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Neergheen VL, Chaer LE, Plough A, Curtis E, Paterson VJ, Short T, Bright A, Lipsitz S, Murphy A, Miller K, Subramanian L, Radichel E, Ervin J, Castleman L, Brown E, Yeboah T, Simas TM, Terk D, Vedam S, Shah N, Weiseth A. Assessing patient autonomy in the context of TeamBirth, a quality improvement intervention to improve shared decision-making during labor and birth. Birth 2024. [PMID: 39140579 DOI: 10.1111/birt.12857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 06/10/2024] [Accepted: 07/24/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND Respectful maternity care includes shared decision-making (SDM). However, research on SDM is lacking from the intrapartum period and instruments to measure it have only recently been developed. TeamBirth is a quality improvement initiative that uses team huddles to improve SDM during labor and birth. Team huddles are structured meetings including the patient and full care team when the patient's preferences, care plans, and expectations for when the next huddle will occur are reviewed. METHODS We used patient survey data (n = 1253) from a prospective observational study at four U.S. hospitals to examine the relationship between TeamBirth huddles and SDM. We measured SDM using the Mother's Autonomy in Decision-Making (MADM) scale. Linear regression models were used to assess the association between any exposure to huddles and the MADM score and between the number of huddles and the MADM score. RESULTS In our multivariable model, experiencing a huddle was significantly associated with a 3.13-point higher MADM score. When compared with receiving one huddle, experiencing 6+ huddles yielded a 3.64-point higher MADM score. DISCUSSION Patients reporting at least one TeamBirth huddle experienced significantly higher SDM, as measured by the MADM scale. Our findings align with prior research that found actively involving the patient in their care by creating structured opportunities to discuss preferences and choices enables SDM. We also demonstrated that MADM is sensitive to hospital-based quality improvement, suggesting that future labor and birth interventions might adopt MADM as a patient-reported experience measure.
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Affiliation(s)
- Vanessa L Neergheen
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Lynn El Chaer
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Avery Plough
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Elizabeth Curtis
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Victoria J Paterson
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Trisha Short
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Amani Bright
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Stuart Lipsitz
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Aizpea Murphy
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Kate Miller
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Laura Subramanian
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Evelyn Radichel
- Hillcrest Medical Center, Peggy V. Helmerich Women's Health Center, Tulsa, Oklahoma, USA
| | - John Ervin
- Hillcrest Medical Center, Peggy V. Helmerich Women's Health Center, Tulsa, Oklahoma, USA
| | - Lindsay Castleman
- Department of Obstetrics and Gynecology, Oklahoma State University Medical Center, Tulsa, Oklahoma, USA
| | - Erin Brown
- Department of Obstetrics and Gynecology, Oklahoma State University Medical Center, Tulsa, Oklahoma, USA
| | - Tracy Yeboah
- Department of Obstetrics and Gynecology, Chan Medical School, University of Massachusetts, Worcester, Massachusetts, USA
- Department of Obstetrics and Gynecology, UMass Memorial Health-UMass Memorial Medical Center, Worcester, Massachusetts, USA
| | - Tiffany Moore Simas
- Department of Obstetrics and Gynecology, Chan Medical School, University of Massachusetts, Worcester, Massachusetts, USA
- Department of Obstetrics and Gynecology, UMass Memorial Health-UMass Memorial Medical Center, Worcester, Massachusetts, USA
| | - Daniel Terk
- Department of Obstetrics and Gynecology, UMass Memorial Health-HealthAlliance-Clinton Hospital, Clinton, Massachusetts, USA
| | - Saraswathi Vedam
- Birth Place Lab, University of British Columbia, Vancouver, British Columbia, Canada
| | - Neel Shah
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Amber Weiseth
- Ariadne Labs, Boston, Massachusetts, USA
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Chantry AA, Merrer J, Blondel B, Le Ray C. Preferences for labor and childbirth, expressed orally or as a written birth plan: Prevalence and determinants from a nationwide population-based study. Birth 2023; 50:847-857. [PMID: 37382211 DOI: 10.1111/birt.12728] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/08/2023] [Accepted: 05/06/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Shared decision-making is an important component of a patient-centered healthcare system. We assessed the prevalence of parturients with preferences for their labor and childbirth, expressed verbally in the birthing room or as a written birth plan, and studied maternal, obstetric, and organizational factors associated with their expression. METHODS Data came from the 2016 National Perinatal Survey, a cross-sectional nationwide population-based survey conducted in France. Preferences for labor and childbirth were studied in three categories: expressed verbally, in writing (birth plan), or unexpressed or nonexistent. Analyses used multinomial multilevel logistic regression. RESULTS The analysis included 11,633 parturients: 3.7% had written a birth plan, 17.3% expressed their preferences verbally, and 79.0% either did not have or did not express any preferences. Compared with the latter group, written or verbal preferences were both significantly associated with prenatal care by independent midwives (respectively, adjusted odds ratio (aOR) 2.19; 95% confidence interval (CI), [1.59-3.03], and aOR 1.43; 95% CI [1.19-1.71]) and with attendance at childbirth education classes (respectively, aOR 4.99; 95% CI [3.49-7.15], and aOR 2.27; 95% CI [1.98-2.62]). As years in traditional schooling increased, so did its association with preferences. Conversely, parturients from African countries were significantly less likely than French mothers to express preferences. A written birth plan was also associated with characteristics of maternity unit organization. CONCLUSION Only one in five parturients reported having expressed preferences for labor and childbirth to healthcare professionals in the birthing room. This expression of preferences was associated with maternal characteristics and the organization of care.
