Women Need Shared Decision-Making in Childbirth

Recently, the National Center for Health Statistics reported another incremental step in the right direction for maternity care: The overall rate of cesarean delivery in the United States declined for the third year in a row, to 32%.^[1]

Many health system forces are at work to reduce unnecessary cesareans, as well as to reduce overuse of other potentially harmful birth interventions, such as early induction or immediate cord clamping. These are all very important and much-needed efforts—yet, as a Lamaze Certified Childbirth Educator and a labor and delivery nurse, I'm concerned that the most critical element in achieving improved outcomes is overlooked: engaging pregnant women with information and shared decision-making for one of the most important health events in their lives.

A Three-Step Process

Shared decision-making means collaboration between patients and professionals. It is often described as a three-step process: 1) introducing choice; 2) describing options, often by integrating patient decision support tools; and 3) helping patients explore preferences and make decisions.^[2] For this process to work, patients must be equipped with the evidence-based information that they need to make informed decisions. This is as true for maternity care as every other area of healthcare.

Recent national efforts to reduce early elective deliveries (EEDs) provide an example of how important it is to engage all stakeholders in improving maternity care outcomes. In 2009, EED rates were found to be nearly 20%.^[3] Recently, a March of Dimes quality improvement toolkit about the risks of EED to mothers and babies was targeted to clinicians and women. These risks include cesarean section, premature birth, fetal distress, infection, umbilical cord problems, hemorrhage after delivery, and hypoglycemia and jaundice in the infant. When the practice of EED and its risks are taught in childbirth education classes, women had lower rates of babies born at less than 39 weeks' gestation.^[4] As of 2015, with combined efforts by many stakeholders, including childbirth educators, national EED rates are less than 3%.^[3]

This success story shows that engaging all stakeholders, including pregnant women, in maternity care is critical in moving the dial in the desired direction. Health system efforts are also under way to reduce cesarean births among first-time, low-risk pregnant women, the primary group taking childbirth classes. Preventing the first cesarean is a major goal of such organizations as the American Congress of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, and it is one of the maternal, infant, and child health objectives for Healthy People 2020.

Progress has been made to encourage the downward trend in cesarean births and EEDs, but the United States is still the only developed country with a maternal mortality rate that has increased over the past 20 years.^[5] Many of the leading causes of maternal mortality in the United States are preventable, and non-medically indicated procedures increase the risk for short- and long-term complications.^[6,7] Childbirth education can help women on the risks associated with choosing or agreeing to a cesarean birth or EED, which comes with a higher rate of maternal mortality.

Role of Healthcare Professionals

Despite a system-wide push for shared decision-making, barriers for women still exist.

Maternity care professionals can do more to effectively engage the approximately 4 million US women who give birth every year.^[8] For example, a nationally representative survey of new mothers found that 22%-30% of women reported reluctance to engage their providers in discussions regarding their personal childbirth preferences because they felt rushed, their providers had differing opinions, or they did not want to be considered difficult.^[9]

Maternity care professionals have an important role in encouraging women to become educated healthcare consumers. Women need to know what to expect, but they also need support to overcome information barriers on the path to a safe and healthy birth.

Maternity care providers are also faced with barriers to providing women with the information they need. Bundled care means that longer visits are not reimbursed. Some providers may not be well trained to address the variety of concerns or questions women have. By partnering with an organization such as Lamaze International, providers can ensure that women have learned evidence-based information about labor and childbirth and, importantly, how to engage in shared decision-making with their maternity caregivers. Women who take an evidence-based class will be equipped to speak the same language as their caregivers and navigate to optimal care in partnership.

I know that I, and every maternity care professional I work with, want the same thing: safe, healthy, and satisfying outcomes for mothers and babies.

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