Achieving Shared Decision Making in Maternity Care

Above photo:  No one is more invested in that baby than she is.

One of my dear expectant mothers is going through the ringer right now. She’s been classified as high risk, and her doctors are recommending increasing levels of monitoring. When she asks questions about the necessity of this monitoring – the trips to the hospital, the waiting around, baby’s exposure to so much ultrasound, the stress and constant uncertainty – the doctors frighten her with the worst case scenario.

“Well, we can’t force you to come in,” they say, “But mothers who don’t take this seriously wind up with dead babies.”

So she complies with their recommendations.  Who wouldn’t?

In recent decades, medical care has evolved from a paternalistic model to an information model.[i] In the paternalistic model, we collectively agreed that Doctor knew best and followed advice without question. The chief advantage of this model was relief from responsibility. In the information model, Doctor gives the patient a complete picture of her health and all courses of action. Doctor and patient then discuss all the options and arrive at “shared decision making”: a course of care that respects both the patient’s values and the physician’s expertise. The chief advantage of this model is the patient has a feeling of control.

The trouble is, this idea of shared decision making rarely is achieved, particularly in maternity care. Mothers end up feeling responsible for care they effectively were frightened into. This post will describe the hurdles to shared decision making and what you can do to make shared decision making not just an ideal but a reality.

The ideal of the information model is rarely achieved in medicine due to two essential imbalances:

1. Information asymmetry. Atul Gawande is a physician who writes about the costs of health care overtreatment. In his recent New Yorker article “Overkill,” he describes how patients are at a disadvantage when discussing treatment options with their physicians: the doctors simply know a lot more than they do. He writes, “One major problem is what economists call information asymmetry. In 1963, Kenneth Arrow, who went on to win the Nobel Prize in Economics, demonstrated the severe disadvantages that buyers have when they know less about a good than the seller does. His prime example was health care. Doctors generally know more about the value of a given medical treatment than patients, who have little ability to determine the quality of the advice they are getting. Doctors, therefore, are in a powerful position. We can recommend care of little or no value because it enhances our incomes, because it’s our habit, or because we genuinely but incorrectly believe in it, and patients will tend to follow our recommendations.”
2. Power asymmetry. It’s hard to question a physician, even harder to disagree with one. New York Times contributor Dr. Pauline Chen addresses the gap between the ideal of shared decision making and the reality in “Afraid to Speak Up at the Doctor’s Office” (2012). She cites a research study published in Health Affairs which demonstrated how even the most educated, affluent patients are intimidated in the clinical setting. Participants said they wanted to collaborate in their care but worried about upsetting or angering their doctors, who were more authoritarian than authoritative; some feared retribution and preferred to research treatment options on their own to trying to discuss them with their physicians.

The institutional and social forces against your empowerment in a medical setting are enormous. In my years as a birth educator I have seen countless strong women, armed with information and intentions, get not the shared decision making they desire but the care their physician always gives.

What to do? If your pregnancy is low risk:

1. Don’t give birth in a hospital. Why organize one of the most important moments of your life around the very small risk of emergency and walk into a 35% risk of cesarian? After years of study, Britain’s National Health Service now recommends out of hospital birth – that is, at an independent, midwife-run birth center or at home with a trained attendant – for low risk mothers who have given birth at least once before. Why? Because the risk of over-intervention in hospital outweighs the risks of under-intervention out of hospital. Recently Dr. Neel Shah, an American obstetrician, argued in the New England Journal of Medicine that many American mothers would be better off giving birth in the UK because, he says, of our culture of over-intervention.
2. Don’t choose an obstetrician for your birth attendant. They are not trained to support physiologic birth. You read that correctly: they are not trained to support physiologic birth. They are trained to actively manage every phase of your birth, from the start of labor through to the birth of the placenta. And how are they doing? They are successful only two-thirds of the time at helping you to achieve the vaginal birth you desire. One-third of the time they resort to the other thing they are trained to do: surgery. Whereas shared authority is inherent to the midwifery model of care. Furthermore, midwives are trained to support physiologic birth, and that includes knowing when to transfer care to a surgical specialist (an obstetrician).

If, like my client, your pregnancy is high risk and midwifery care is not an option for you, here are some suggestions for empowerment in the medical setting:

1. Go to appointments with support. This person is there to ask questions, to help you represent your values and for moral support. A doula is ideal for this role. A friend who is a mother is also a great bet. Your partner, however, is likely to be just as susceptible to fear as you are, as is your own mother, so I don’t recommend them for this particular job.
2. Make relaxation (not research) your job. You are probably under a lot of stress and think you can put your mind at ease by researching your condition. But you cannot think yourself out of stress or out-information your doctor. The best use of your energy now is active relaxation of body and mind. Before, during and after medical appointments, spend more of your time in active relaxation than seems reasonable. It will give you the peace your body and baby need to stay healthy, and it will facilitate the next item.
3. Connect to your intuition. You do have access to knowledge that your care providers do not: your intuition. We’ve been socialized to overvalue the specialized knowledge and technology that medical providers are masters of, but there are other ways of knowing. If your provider is proposing an intervention, get the information you can with the help of your support person. Then ask for a few minutes of privacy to think it over. Once you’re alone, drop into relaxation and ask for internal guidance. Ask Baby.  Listen for guidance, which comes in many forms:  a physical sensation, an emotion, an image.  Trust it.

The hurdles to shared decision making with a doctor are real. But if you are low risk, you’re in luck: that model is thriving in midwifery care, particularly outside of hospitals. If you need obstetric care, however, recognize what you’re up against and support yourself accordingly, enlisting a doula and strengthening and empowering yourself through relaxation and intuition.

How about you?  Did you achieve shared decision making with your maternity care provider?  How did you do it?  Tell your story in the comments!

[i] I first read about health care models in Atul Gawande’s book Being Mortal (2015). I found more information on it online in an article called, “Four Models of the Physician-Patient Relationship,” by Ezekiel and Linda Emanuel, published in The Journal of the American Medical Association. [April 22, 1992 v 267 n 16 p 2221(6)].