Subjective risk vs. objective risk can lead to different post-cesarean birth decisions based on multiattribute modeling

Objective: To compare birth recommendations for pregnant women with a prior cesarean produced from a decision model using absolute risks vs. one using subjective interpretation of the same risks: (1) a multiattribute decision model based on patient prioritization of risks (subjective risk) and (2) a hybrid model that used absolute risks (objective risk). Study Design and Setting: The subjective risk multiattribute model used the Analytic Hierarchy Process to elicit priorities for maternal risks, neonatal risks, and the delivery experience from 96 postnatal women with a prior cesarean. The hybrid model combined the priorities for delivery experience obtained in the first model with the unadjusted absolute risk values. Results: The multiattribute model generated more recommendations for repeat cesarean delivery than the hybrid model: 73% vs. 18%, (P-value <0.001). The multiattribute model favored repeat cesarean because women heavily prioritized avoiding any risk (even rare risk) to the infant. The hybrid model favored the trial of labor because of lower probabilities of risk to the mother and its high success rate of vaginal birth after cesarean. Conclusion: This study highlights the importance of patients and clinicians discussing the patient's priorities regarding the risks and other nonclinical considerations that may be important to her in the birthing decision.