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Affiliation(s)
- Anne Alice Chantry
- Université Paris Cité, Center of Research in Epidemiology and Statistics/CRESS/Obstetrical Pediatric and Perinatal Epidemiology Research Team (EPOPé), INSERM, INRA, Paris, France
- Baudelocque Midwifery School, AP-HP, Université Paris Cité, Paris, France
| | - Jade Merrer
- Université Paris Cité, Center of Research in Epidemiology and Statistics/CRESS/Obstetrical Pediatric and Perinatal Epidemiology Research Team (EPOPé), INSERM, INRA, Paris, France
| | - Béatrice Blondel
- Université Paris Cité, Center of Research in Epidemiology and Statistics/CRESS/Obstetrical Pediatric and Perinatal Epidemiology Research Team (EPOPé), INSERM, INRA, Paris, France
| | - Camille Le Ray
- Université Paris Cité, Center of Research in Epidemiology and Statistics/CRESS/Obstetrical Pediatric and Perinatal Epidemiology Research Team (EPOPé), INSERM, INRA, Paris, France
- Port-Royal Maternity Unit, Department of Obstetrics, Cochin Broca Hôtel-Dieu Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), FHU PREMA, Paris, France
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Chao GF, Yang J, Peahl A, Thumma JR, Dimick JB, Arterburn DE, Telem DA. Births After Bariatric Surgery in the United States: Incidence, Obstetric Outcomes, and Reinterventions. Ann Surg 2023; 277:e801-e807. [PMID: 35762610 PMCID: PMC9794635 DOI: 10.1097/sla.0000000000005438] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To characterize incidence and outcomes for bariatric surgery patients who give birth. BACKGROUND Patients of childbearing age comprise 65% of bariatric surgery patients in the United States, yet data on how often patients conceive and obstetric outcomes are limited. METHODS Using the IBM MarketScan database, we performed a retrospective cohort study of female patients ages 18 to 52 undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass from 2011 to 2017. We determined the incidence of births in the first 2 years after bariatric surgery using Kaplan-Meier estimates. We then restricted the cohort to those with a full 2-year follow-up to examine obstetric outcomes and bariatric-related reinterventions. We reported event rates of adverse obstetric outcomes and delivery type. Adverse obstetric outcomes include pregnancy complications, severe maternal morbidity, and delivery complications. We performed multivariable logistic regression to examine associations between birth and risk of reinterventions. RESULTS Of 69,503 patients who underwent bariatric surgery, 1464 gave birth. The incidence rate was 2.5 births per 100 patients in the 2 years after surgery. Overall, 85% of births occurred within 21 months after surgery. For 38,922 patients with full 2-year follow-up, adverse obstetric event rates were 4.5% for gestational diabetes and 14.2% for hypertensive disorders. In all, 48.5% were first-time cesarean deliveries. Almost all reinterventions during pregnancy were biliary. Multivariable logistic regression analysis showed no association between postbariatric birth and reintervention rate (odds ratio: 0.93, 95% confidence interval: 0.78-1.12). CONCLUSIONS In this first national US cohort, we find giving birth was common in the first 2 years after bariatric surgery and was not associated with an increased risk of reinterventions. Clinicians should consider shifting the dialogue surrounding pregnancy after surgery to shared decision-making with maternal safety as one component.
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Affiliation(s)
- Grace F. Chao
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Veterans Affairs Ann Arbor, Ann Arbor, MI
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Jie Yang
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Alex Peahl
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Jyothi R. Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Justin B. Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - David E. Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Dana A. Telem
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
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Wong HYC, Asim S, Feng Q, Fu SXH, Sahota DS, So PL, Dong D. Effectiveness of Interactive Digital Decision Aids in Prenatal Screening Decision-making: Systematic Review and Meta-analysis. J Med Internet Res 2023; 25:e37953. [PMID: 36917146 PMCID: PMC10131906 DOI: 10.2196/37953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 12/20/2022] [Accepted: 01/31/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Increasing prenatal screening options and limited consultation time have made it difficult for pregnant women to participate in shared decision-making. Interactive digital decision aids (IDDAs) could integrate interactive technology into health care to a facilitate higher-quality decision-making process. OBJECTIVE The objective of this study was to assess the effectiveness of IDDAs on pregnant women's decision-making regarding prenatal screening. METHODS We searched Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO, World Health Organization International Clinical Trials Registry Platform, Google Scholar, and reference lists of included studies until August 2021. We included the randomized controlled trials (RCTs) that compared the use of IDDAs (fulfilling basic criteria of International Patient Decision Aid Standards Collaboration and these were interactive and digital) as an adjunct to standard care with standard care alone and involved pregnant women themselves in prenatal screening decision-making. Data on primary outcomes, that is, knowledge and decisional conflict, and secondary outcomes were extracted, and meta-analyses were conducted based on standardized mean differences (SMDs). Subgroup analysis based on knowledge was performed. The Cochrane risk-of-bias tool was used for risk-of-bias assessment. RESULTS Eight RCTs were identified from 10,283 references, of which 7 were included in quantitative synthesis. Analyses showed that IDDAs increased knowledge (SMD 0.58, 95% CI 0.26-0.90) and decreased decisional conflict (SMD -0.15, 95% CI -0.25 to -0.05). Substantial heterogeneity in knowledge was identified, which could not be completely resolved through subgroup analysis. CONCLUSIONS IDDAs can improve certain aspects of decision-making in prenatal screening among pregnant women, but the results require cautious interpretation.
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Affiliation(s)
- Hong Yat Conrad Wong
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong.,Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Saba Asim
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Qi Feng
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Sherry Xiao-Hong Fu
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Daljit Singh Sahota
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Po Lam So
- Department of Obstetrics and Gynaecology, Tuen Mun Hospital, Tuen Mun, Hong Kong
| | - Dong Dong
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong.,Shenzhen Research Institute, The Chinese University of Hong Kong, Shenzhen, China
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Kalpakjian CZ, Haapala HJ, Ernst SD, Orians BR, Barber ML, Mulenga L, Bolde S, Kreschmer JM, Parten R, Carlson S, Rosenblum S, Jay GM. Development and pilot test of a pregnancy decision making tool for women with physical disabilities. Health Serv Res 2023; 58:223-233. [PMID: 36401816 PMCID: PMC9836953 DOI: 10.1111/1475-6773.14103] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Design and pilot test a new decision making tool for women with physical disabilities (impairment of physical function due to chronic conditions) considering pregnancy. DATA SOURCES AND STUDY SETTING Quantitative surveys and qualitative interviews were collected from participants living in the community. STUDY DESIGN Clinical guidelines and survey and focus group data about pregnancy informational and decisional needs guided content development. The tool was pilot tested in a 12-week trial with participants with physical disabilities considering or actively planning a pregnancy. Feasibility outcomes were acceptability, implementation, and demand (collected at end of the trial); preliminary efficacy focused on decisional conflict and readiness (baseline, 6 weeks, and end of trial). DATA COLLECTION Survey data were collected using an online form. One-on-one interviews were conducted to learn more about experience using the tool. PRINCIPAL FINDINGS Thirty eight participants with mild, moderate, or severe physical disabilities participated. Feasibility outcomes indicated that the tool provided participants with information, guiding questions, and helped them to consider multiple aspects of the decision about pregnancy. Most participants responded positively to the new decision making tool, finding it easy to use and the information balanced. Feedback highlighted opportunity for improvement, such as more specific information, peer stories, and the limitations of a paper format. There was significant linear effect of time, with increased decisional certainty and readiness, values clarity, and decisional support (partial η2 [90% CI] = 0.310 [0.08, 0.46], 0.435 [0.19, 0.60], 0.134 [0, 0.29], 0.178 [0.01, 0.35], respectively). Decisional certainty and readiness had high observed power (96.7% and 99.3%, respectively) with lower observed power for clarity and support (60.6% and 75.1%, respectively). CONCLUSIONS The new tool shows promise for supporting women with physical disabilities in navigating pregnancy decision making. Future development of complementary strategies to support health care providers will help improve shared decision making and patient-centered care.
