Lack of Shared Decision-Making in Maternity Care.
A growing number of policy and practice initiatives encourage healthcare providers to share balanced, evidence-based information about possible benefits and harms of care options, so that the provider and patient can arrive at a decision together. Recent research has linked this shared decision-making with increased patient satisfaction, improved health outcomes, and lower healthcare costs.
But a new study, led by a School of Public Health researcher, suggests maternity care providers are tipping the scales by giving patients much more information in favor of an intervention than against one.
The study, published in the journal Birth, found 68 percent of women who discussed inducing labor for a potentially large baby had an induction, compared to 43 percent of those who didn’t have a discussion. They also found 87 percent of women who discussed the possibility of a repeat cesarean had one, compared to 79 percent of those who didn’t have a discussion.
“At the end of the day, the best predictor of whether or not a mother received an intervention was whatever the clinician wanted in the first place,” says lead author Eugene Declercq, professor of community health sciences. “While the form of shared decision-making appears to be happening, in practice mothers reported a wide imbalance of information provided in favor of interventions.”
The researchers used data from Listening to Mothers III, a national survey developed by Childbirth Connection in collaboration with SPH and an international survey firm.
The researchers identified 349 survey participants who were told their baby may be “getting quite large,” and 393 who had had one or two prior cesareans. They found 47 percent of the women who were told their baby might be large reported having a discussion with their healthcare provider about labor induction versus waiting for labor, while 82 percent of women with a prior cesarean discussed having a repeat cesarean versus planning for a vaginal birth.
More than half of the women who had discussions about inducing labor said their providers spoke “some” or “a lot” (versus “a little” or “not at all”) about reasons for labor induction, while 77 percent of the women with prior cesareans reported their providers spoke “some” or “a lot” about reasons for a repeat cesarean. Almost all of the women who had a discussion said their providers discussed points in favor of the intervention at least “a little,” but 29 percent of providers failed to mention any reason not to induce labor, and 40 percent failed to mention any reason not to have a repeat cesarean.
Additionally, 27 percent of mothers with prior cesareans and 18 percent of mothers whose babies might be large said that their providers had not explained that they had choices.
The researchers also noted disparities in who had these discussions at all. Women who had discussions about inducing labor were most likely to be between the ages of 25 and 34, non-Hispanic white, privately insured, and have higher levels of income and education. Women with prior cesareans who did not discuss having a repeat cesarean were most likely to have lower incomes, less than a college degree, and be Hispanic.
“Both best evidence and national professional guidance discourage the liberal or routine use of interventions for the decisions examined here, yet at least two-thirds of women who engaged in discussions with care providers about these procedures experienced them,” Declercq says. “This has major implications for maternity care quality, outcomes, and costs.”
The study was co-authored by Erika Cheng of the Department of Pediatrics at Indiana University School of Medicine and Carol Sakala of the National Partnership for Women and Families.
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