Evaluating childbirth options for women with obesity: a multi-criteria decision analysis

Childbirth in women with obesity (body mass index ≥30 kg/m²) has been linked to high medical intervention rates, adverse biomedical and psychosocial outcomes, and increased resource utilization. Person-centered decision-making on high-quality childbirth care should thus account for biopsychosocial and resource-related considerations aligned with individual preferences. This study evaluated childbirth options for women with obesity across obstetric scenarios by integrating multidimensional goals of care and stakeholder preferences with empirical evidence.

We employed multi-criteria decision analysis (MCDA) using multi-attribute value theory (MAVT). The study population included women with obesity and term, singleton, cephalic pregnancies without compelling indications for cesarean birth. Options encompassed vaginal birth and intrapartum cesarean birth, each with either standard hospital care or continuous midwifery care, and prelabor cesarean birth. Stakeholder-informed goals related to biomedical safety, physiological processes, psychosocial care experience, physical strain for care providers, care setting resource use, and direct healthcare costs. Scenarios accounted for cesarean birth history and maternal comorbidities. We estimated the goal performance of the options using Swiss hospital inpatient data from 22,464 childbirths among women with obesity and assessments from experienced experts. To illustrate how stakeholder preferences may influence person-centered decision-making, we considered four hypothetical extreme and three real preference profiles. All data were aggregated into the options' overall values using a non-additive MAVT model. Sensitivity analyses addressed preference uncertainty. Direct healthcare costs were mapped onto the aggregated value of all other goals in cost-benefit visualizations.

Vaginal birth with standard hospital care or continuous midwifery care achieved similar or higher overall values compared to cesarean birth across a wide range of preference profiles. Prelabor and intrapartum cesarean birth generally achieved lower or comparable overall values, with greater variability depending on stakeholder preferences. Cost-benefit visualizations showed that vaginal birth provided good value at the lowest costs. Findings were largely consistent across obstetric scenarios.

This study highlights the importance of integrating multidimensional goals and stakeholder preferences into decision-making on childbirth options, alongside empirical data. In doing so, vaginal birth with either model of care performed well across the considered scenarios and preference profiles, though the findings should not be interpreted as prescriptive. This MCDA approach offers a novel framework to support evidence-based and person-centered decision-making deliberations on high-quality childbirth care for women with obesity.