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Affiliation(s)
- Claire Z. Kalpakjian
- Department of Physical Medicine and RehabilitationUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Heidi J. Haapala
- Department of Physical Medicine and RehabilitationUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Susan D. Ernst
- Department of Obstetrics and GynecologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | | | | | - Lukonde Mulenga
- Department of Physical Medicine and RehabilitationUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Shannen Bolde
- Department of Physical Medicine and RehabilitationUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Jodi M. Kreschmer
- Department of Physical Medicine and RehabilitationUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Rebecca Parten
- Department of Physical Medicine and RehabilitationUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Susan Carlson
- Department of Obstetrics and GynecologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
- Department of Obstetrics and GynecologyDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Sara Rosenblum
- Department of Physical Medicine and RehabilitationUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Gina M. Jay
- Department of Physical Medicine and RehabilitationUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
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Wiggins D, Hundley VA, Bond C, Wilkins C, Walton G. Could a decision support tool be the key to supporting choice for women regarding place of birth? Midwifery 2023; 117:103564. [PMID: 36525895 DOI: 10.1016/j.midw.2022.103564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 08/09/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess the effectiveness of using an innovative decision aid, MyBirthplace, to facilitate shared decision-making regarding place of birth. DESIGN A quasi-experimental study comparing pre-test and post-test responses from participants who had access to the intervention. SETTING A large urban hospital in the south of England. PARTICIPANTS All pregnant women who accessed maternity care between April and December 2016. INTERVENTION A decision aid (MyBirthplace) designed to provide information and support regarding place of birth. The digital tool (available in both an app and web-based version) was used to facilitate discuss between the women and her midwife at the booking visit. MEASUREMENTS Women's stage of decision making as measured by the Stage of Decision Making Scale. A questionnaire was administered before and after using MyBirthplace at booking, and again at 28 weeks gestation. FINDINGS Nearly half the women (42.1%) had already decided where they wanted to give birth before the booking appointment, but a third (34.3%) had not yet begun to think about their choices. The introduction of the decision aid during the booking visit was associated with a significant increase in the stage of decision making suggesting that women had greater certainty in their decision P< 0.0001 [SD 1.077]. Women who accessed MyBirthplace had lower decisional conflict after the booking appointment than those women that did not access the decision aid (35.5% compared with 22.0%) but this difference was not statistically significant. KEY CONCLUSIONS Decision aids, as a standard part of practice, have the potential to ensure women are informed of their options and encourage shared decision making about place of birth. Women were more confident with their decision following the booking appointment and by 28 weeks; however, further research is needed to identify the role that the decision aid played in building this confidence. IMPLICATIONS FOR PRACTICE The introduction of a decision aid, Mybirthplace, within the hospital impacted early discussions between the woman and the midwife and appeared to benefit women's decision making regarding place of birth. Further studies of midwives' use of innovative technologies and their implementation are required.
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Affiliation(s)
- Daisy Wiggins
- Centre for Midwifery, Maternal & Perinatal Health, Bournemouth University, BH1 3LT, United Kingdom.
| | - Vanora A Hundley
- Centre for Midwifery, Maternal & Perinatal Health, Bournemouth University, BH1 3LT, United Kingdom
| | - Carol Bond
- Health in Higher Education, Faculty of Education Health & Wellbeing, University of Wolverhampton, WV1 1LY, United Kingdom
| | - Carol Wilkins
- Faculty of Health & Social Sciences, Bournemouth University, BH1 3LT, United Kingdom
| | - Gill Walton
- The Royal College of Midwives, 15 Mansfield St, London, W1G 9NH, United Kingdom
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7
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Waddell A, Spassova G, Sampson L, Jungbluth L, Dam J, Bragge P. Co-designing a theory-informed intervention to increase shared decision-making in maternity care. Health Res Policy Syst 2023; 21:15. [PMID: 36721156 PMCID: PMC9888748 DOI: 10.1186/s12961-023-00959-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 01/09/2023] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Shared decision-making (SDM) has been shown to improve healthcare outcomes and is a recognized right of patients. Policy requires health services to implement SDM. However, there is limited research into what interventions work and for what reasons. The aim of the study was to develop a series of interventions to increase the use of SDM in maternity care with stakeholders. METHODS Interventions to increase the use of SDM in the setting of pregnancy care were developed using Behaviour Change Wheel and Theoretical Domains Framework and building on findings of an in-depth qualitative study which were inductively analysed. Intervention development workshops involved co-design, with patients, clinicians, health service administrators and decision-makers, and government policy makers. Workshops focused on identifying viable SDM opportunities and tailoring interventions to the local context (the Royal Women's Hospital) and salient qualitative themes. RESULTS Pain management options during labour were identified by participants as a high priority for application of SDM, and three interventions were developed including patient and clinician access to the Victorian Government's maternity record via the patient portal and electronic medical records (EMR); a multi-layered persuasive communications campaign designed; and clinical champions and SDM simulation training. Factors identified by participants for successful implementation included having alignment with strategic direction of the service, support of leaders, using pre-standing resources and workflows, using clinical champions, and ensuring equity. CONCLUSION Three interventions co-designed to increase the use of SDM for pain management during labour address key barriers and facilitators to SDM in maternity care. This study exemplifies how health services can use behavioural science and co-design principles to increase the use of SDM. Insights into the co-design of interventions to implement SDM in routine practice provide a framework for other health services, policy makers and researchers.
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Affiliation(s)
- Alex Waddell
- Monash Sustainable Development Institute, Monash University, 8 Scenic Boulevard, Clayton Campus, VIC, 3800, Clayton, Australia.
