Decision making in pregnancy and childbirth : hopes, expectations and realities

Abstract

Introduction: Pregnant women increasingly expect to be involved in decisions about their care in collaboration with their clinicians. This involves a of sharing information, knowledge, experience and values, by both the woman and the clinician in order to make decisions together. Shared decision making is especially pertinent in the management of pain in labour where there are many options available, with varying degrees of evidence and acceptability. Pregnancy and childbirth is a context in which the appropriateness of shared decision making has been yet to be thoroughly investigated. Objectives The key objectives of this research are as follows:. · To carry out a systematic literature review covering women’s experience of labour and of pain relief in labour;, · To ascertain the views and expectations of various groups of women and professionals using qualitative methodology in order to develop appropriate decision support;, · To develop the most appropriate decision support for choice of pain relief in labour in order to assist women in the decision making process. Methods A qualitative approach was used to gain an in-depth perspective of the experience of women and professionals. Semi-structured interviews were conducted with women at various stages of their pregnancy and during their post natal period, whilst focus groups were undertaken with obstetricians, anaesthetists, delivery suite and community midwives. Data were transcribed verbatim and analysed using the principles of the constant comparison method. My analysis was informed by my relativist approach to my work, understanding that there are multiple realities which need to be examined to gain a full understanding of shared decision making in this context. The themes that emerged were used to identify the issues that were important to the two groups. Results: The three3 key result areas were identified were::- 1. Discordance between expectations and realities Discordance was identified between what women expected in areas such as how painful and how long labour would be, as well as in what support would be provided for example. There was also discordance between what the professionals said they told women and the information women wanted;;. 2. Information Despite the information provision professionals still felt that women were generally unprepared for labour. This ill preparation pointed to information that did not answer questions women were asking, was presented at times when women were not receptive and in a format that was not appropriate;;. 3. Values At no point in pregnancy were women routinely asked what was important to them regarding their labour in relation to pain relief. Understanding a woman’s values would allow a midwife to offer options of pain relief and support that were congruent with these values, thus helping the woman achieve the birth she hoped for. Discussion The information needs of both women and professional’s needs to be recognised to ensure that woman have access to sufficient detail to enable them to engage in decision making. The information should be delivered in a format and at a time which is acceptable to the women and which translates into knowledge. During the antenatal preparation of women it is important for midwives to support women in clarifying what is important them – their values. Clarification of a woman’s values will enable the healthcare professionals to discuss options that fit with women’s values and ensure they receive the support they desire during labour. I propose that during pregnancy we need to ensure women are fully informed about their options, the risks and benefits and are clear of their values, but do make a decision antenatally – merely express a preference. This model of antenatal preparation would ensure that a woman was making decisions during labour in reaction to the level of pain she was experiencing based on her knowledge and how these choices related to her values. Women also need to be made aware antenatally that during labour there are elements of unpredictability and events may rapidly become of a more urgent clinical nature. At times of an emerging urgent clinical situation midwives and clinical staff are in a better position to recommend a course of action rather than deliberate options with the woman. Conclusion To support women and healthcare professionals in engaging in shared decision making the following recommendations needs to be considered. The maternity service needs to refine its information provision including the risks and benefits of each option. Provision needs to be made for those women who require enough information to allow them to make informed decision as well as those who require a greater depth of information. Support needs to be developed for midwives and women to allow them to develop new skills to allow engagement in shared decision making. Developing skills for shared decision making early in pregnancy will equip women to make the many decisions they face during pregnancy and once their baby is born. A critical examination of antenatal education provision needs to undertaken to ensure information is being provided at a time and in a format that is both appropriate and accessible to a wide range of women. Responsibility for preparation needs to be made explicit and suitable resources of information accessed and shared. Finally there needs to be a review of the current birth plan, to assess it’s suitability as a tool for assessment of knowledge, clarification of values and communication to support shared decision making. In conclusion the most appropriate way of supporting women is to ensure that, at the beginning of pregnancy, midwives start to prepare women to make decisions by giving them the skills necessary to be involved in shared decision making. This preparation needs to be underpinned by appropriate information delivered in an accessible manner and informed by what is important to the woman.