Q&A: Shared decision-making ‘extremely important’ in maternal care

Many pregnant women refrain from asking questions during maternal care visits, according to research published in JAMA Network Open.

Researchers surveyed 2,400 women who delivered in hospitals in the United States from July 2011 through June 2012 to evaluate their communication experiences when receiving maternal care.

They found that more than 41% of the women reported holding back questions from their clinician. Their reasons were that the clinician seemed rushed (29.6%), they were afraid they would be seen as difficult (23.3%) and the care they wanted differed from the care their clinician favored (20.5%).

The researchers also determined that women who held back from asking questions were more than five times more likely to report feeling pressured into an intervention (adjusted OR = 5.3; 95% CI, 4-7.1).

Healio Primary Care spoke with Erika R. Cheng, PhD, MPA, assistant professor of pediatrics at the Indiana University School of Medicine and lead author of the study, to discuss the importance of communication and shared decision-making in maternal care. – by Erin Michael

Q: What is the role of shared decision-making in maternal care? How important is it?

A: Shared decision-making means that patients and their providers share balanced, evidence-based information about benefits and harms of care options and make decisions together. This collaboration is extremely important for pregnant women and their providers because maternity care in the U.S. can be complex and procedure intensive. Decisions made during pregnancy also have considerable implications for the health of women and newborns, meaning that women should be full partners with their providers in making those decisions. Evidence also shows that collaborative decision-making increases patient satisfaction, leads to more positive relations among the care team and builds trust.

Q: Why would some pregnant women feel that they are a burden to physicians for asking questions about their health?

A: This isn’t something we directly examined in our study, but other research has shown that many women have inadequate knowledge to make informed choices about their pregnancies and maternity care. So, obviously, patient education is key; but it’s not just the provision of information that is important. In our study, women who were reluctant to ask their provider questions were also more likely to report discrimination because of their race, ethnicity or health insurance status. We need to work harder to empower women, particularly those who are disadvantaged when it comes to advocating for their health care, to play more active roles in the clinical encounter.

Q: More than 20% of women said they did not ask questions because they wanted care that differed from their physician's preference. What can physicians do to ensure patients are voicing their concerns or disagreements, if they have any?

A: In an ideal scenario, pregnant women and their providers would work together as equal partners to align maternity care decisions with women’s preferences. Our study suggests that women may wish to be more engaged but fear the consequences of doing so. So, the question is “How can we change this?” Educating physicians about the need for safe environments that promote communication for all women is critical. Others have suggested using high-quality, up-to-date decision aids and reorganizing payment and delivery systems so physicians are reimbursed for shared decision-making.

Q: How can pressure or coercion from clinicians negatively impact maternal health?

A: Ensuring patients have authority to making health care decisions for themselves requires more than just giving them information. Patients also need to be able to make those choices without feeling coerced.

Q: What types of interventions can encourage pregnant patients to ask questions?

A: Decision aids, which work to supplement provider counseling, are the most widely tested form of decision support in maternity care. They are typically designed to give patients information about care options when there are multiple options that each have benefits and harms that patients may value differently. Research has shown that such aids offer important benefits to women, including increased knowledge, decisional satisfaction and reduced decisional conflict.

Disclosure: Cheng reports no relevant financial disclosures.