- Victorian Department of Health, Safer Care Victoria, 50 Lonsdale St, Melbourne, VIC, 3000, Australia.
| | - Gerri Spassova
- Department of Marketing, Monash Business School, 900 Dandenong Rd, Caulfield East, Victoria, 3145, Australia
| | - Louise Sampson
- Royal Women's Hospital, 20 Flemington Rd, Parkville, Melbourne, VIC, 3052, Australia
| | - Lena Jungbluth
- Monash Sustainable Development Institute, Monash University, 8 Scenic Boulevard, Clayton Campus, VIC, 3800, Clayton, Australia
| | - Jennifer Dam
- Monash Sustainable Development Institute, Monash University, 8 Scenic Boulevard, Clayton Campus, VIC, 3800, Clayton, Australia
| | - Peter Bragge
- Evidence Review Service, Monash Sustainable Development Institute, Monash University, 8 Scenic Boulevard, Clayton, VIC, 3800, Australia
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8
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Weiseth A, Plough A, Aggarwal R, Galvin G, Rucker A, Henrich N, Miller K, Subramanian L, Hawrusik R, Berry W, Gullo S, Spigel L, Dever K, Loveless D, Graham K, Paek B, Shah NT. Improving communication and teamwork during labor: A feasibility, acceptability, and safety study. Birth 2022; 49:637-647. [PMID: 35233810 PMCID: PMC9790687 DOI: 10.1111/birt.12630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 02/15/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND TeamBirth was designed to promote best practices in shared decision making (SDM) among care teams for people giving birth. Although leading health organizations recommend SDM to address gaps in quality of care, these recommendations are not consistently implemented in labor and delivery. METHODS We conducted a mixed-methods trial of TeamBirth among eligible laboring patients and all clinicians (nurses, midwives, and obstetricians) at four high-volume hospitals during April 2018 to September 2019. We used patient and clinician surveys, abstracted clinical data, and administrative claims to evaluate the feasibility, acceptability, and safety of TeamBirth. RESULTS A total of 2,669 patients (approximately 28% of eligible delivery volume) and 375 clinicians (78% response rate) responded to surveys on their experiences with TeamBirth. Among patients surveyed, 89% reported experiencing at least one structured full care team conversation ("huddle") during labor and 77% reported experiencing multiple huddles. There was a significant relationship between the number of reported huddles and patient acceptability (P < 0.001), suggestive of a dose response. Among clinicians surveyed, 90% would recommend TeamBirth for use in other labor and delivery units. There were no significant changes in maternal and newborn safety measures. CONCLUSIONS Implementing a care process that aims to improve communication and teamwork during labor with high fidelity is feasible. The process is acceptable to patients and clinicians and shows no negative effects on patient safety. Future work should evaluate the effectiveness of TeamBirth in improving care experience and health outcomes.
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Affiliation(s)
- Amber Weiseth
- Ariadne LabsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Avery Plough
- Ariadne LabsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Reena Aggarwal
- Obstetrics and GynaecologyUniversity College London HospitalLondonUK
| | - Grace Galvin
- Ariadne LabsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Amber Rucker
- Ariadne LabsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Natalie Henrich
- Ariadne LabsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Kate Miller
- Ariadne LabsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Laura Subramanian
- Ariadne LabsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Rebecca Hawrusik
- Ariadne LabsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - William Berry
- Ariadne LabsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Susan Gullo
- Ariadne LabsBrigham and Women’s HospitalBostonMassachusettsUSA
| | - Lauren Spigel
- Ariadne LabsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Kimberly Dever
- Department of Obstetrics and GynecologySouth Shore HospitalWeymouthMassachusettsUSA
| | | | - Kristin Graham
- Obstetrics and GynecologyOverlake Medical Center & ClinicsBellevueWashingtonUSA
| | - Bettina Paek
- Department of Women’s & Children’sEvergreenHealthKirklandWashingtonUSA
| | - Neel T. Shah
- Ariadne LabsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
- Beth Israel Deaconess Medical CenterBostonMassachusettsUSA
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9
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Spigel L, Plough A, Paterson V, West R, Jurczak A, Henrich N, Gullo S, Corrigan B, Patterson P, Short T, Early L, Bridges M, Pesek E, Pizzitola M, Davis D, Kirby K, Borduz C, Shah N, Weiseth A. Implementation strategies within a complex environment: A qualitative study of a shared decision-making intervention during childbirth. Birth 2022; 49:440-454. [PMID: 34997610 PMCID: PMC9543488 DOI: 10.1111/birt.12611] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 12/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Shared decision-making (SDM) may improve communication, teamwork, patient experience, respectful maternity care, and safety during childbirth. Despite these benefits, SDM is not widely implemented, and strategies for implementing SDM interventions are not well described. We assessed the acceptability and feasibility of TeamBirth, an SDM solution that centers the birthing person in decision-making through simple tools that structure communication among the care team. We identified and described implementation strategies that bridge the gap between knowledge and practice. METHODS We conducted a qualitative study among four hospitals in the United States to understand the acceptability and feasibility of TeamBirth. We interviewed 103 clinicians and conducted 16 focus group discussions with 52 implementers between June 2018 and October 2019. We drew on the Consolidated Framework for Implementation Research to understand acceptability and feasibility, and to identify and describe the underlying contextual factors that affected implementation. RESULTS We found that clinicians and implementers valued TeamBirth for promoting clarity about care plans among the direct care team and for centering the birthing person in decision-making. Contextual factors that affected implementation included strength of leadership, physician practice models, and quality improvement culture. Effective implementation strategies included regular data feedback and adapting "flexible" components of TeamBirth to the local context. DISCUSSION By identifying and describing TeamBirth's contextual factors and implementation strategies, our findings can help bridge the implementation gap of SDM interventions. Our in-depth analysis offers tangible lessons for other labor and delivery unit leaders as they seek to integrate SDM practices in their own settings.
