It’s MINE! Shared decision-making and evidence-based practice in childbirth

This is a brief, but interesting interview with Maureen Corry, MPH, Executive Director of Childbirth Connection on the subject of shared decision making.

Right off the bat, Corry mentions exactly what came to mind for me when I was confronted with the term “shared decision making”. She says,

…we’ve heard some concerns from women that shared decision making means giving up some control of decision making to the care provider – essentially a move away from informed consent and refusal. Because of the history of childbirth in the United States, and many troubling practices that still happen today, childbearing women are justified in being concerned about their rights.

Always mindful of how things are phrased, my knee-jerk reaction to the term was indeed one of concern based on these issues. I consider it to be of utmost importance that women are given the space, the information and the respect they need to make their own decisions. By using the term “shared” I worry that ownership of that decision is compromised and that it may begin to “belong” as much to the practitioner as it does to the woman giving birth. On the other hand, it is clear that practitioners do have an important role to play in a woman’s decision-making process, as they are usually a primary source of information, which is a fundamental aspect of choice. Making a decision without relevant information is really not making a decision at all, it’s just ‘going with your gut’ – a gut which may already be seeded with fear, anxiety, bias, self-judgement, etc. Furthermore, ensuring that a woman has received the information provided to her and is capable of processing it in the format given is an additional complication. This is why the Maternity Care Shared Decision Making Initiative is partly about developing “decision aids” for women with low literacy skills, a move which I wholeheartedly support. In addition to wondering what the role of the practitioner really is in relation to decision-making, I also am prompted to wonder what other pieces are missing. Where else are women getting the information they need? How is this facilitated? How do we even decide what is relevant or not? On top of these many questions is one of access too; doctors and midwives are covered by OHIP, so it makes sense to make them guardians of information because (almost) everyone can access them, but my sense is that for other reasons they are not ideally positioned for this, as long as there are no supporting roles that are equally accessible.

Obviously, I feel that practitioners have a responsibility to the women they care for. It is as much their job to ensure that we are well-informed about the things they recommend as it is to perform the interventions that we choose. Does this make the decision to have or not to have an intervention performed partly theirs? I think not. They have a role to play in informed-decision making, but I don’t think that that makes it their decision, in whole or in part.

The first decision a woman should be able to make with regard to her labour and birth preferences is choosing her practitioner. True, some women can, as Corry suggests, “vote with their feet” by choosing providers who have demonstrated low-intervention rates, high VBAC rates, etc. and that power may make trusting the practitioner with whom they are “sharing” more straightforward, but choosing a practitioner from a pool of many is a luxury not available to all women equally. For instance, women in rural areas continue to face midwife shortages and women in very remote areas often only have access to one physician and no midwives at all. Even in a large city like Toronto, most women seeking midwives have to wait on a list and as a result will likely not feel that their practitioner options are many (though they may be greater than they realize). Even when women do have a wide variety of practitioners to choose from, are we ensuring that they know their practitioner options and have the evidence-based information they need to select someone? I still encounter many educated women who think they “can’t afford” a midwife, not knowing that that choice is covered by OHIP. Clearly information sharing and the decision-making process starts before a practitioner is even in the picture.

Rather than encouraging us to share our decision-making with our practitioners, who we may or may not have chosen for ourselves, perhaps another route would be to provide coverage (e.g. OHIP) for prenatal education from certified, independent educators. That kind of education, in addition to providing women with the evidence-based information they need, should also include self-advocacy and informed-decision making skills development. This can empower women to request the information they need from their practitioners, as well as seeking it from other sources. It lets them know that they have the right to ask and the right to refuse. Adding a doula to that mix – someone who provides evidence-supported resources but not recommendations, who works for the woman not for the hospital or the government, who has nothing to gain or lose financially based on what kind of birth the woman winds up having – would be a further boon. In covering these two things, we would be strengthening women’s abilities to acquire information and to make evidence-supported, individually appropriate decisions in a context of comfort and support, removing the need for them to share that decision with a person in a position of authority over them. In effect, rather than needing the practitioner share the burden of the decision itself, we’d be making the decision itself a much lighter weight to bear.

Beyond the choice of who will attend her labour, birthing women make many other decisions along the way about their birth preferences – location, comfort measures, tests, support people, medications, etc. In a system where obstetricians make more money for performing caesareans (which also often take less time) than vaginal deliveries, is there not a potential conflict of interest in, for example, that same obstetrician having a say in whether a mom who’s had a previous caesarean should plan a VBAC or schedule another caesarean? This is not to say that every OB out there would make a decision based on profit alone, but a system that, as Corry notes, “still rewards procedure-intensive care rather than high-quality care” makes the notion of sharing these decisions very complicated indeed. What about options that are not provided by the health-care system itself? Will practitioners across the board provide information about doulas, acupuncture and TCM, pelvic floor physiotherapists and the like? If practitioners (i.e. doctors and midwives) are being isolated as co-decision-makers, how do we ensure that all women are getting the same, evidence-based information? Given that there are still practitioners out there performing routine episiotomies when the SOGC has been recommending against them as routine procedures for years, I would be concerned about giving more decision-making power to someone who may not even be aware of the evidence on all fronts, never mind practising according to it.

I realize that what Corry is advocating for is effectively the same as what I am advocating for – a system where women make decisions with the help of practitioners who provide them with the evidence-based information they need to do so in a format that makes sense to them. What I worry about in using the term “shared decision making” is that we are essentially using our language to validate the preferences of an individual whose agenda may include things that are potentially at odds with the health and well-being (both physical and emotional) of the mother and her baby, such as making it home in time for dinner or making more money or fear of liability. In addition to validating the preferences of the practitioner, this initiative doesn’t add anything in terms of access to information and evidence outside of the practitioner’s office. Given that we already have a tendency to make decisions differently when faced with a person in a  position of authority (an understanding of “white coat syndrome” shows that many people respond with measurable fear to the very presence of a doctor, which can impact their responses), is this a concession that can be made without negative consequences? Or conversely, maybe the word ‘shared’ will encourage both practitioners and birthing women to see one another as part of the same team, potentially reducing the effect of the white coat.

Am I worrying too much about the wording when the goal and the reasons behind it are identical to my own? Tell me what you think by answering my poll or responding in the comments.

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