selecting a safety net hospital with a very diverse group of pregnant patients as our development and testing site, testing it in three languages from the beginning, solving for a SMOG reading level of grade 6, and choosing to use diverse and inclusive images and language.

To learn more: read the article published in Birth describing the development and testing process here.

From there, we worked with the product design agency, Blink UX, to conduct user experience (UX) research and design the digital experience for the induction decision aid. In this process we continued to listen to Black and brown birthing people with Medicaid insurance. We updated the paper tool to complement the web experience and will be testing and further refining both in 2024.

The decision aid includes evidence from the most recent peer-reviewed systematic reviews of randomized controlled trial data and a recent systematic review of qualitative studies. The full list of citations is included on the decision aid. You can read more about the evidence used and considered in the Provider FAQ document.

To create and refine the original decision aid, we used a quality improvement process to test and refine the tool. We conducted qualitative interviews with pregnant people who used the tool to assess outcomes related to shared decision-making and get feedback. We interviewed a very diverse group of 6-9 pregnant people during each testing cycle (24 total). Additionally we sought feedback from the nine medical providers who piloted the tool in one on one sessions.

See more detail about this in article about it published in Birth here.

Blink UX did user testing with people who were Black and/or Latine, had Medicaid insurance, and were pregnant or recently postpartum when they designed the web experience in 2022.

We will be using similar methods to test implementation and impact of this new version with testing sites in 2024 to refine it.

A very diverse group of pregnant people who used the tool gave feedback on their experience. They learned a lot about induction, understood that they had more than one option, could name pros and cons of each option, and felt that the decision regarding if and when to have labor induction was theirs or one they shared with their provider. Many of them used powerful words to describe what it meant to them for their provider to give them this decision aid and support them in making a decision that was right for them - words like “awesome” and “empowering”.

Medical providers (obstetricians, midwives, and nurse practitioners) who tested the tool said it improved the quality and consistency of their care and reduced bias in their care.

This decision aid should be used by pregnant people who have no medical reason for induction and their medical providers. In testing it worked best for a medical provider to give their pregnant patient a paper copy of the decision aid and discuss the decision some time between 36 and 39 weeks, depending on the preferences and values of the pregnant person.

The team of medical providers and public health professionals who created the tool made a one page application guide for other institutions. It can be accessed here. This guide includes how to use the paper version and will be updated once we have learnings from implementation sites on using the web component.

Please contact us about support in adopting and implementing the tool in your setting by emailing Ann Peralta at aperalta@partnertodecide.org.

This decision aid above summarizes the evidence about induction timing when there is no medical reason (or indication) for labor induction. If you are wondering about a specific medical reason you can see the latest American College of Obstetricians and Gynecologists guidelines here (table 1).

While the new version is being tested and refined, we will continue to host the original version as well. Please note this has not been updated with a newer systematic review that better addresses the randomized controlled trial evidence about 39 week inductions. You can find the original version and information here.