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Affiliation(s)
- Lauren Spigel
- Ariadne LabsHarvard School of Public HealthBostonMassachusettsUSA
| | - Avery Plough
- Ariadne LabsHarvard School of Public HealthBostonMassachusettsUSA
| | | | - Rebecca West
- Ariadne LabsHarvard School of Public HealthBostonMassachusettsUSA
| | - Amanda Jurczak
- Ariadne LabsHarvard School of Public HealthBostonMassachusettsUSA
| | - Natalie Henrich
- Ariadne LabsHarvard School of Public HealthBostonMassachusettsUSA
| | - Susan Gullo
- Ariadne LabsBrigham and Women’s HospitalBostonMassachusettsUSA
| | - Brett Corrigan
- Quality Management DepartmentSouth Shore HospitalSouth WeymouthMassachusettsUSA,Maternity CenterSouth Shore HospitalSouth WeymouthMassachusettsUSA
| | - Pam Patterson
- Quality Management DepartmentSouth Shore HospitalSouth WeymouthMassachusettsUSA,Maternity CenterSouth Shore HospitalSouth WeymouthMassachusettsUSA
| | - Trisha Short
- Ariadne LabsHarvard School of Public HealthBostonMassachusettsUSA,Labor and DeliverySaint Francis HospitalTulsaOklahomaUSA
| | - Lisa Early
- Labor and DeliverySaint Francis HospitalTulsaOklahomaUSA
| | - Margie Bridges
- Women and Infant ServicesOverlake Medical Center & ClinicsBellevueWashingtonUSA
| | - Elizabeth Pesek
- Quality DepartmentOverlake Medical Center & ClinicsBellevueWashingtonUSA
| | - Marianne Pizzitola
- Women and Infant ServicesOverlake Medical Center & ClinicsBellevueWashingtonUSA
| | - Dianna Davis
- Operational ExcellenceEvergreenHealth Medical CenterKirklandWashingtonUSA
| | - Keri Kirby
- Quality DepartmentEvergreenHealth Medical CenterKirklandWashingtonUSA
| | - Christina Borduz
- Family Maternity CenterEvergreenHealth Medical CenterKirklandWashingtonUSA
| | - Neel Shah
- Ariadne LabsHarvard School of Public HealthBostonMassachusettsUSA
| | - Amber Weiseth
- Ariadne LabsHarvard School of Public HealthBostonMassachusettsUSA
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A Novel Decision Aid Improves Quality of Reproductive Decision-Making and Pregnancy Knowledge for Women with Inflammatory Bowel Disease. Dig Dis Sci 2022; 67:4303-4314. [PMID: 35499712 PMCID: PMC9352739 DOI: 10.1007/s10620-022-07494-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/14/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Women with inflammatory bowel disease (IBD) with poor IBD-specific reproductive knowledge experience more childlessness and fear of IBD medications in pregnancy. The Pregnancy in IBD Decision Aid (PIDA), developed by an international multidisciplinary team, offers personalized online decision support regarding pregnancy in IBD. AIMS Assess the impact of PIDA on quality of reproductive decision-making and pregnancy-related knowledge among preconception (PC) and pregnant patients with IBD, and evaluate acceptability to patients and clinicians. METHODS PC and pregnant patients with IBD aged 18-45 completed questionnaires pre- and post-PIDA to assess quality of decision-making (Decisional Conflict Scale (DCS); Decision Self-Efficacy Scale (DSES) and IBD-in-pregnancy knowledge (Crohn's and Colitis Pregnancy Knowledge Score (CCPKnow)). Paired t test assessed for differences pre- and post-PIDA. Patients and clinicians completed acceptability surveys. RESULTS DCS and DSES were completed by 74 patients (42 Crohn's disease, 32 ulcerative colitis); 41 PC and 33 pregnant. DCS improved significantly post-PIDA in PC patients regarding pregnancy planning (t(40) = 4.83, p < 0.0001, Cohen's dz = 0.75) and in pregnant patients regarding medication management (t(32) = 2.37, p = 0.0242, dz = 0.41). DSES for PC patients improved significantly post-PIDA (t(40) = -3.56, p = 0.001, dz = -0.56). CCPKnow improved significantly post-PIDA in PC (t(42) = 4.93, p < 0.0001, dz = -0.75) and pregnant patients (t(32) = 5.1, p < 0.0001, dz = -0.89). PIDA was deemed optimal for length, readability, and content amount and considered highly useful by patients (n = 73) and clinicians (n = 14). CONCLUSIONS Patients using PIDA developed an improved quality of reproductive decision-making and IBD-in-pregnancy knowledge. PIDA is an accessible tool that can empower women with IBD to make values-congruent, evidence-based decisions regarding pregnancy and may reduce voluntary childlessness.
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11
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Miazga E, Reed C, Shapiro J, Shore E. Healthcare Practitioners' Attitudes and Knowledge Regarding Trial of Labour After Caesarean Delivery (TOLAC): a survey of Canadian obstetrical care providers. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 44:658-663. [PMID: 34920189 DOI: 10.1016/j.jogc.2021.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/16/2021] [Accepted: 11/18/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To understand current attitudes and practice patterns of obstetrical care providers regarding trial of labour after cesarean (TOLAC) and to assess misconceptions regarding eligibility for and risks associated with TOLAC. METHODS A survey was developed based on published literature, validated by a statistician, and piloted with Canadian obstetricians. French and English versions were distributed via the mailing list of the Society of Obstetricians and Gynaecologists of Canada and social media. Practising obstetrical care providers with an office antenatal practice were eligible to participate. Data were analyzed using descriptive statistics and correlational and multiple regression analyses. RESULTS A total of 381 people responded, with representation from every Canadian province and territory. Obstetrician-gynaecologists (239, 63%), family physicians (100, 26%), and midwives (42, 11%) responded. Most participants (277, 78%) thought that TOLAC should be actively encouraged. Only 141 (40%) used a decision aid when counselling patients, although most respondents (250, 71%) thought it would be useful. Providers were less comfortable offering oxytocin induction compared with cervical foley or amniotomy (P < 0.001) and offering TOLAC to patients with an unknown uterine scar (P < 0.001). Providers in western Canada reported more comfort offering TOLAC to patients with more than 1 previous cesarean delivery compared with other regions. Two hundred nine participants (62%) reported that they had had at least 1 patient with a uterine rupture, with the minority of cases (13, 6%) resulting in litigation. CONCLUSIONS This study offers new information on current national practice patterns and provider attitudes regarding TOLAC. These results can be used to guide future educational initiatives to increase TOLAC rates.
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Affiliation(s)
- Elizabeth Miazga
- University of Toronto, 15-018B Cardinal Carter, Department of Obstetrics and Gynecology, 30 Bond St, Toronto ON M5B 1W8.
| | - Cheyanne Reed
- University of Toronto, Department of Obstetrics and Gynecology, University of Toronto, 123 Edward Street, Suite 1200, Toronto, ON M5G 1E2
| | - Jodi Shapiro
- University of Toronto, Mount Sinai Hospital, 700 University Avenue, 3-919 Toronto, ON M5G 1Z5
| | - Eliane Shore
- University of Toronto, St. Michael's Hospital, 61 Queen Street East, 5th Floor, Toronto, ON M5C 2T2
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12
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Kirubarajan A, Lam A, Yu A, Taheri C, Khan S, Sethuram C, Mehta V, Olivieri N. Knowledge, Information Sources, and Institutional Trust of Patients Regarding Medication Use in Pregnancy: A Systematic Review. J Family Reprod Health 2021; 15:160-171. [PMID: 34721607 PMCID: PMC8536826 DOI: 10.18502/jfrh.v15i3.7133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective: The objective of our study is to characterize the knowledge, information sources, and institutional trust of patients regarding medication use in pregnancy. Materials and methods: We conducted a review of three databases: MEDLINE, EMBASE, and CINAHL. We included observational studies and knowledge assessments that examined the knowledge, attitudes, beliefs or information sources of pregnant patients related to medication use during pregnancy. Extraction was completed by two independent reviewers, outcomes were summarized descriptively, and appraisal was conducted. Results: Of the 1359 search results, 34 studies met inclusion criteria. Thus, our systematic review encompasses the beliefs of 11,757 pregnant participants. In most studies, participants described apprehension regarding potential risks to the fetus and the inadequacy of safety information. Across the 23 knowledge assessments, the majority of studies reported patient misconceptions about prescription medication in pregnancy. The most preferred information source was a healthcare provider. However, many participants expressed frustration, mistrust, and skepticism regarding physician knowledge. A common source of mistrust was due to perceived physician self-interest as well as a lack of education tailored to pregnancy. Consequently, informal sources of information were also popular. Conclusion: There is a need to improve the health literacy and trust among pregnant patients regarding drug prescribing. There are modifiable risk factors for mistrust that require further attention.
