Who gets to decide?

One of the areas I looked at in my doctoral research was about how decisions were made about the sort of fetal heart rate monitoring women would use during labour, and who made those decisions. You can read more about it here. Women were given limited and sometimes biased advice and midwives felt they needed to encourage women to make decisions aligned with hospital policy. Obstetricians rarely participated in decisions about which approach to use, and when they did, they acted as an interpreter of hospital policy rather than engaging with women to support their decision making.

The phenomenon of excluding women from decision making about issues affecting their pregnancy and birth has also been examined more broadly, rather than only relating to fetal heart rate monitoring. Vanessa Watkins, from the Centre for Quality and Patient Safety at Deakin University and colleagues from both Australia and the UK examined women’s experiences of collaboration and decision making in maternity care in the state of Victoria (Australia). Their paper, called Labouring Together was published in July 2022, and highlights the widespread nature of the problem.

How was the research done?

182 women who had given birth in one of four maternity hospitals in Victoria were surveyed during their postnatal hospital stay. They recruited women who had experienced care in midwifery group practice, midwifery shared care, GP shared care, obstetric high risk, public hospital maternity, and private obstetric care models. The survey assessed the degree to which women wanted to have control over decisions made during their care, and the amount of control they actually experienced. A selection of women were also interviewed after hospital discharge. As well as assessing their experiences of collaboration and decision-making, the extent to which women experienced decisional-conflict was assessed.

Most women wanted to be involved in decision-making but many didn’t get what they wanted

35% of women who responded to the survey said they wanted an active role in decision-making, 48% wanted a shared role in decision-making with their maternity professional, and 17% wanted a passive role. Women in private obstetric care were more likely to prefer a passive role (29%). 49% of women reported experiencing shared decision-making, and there was a close to equal split between passive and active decision-making experiences for the remainder of the women.

On the face of it that seems pretty good. But when the researchers compared the type of decision-making approach women wanted and what they got, the rates of concordance show a different picture. About half of the women reported experiencing a decision-making approach that was different to the approach they wanted to experience, and when there was discordance 88% of the time women experienced less decisional control than they desired. Women in private obstetric care were much less likely to experience the sort of decision-making they wanted (77%).

Organisation of care

Findings from the interviews were described in relation to two themes: Organisation of care and Woman-centred care. Under the theme of organisation of care, women described the process of navigating the public system as confusing and often being unable to access their preferred care option due to organisational constraints. Women using the private system had a very different experience, finding the system easy to navigate and the option of a longer postnatal stay was valued.

Women described experiencing inflexible organisational culture and some experienced resistance to their attempts to take an active role in decision-making. One women described the lack of respect she experienced in relation to her birth plan:

If you pull out your birth plan you inevitably get the “things don’t always go according to plan”, and their eyes roll back. And I think that is a really unhelpful way to go.”
p. 10

Woman-centred care

Women who were not able to access continuity of carer found it challenging to build a relationship in order to feel safe discussing their choices. Most women felt comfortable discussing their concerns with midwifery staff, though one women described having a sense of “luck” when experiencing care from an obstetrician who addressed her questions and supported her decisions. Women in private obstetric care valued the relational continuity they experienced with their obstetrician but noted the absence of midwifery continuity in the postnatal period.

In the interviews, women also expressed their intention to take an active or shared role in decision-making, and described how the development of an emergency situation, or having complex physical or mental health care needs resulted in them being bypassed in the decision-making process. In contrast, women accessing private care described being comforted by the financial arrangement with their obstetrician, knowing this meant they didn’t need to make decisions, for example:

We were happy to pay for his expertise, so we did not need to worry or to second guess his suggestions.
p. 11

Two of the hospitals women were recruited from used hand-held records, and women described feeling that this went some way towards compensating for a lack of relational continuity. Women described confidence in accessing a variety of information sources to support their decision-making conversations with maternity professionals.

In summary

The authors concluded:

Findings from the Labouring Together study indicate that the majority of childbearing women would prefer to participate in collaborative decision-making with clinicians to develop plans for maternity care relevant to their individual context, health, and wellbeing. However, effective collaboration and shared decision-making with women are not routine practice and woman’s autonomy is hindered by a variety of factors; primarily the dominant discourse of risk avoidance at the micro, meso and macro levels of maternity care that ultimately veto choice.
p. 12

We clearly have some way to go in Australia to recognise women’s autonomy in maternity services. My own research identified the role that hospital, state, and national policy played in undermining women’s autonomy. This is a system issue, not an individual clinician issue, and as such the solutions need to begin at a system level. I look forward to the day when any clinician not providing women-centred care will find themselves very much at odds with organisational norms.

References

Watkins, V., Nagle, C., Kent, B., Street, M., & Hutchinson, A. M. (2022, Jul 2). Labouring Together: Women’s experiences of “Getting the care that I want and need” in maternity care. Midwifery, 113, 103420. https://doi.org/10.1016/j.midw.2022.103420

Categories: New research

Tags: collaboration, Continuity of care, decision making, midwife, woman-centred care

Birth Small Talk

Talking about birth