Visual aids for induction of labor education: a randomized controlled trial

Background: Approximately 20% of patients in the United States undergo an induction of labor (IOL). Patients undergoing induction are more likely to report lower birth satisfaction, especially Black patients. Visual aids have been shown to improve patient satisfaction in medical decision-making, however, there are few studies investigating the use of visual aids for IOL counseling. Objective: To compare standard counseling for IOL to standard counseling plus a patient-informed visual aid and evaluate differences in patient knowledge of IOL and satisfaction with counseling. Study design: This was a randomized controlled trial of patients with singleton gestations ≥37 weeks admitted for IOL. Patients who were <18 years old, non-English speaking, with prior cesareans, fetal anomalies, intrauterine fetal demise, or whose induction agent had already been determined were excluded. We developed a visual aid handout on induction methods with input from patients that had recently undergone an induction. On admission, patients were randomized to routine counseling or counseling with the visual aid. The primary outcome was patient knowledge, using questions adapted from a published IOL knowledge assessment. Our secondary outcome was satisfaction with IOL counseling, rated on 0 to 10 scale. Eighty-four patients (42 in each arm) were required to detect a 25% difference in knowledge scores with 85% power. We used an intention-to-treat approach for our analyses; we compared the percentage of correct answers on the IOL knowledge assessment and satisfaction with IOL counseling using Wilcoxon rank sum. We conducted planned stratified analyses by historically marginalized race, level of education, and insurance type. Results: Eighty-four patients were randomized; 39% self-identified as Asian, Black, or Hispanic. The percentage of correct IOL knowledge answers were similar between the visual aid group and the standard counseling group: median 80 (IQR: 60–90) versus 70 (60–90), P=.23. We observed no significant differences between groups after stratifying by historically marginalized race and ethnicity, insurance type, or level of education. Satisfaction with counseling scores were similar between participants receiving the visual aid compared to regular counseling: 9 (8–10) versus 10 (9–10), P=.08. Conclusion: The introduction of a patient-informed visual aid did not change IOL knowledge or satisfaction with counseling compared to standard counseling. Future directions include modifying the visual aid using patient feedback and evaluating its implementation earlier in antenatal care.