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Affiliation(s)
- Abirami Kirubarajan
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Lam
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Amy Yu
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Cameron Taheri
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shawn Khan
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Claire Sethuram
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vikita Mehta
- Arts and Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Nancy Olivieri
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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Carlisle N, Watson HA, Kuhrt K, Carter J, Seed PT, Tribe RM, Sandall J, Shennan AH. Ten women's decision-making experiences in threatened preterm labour: Qualitative findings from the EQUIPTT trial. SEXUAL & REPRODUCTIVE HEALTHCARE 2021; 29:100611. [PMID: 33882392 DOI: 10.1016/j.srhc.2021.100611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 01/15/2021] [Accepted: 03/04/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Clinical triage of women in threatened preterm labour (TPTL) could be improved through utilising the QUiPP App, as symptoms alone are poor predictors of early delivery. As most women in TPTL ultimately deliver at term, they must weigh this likelihood with their own personal considerations, and responsibilities. The importance of personal considerations was highlighted by the 2015 Montgomery ruling, and the significance of shared decision-making. AIMS Through qualitative interviews, the primary aim was to explore women's decision-making experiences in TPTL through onset of symptoms, triage, clinical assessment, and discharge. METHODS Qualitative interviews were undertaken as part of the EQUIPTT study (REC: 17/LO/1802) using a semi-structured interview schedule. Descriptive labels of the coding scheme were applied to the raw transcript data. This coding scheme was then increasingly refined into key themes and allowed parallels to be made within and between cases. RESULTS Ten ethnically diverse women who presented at six different London hospitals sites in TPTL were interviewed. Three final themes emerged from the data incorporating 10 sub-themes, 'Seeking help', 'Being "assessed" vs making clinical decisions together', and 'End result.' CONCLUSION Women described their busy lives and the need to juggle their commitments. Participants drew comparisons between their TPTL symptoms and 'period pain,' contrasting to typical medical terminology. Shared decision-making and the clinician-patient relationship could be improved through clinicians utilizing terminology women understand and relate to. Women used language that highlighted the clinician-patient power balance. While not fully involved in shared decision-making, women were overall satisfied with their care.
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Affiliation(s)
- N Carlisle
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, 10(th) Floor North Wing, St Thomas' Hospital, Westminster Bridge Road, SE1 7EH, United Kingdom.
| | - H A Watson
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, 10(th) Floor North Wing, St Thomas' Hospital, Westminster Bridge Road, SE1 7EH, United Kingdom
| | - K Kuhrt
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, 10(th) Floor North Wing, St Thomas' Hospital, Westminster Bridge Road, SE1 7EH, United Kingdom
| | - J Carter
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, 10(th) Floor North Wing, St Thomas' Hospital, Westminster Bridge Road, SE1 7EH, United Kingdom
| | - P T Seed
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, 10(th) Floor North Wing, St Thomas' Hospital, Westminster Bridge Road, SE1 7EH, United Kingdom
| | - R M Tribe
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, 10(th) Floor North Wing, St Thomas' Hospital, Westminster Bridge Road, SE1 7EH, United Kingdom
| | - J Sandall
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, 10(th) Floor North Wing, St Thomas' Hospital, Westminster Bridge Road, SE1 7EH, United Kingdom
| | - A H Shennan
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, 10(th) Floor North Wing, St Thomas' Hospital, Westminster Bridge Road, SE1 7EH, United Kingdom
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14
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Moudi Z, Jam R, Ansari H, Montazer Zohour M. Effect of Shared Decision-making on Anxiety of Women Recommended for Prenatal Screening Tests in Southeast of Iran. J Family Reprod Health 2021; 14:192-197. [PMID: 33603812 PMCID: PMC7868651 DOI: 10.18502/jfrh.v14i3.4673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective: To study the effect of shared decision-making (SDM) on the anxiety of women who were recommended for prenatal screening tests. Materials and methods: This quasi-experimental study was conducted on a total of 200 pregnant women who referred to the health centers of Zahedan, Iran, for prenatal care within April 7 to September 7, 2019. The control group received routine care, and the intervention group attended a session based on SDM. The demographic characteristics form and Spielberger Six-item State-Trait Anxiety Inventory were filled out before and immediately after the counseling, as well as before receiving the results of maternal serum biochemical markers. Results: No statistically significant effect of SDM on anxiety was reported between the control and intervention groups immediately after the counseling session (P=0.46). However, the obtained data showed that the mean value of anxiety scores (16.52±3.06) was higher among the women in the intervention group than that reported for the control group (13.80±3.55) on the day before receiving the results of the blood tests (P<0.001). Nevertheless, logistic regression analysis showed only women with a university level of education were likely to have higher anxiety scores than women with lower educational levels (AOR=10.60; 95% CI: 2.07-54.24; P=0.005). Conclusion: Offering prenatal screening can cause a slight increase in the level of anxiety among women with a university level of education. Therefore, it is required to implement supportive strategies to help high-risk pregnant women in coping with anxiety.
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Affiliation(s)
- Zahra Moudi
- Department of Midwifery, Pregnancy Health Research Center, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Raheleh Jam
- Department of Midwifery, Pregnancy Health Research Center, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Hossein Ansari
- Department of Epidemiology & Biostatistics, Zahedan University of Medical Sciences, Zahedan, Iran
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15
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Ngo E, Truong MBT, Nordeng H. Use of Decision Support Tools to Empower Pregnant Women: Systematic Review. J Med Internet Res 2020; 22:e19436. [PMID: 32924961 PMCID: PMC7522732 DOI: 10.2196/19436] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/25/2020] [Accepted: 06/25/2020] [Indexed: 01/22/2023] Open
Abstract
Background Women face many health-related decisions during pregnancy. Digitalization, new technology, and a greater focus on empowering patients have driven the development of patient-centered decision support tools. Objective This systematic review provides an overview of studies investigating the effect of patient-centered decision support tools for pregnant women. Methods We searched 5 online databases, MEDLINE, EMBASE, Web of Science, PsycINFO, and Scopus, from inception to December 1, 2019. Two independent researchers screened titles, abstracts, and full-texts against the inclusion criteria. All studies investigating the effect of patient-centered decision support tools for health-related issues among pregnant women were included. Study characteristics and results were extracted using the review management tool Rayyan and analyzed according to topic, type of decision support tools, control group, outcome measurements, and results. Results The 25 eligible studies covered a range of health topics, including prenatal screening (n=10), gestational diabetes and weight gain (n=7), lifestyle (n=3), blood pressure and preeclampsia (n=2), depression (n=1), asthma (n=1), and psychological well-being (n=1). In general, the use of decision support tools increased women's knowledge, and recording symptoms enhanced satisfaction with maternity care. Conclusions The opportunities created by digitalization and technology should be used to develop innovative patient-centered decision support tools tailored to support pregnant women. Effect on clinical outcomes should be documented.
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Affiliation(s)
- Elin Ngo
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Maria Bich-Thuy Truong
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Hedvig Nordeng
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, University of Oslo, Oslo, Norway.,Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
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Jolles MW, de Vries M, Hollander MH, van Dillen J. Prevalence, characteristics, and satisfaction of women with a birth plan in The Netherlands. Birth 2019; 46:686-692. [PMID: 31524298 DOI: 10.1111/birt.12451] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 08/18/2019] [Accepted: 08/18/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The use of birth plans to facilitate shared decision making in childbirth is widely recommended by international agencies and by the Dutch Integrated Birth Care protocol (2016). This study evaluated the use of birth plans in The Netherlands. METHODS A retrospective study was conducted during 2017 in a Dutch academic hospital. Women who gave birth after 33 weeks of gestational age were included (N = 1159). Medical records were searched for a birth plan, either a note or attached file. Socio-demographic, relevant medical and obstetrical characteristics fulfilling criteria for secondary care, and postpartum satisfaction were collected and related to birth plans. Postpartum satisfaction was scored on a scale from 0 to 10. The "net promoter score" (NPS), a quality of care indicator, was also computed. For analysis, independent t test, chi-square test, ANOVA, and two-way between ANOVA were used. RESULTS A birth plan was noted in the medical records of 34.7% of women. Women with a birth plan were on average older, primiparous, of Dutch ethnicity, and more likely to have a complicated medical history, psychological condition, or fertility treatment. The mean postpartum satisfaction score was 8.28 and the NPS for customer satisfaction was 36.1, falling in the good range. No significant differences in postpartum satisfaction related to birth plans were found. CONCLUSIONS Although birth plans are recommended for every pregnant woman, this is not everyday practice yet. The purpose of birth plans, to facilitate shared decision making, is therefore not fully realized. Implementation strategies are needed to increase adoption of birth plans for every woman.
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Affiliation(s)
- Myrthe W Jolles
- Department of Obstetrics, Amalia Children's Hospital Radboudumc, Nijmegen, The Netherlands
| | - Marieke de Vries
- Dat Science Institute for Computing and Information Sciences (iCIS) & Social and Cultural Psychology, Behavioural Science Institute (BSI), Radboud University, Nijmegen, The Netherlands
| | - Martine H Hollander
- Department of Obstetrics, Amalia Children's Hospital Radboudumc, Nijmegen, The Netherlands
| | - Jeroen van Dillen
- Department of Obstetrics, Amalia Children's Hospital Radboudumc, Nijmegen, The Netherlands
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Kennedy K, Adelson P, Fleet J, Steen M, McKellar L, Eckert M, Peters MDJ. Shared decision aids in pregnancy care: A scoping review. Midwifery 2019; 81:102589. [PMID: 31790856 DOI: 10.1016/j.midw.2019.102589] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 09/11/2019] [Accepted: 11/23/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Shared decision making in pregnancy, labour, and birth is vital to woman-centred care and despite strong evidence for the effectiveness of shared decision making in pregnancy care, practical uptake has been slow. DESIGN AND AIM This scoping review aimed to identify and describe effective and appropriate shared decision aids designed to be provided to women in the antenatal period to assist them in making informed decisions for both pregnancy and birth. Two questions guided the enquiry: (i) what shared decision aids for pregnancy and perinatal care are of appropriate quality and feasibility for application in Australia? (ii) which of these decision aids have been shown to be effective and appropriate for Aboriginal and Torres Strait Islander peoples, culturally diverse women, or those with low literacy? METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) was used to conduct the review. Five key databases and selected grey literature sources were examined. English language evidence from Australia, Europe, Canada, United Kingdom, New Zealand, and United States of America produced from 2009 was eligible for inclusion, checked against apriori inclusion criteria, and assessed for quality and usability using the International Patient Decision Aid Standards. RESULTS From a total of 5,209 search results, 35 sources of evidence reporting on 27 decision aids were included following title/abstract and full-text review. Most of the decision aids concerned decisions around birth (52%, n = 14) or antenatal screening 37% (n = 10). The quality of the decision aids was moderate to high, with most communicating risks, benefits, and choice pathways via a mix of Likert-style scales, quizzes, and pictures or graphs. Use of decision aids resulted in significant reductions in decisional conflict and increased knowledge. The format of decision aids appeared to have no effect on these outcomes, indicating that paper-based are as effective as video- or audio-based decision aids. Eleven decision aids were suitable for low literacy or low health literacy women, and six were either developed for culturally diverse groups or have been translated into other languages. No decision aids found were specific to Aboriginal and Torres Strait Islander peoples. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE The 27 decision aids are readily adoptable into westernised healthcare settings and can be used by midwives or multidisciplinary teams in conjunction with women. Decision aids are designed to support women, and families to arrive at informed choices and supplement the decision-making process rather than to replace consumer-healthcare professional interaction. If given before an appointment, high quality decision aids can increase a woman's familiarity with medical terminology, options for care, and an insight into personal values, thereby decreasing decisional conflict and increasing knowledge.
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Affiliation(s)
- Kate Kennedy
- Rosemary Bryant AO Research Centre, School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, Australia. GPO Box 2471, Adelaide, SA 5001, Australia.
| | - Pamela Adelson
- Rosemary Bryant AO Research Centre, School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, Australia. GPO Box 2471, Adelaide, SA 5001, Australia; Mothers, Babies and Families: Health Research Group, Rosemary Bryant AO Research Centre, School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, Australia
| | - Julie Fleet
- Mothers, Babies and Families: Health Research Group, Rosemary Bryant AO Research Centre, School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, Australia
| | - Mary Steen
- Mothers, Babies and Families: Health Research Group, Rosemary Bryant AO Research Centre, School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, Australia
| | - Lois McKellar
- Mothers, Babies and Families: Health Research Group, Rosemary Bryant AO Research Centre, School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, Australia
| | - Marion Eckert
- Rosemary Bryant AO Research Centre, School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, Australia. GPO Box 2471, Adelaide, SA 5001, Australia
| | - Micah D J Peters
- Rosemary Bryant AO Research Centre, School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, Australia. GPO Box 2471, Adelaide, SA 5001, Australia
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Vilkins AL, Sahara M, Till S, Ceci C, Howard R, Griffith K, Waljee J, Lim C, Skinner B, Clauw DJ, Brummett CM, As-Sanie S. Effects of Shared Decision Making on Opioid Prescribing After Hysterectomy. Obstet Gynecol 2019; 134:823-833. [PMID: 31503160 PMCID: PMC6945818 DOI: 10.1097/aog.0000000000003468] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate the effects of shared decision making using a simple decision aid for opioid prescribing after hysterectomy. METHODS We conducted a prospective quality initiative study including all patients undergoing hysterectomy for benign, nonobstetric indications between March 1, 2018, and July 31, 2018, at our academic institution. Using a visual decision aid, patients received uniform education regarding postoperative pain management. They were then educated on the department's guidelines regarding the maximum number of tablets recommended per prescription and the mean number of opioid tablets used by a similar cohort of patients in a previously published study at our institution. Patients were then asked to choose their desired number of tablets to receive on discharge. Structured telephone interviews were conducted 14 days after surgery. The primary outcome was total opioids prescribed before compared with after implementation of the decision aid. Secondary outcomes included opioid consumption, patient satisfaction, and refill requests after intervention implementation. RESULTS Of 170 eligible patients, 159 (93.5%) used the decision aid (one patient who used the decision aid was subsequently excluded from the analysis owing to significant perioperative complications), including 110 (69.6%) laparoscopic, 40 (25.3%) vaginal, and eight (5.3%) abdominal hysterectomies. Telephone surveys were completed for 89.2% (n=141) of participants. Student's t-test showed that patients who participated in the decision aid (post-decision aid cohort) were discharged with significantly fewer oral morphine equivalents than patients who underwent hysterectomy before implementation of the decision aid (pre-decision aid cohort) (92±35 vs 160±81, P<.01), with no significant change in the number of requested refills (9.5% [n=15] vs 5.7% [n=14], P=.15). In the post-decision aid cohort, 76.6% of patients (n=121) chose fewer tablets than the guideline-allotted maximum. Approximately 76% of patients (n=102) reported having leftover tablets. CONCLUSION This quality improvement initiative illustrates that a simple decision aid can result in a significant decrease in opioid prescribing without compromising patient satisfaction or postoperative pain management.
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Affiliation(s)
| | | | - Sara Till
- University of Michigan Department of Obstetrics and Gynecology
| | | | - Ryan Howard
- University of Michigan Department of Surgery
| | | | - Jennifer Waljee
- University of Michigan Section of Plastic Surgery, Department of Surgery
- University of Michigan Institute for Healthcare Policy and Innovation
| | - Courtney Lim
- University of Michigan Department of Obstetrics and Gynecology
| | - Bethany Skinner
- University of Michigan Department of Obstetrics and Gynecology
| | | | - Chad M. Brummett
- University of Michigan Department of Anesthesia
- University of Michigan Institute for Healthcare Policy and Innovation
| | - Sawsan As-Sanie
- University of Michigan Department of Obstetrics and Gynecology
- University of Michigan Institute for Healthcare Policy and Innovation
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Guille C, Jones HE, Abuhamad A, Brady KT. Shared Decision‐Making Tool for Treatment of Perinatal Opioid Use Disorder. PSYCHIATRIC RESEARCH AND CLINICAL PRACTICE 2019; 1:27-31. [PMID: 36101566 PMCID: PMC9176026 DOI: 10.1176/appi.prcp.20180004] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 08/17/2018] [Accepted: 09/27/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
- Constance Guille
- Departments of Psychiatry and Behavioral Sciences
- Departments of Obstetrics and GynecologyMedical University of South CarolinaCharleston
| | - Hendree E. Jones
- UNC HorizonsDepartment of Obstetrics and GynecologyUniversity of North Carolina at Chapel HillDepartment of Psychiatry and Behavioral SciencesSchool of MedicineJohns Hopkins UniversityBaltimore
| | - Alfred Abuhamad
- Department of Obstetrics and GynecologyEastern Virginia Medical SchoolNorfolk
| | - Kathleen T. Brady
- Departments of Psychiatry and Behavioral Sciences
- Ralph H. Johnson Veterans Administration Medical CenterCharlestonS.C
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Adams T, Sarnak D, Lewis J, Convissar J, Young SS. What Do Clinicians Who Deliver Maternity Services Think Patient-Centered Care Is and How Is That Different for Vulnerable Women? A Qualitative Study. J Pregnancy 2018; 2018:5853235. [PMID: 30643647 PMCID: PMC6311250 DOI: 10.1155/2018/5853235] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 11/07/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Patient-centered care is said to have a myriad of benefits; however, there is a lack of agreement on what exactly it consists of and how clinicians should deliver it for the benefit of their patients. In the context of maternity services and in particular for vulnerable women, we explored how clinicians describe patient-centered care and how the concept is understood in their practice. METHODS We undertook a qualitative study using interviews and a focus group, based on an interview guide developed from various patient surveys focused around the following questions: (i) How do clinicians describe patient-centered care? (ii) How does being patient-centered affect how care is delivered? (iii) Is this different for vulnerable populations? And if so, how? We sampled obstetricians and gynecologists, midwives, primary care physicians, and physician assistants from a health management organization and fee for service clinician providers from two states in the US covering insured and Medicaid populations. RESULTS Building a relationship between clinician and patient is central to what clinicians believe patient-centered care is. Providing individually appropriate care, engaging family members, transferring information from clinician to patient and from patient to clinician, and actively engaging with patients are also key concepts. However, vulnerable women did not benefit from patient-centered care without first having some of their nonmedical needs met by their clinician. DISCUSSION Most providers did not cite the core concepts of patient-centered care as defined by the Institute of Medicine and others.
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Affiliation(s)
- Ted Adams
- MBChB MRCOG MSc, Consultant in Obstetrics and Gynaecology, Southport and Ormskirk NHS Trust, Wigan Road, Lancashire L39 2AZ, UK
| | - Dana Sarnak
- MPH, Research Associate, Commonwealth Fund of New York, 1 East 75th Street, New York, NY 10021, USA
| | - Joy Lewis
- MSW MPH, Senior Health Policy Consultant, Institute for Health Policy, Kaiser Permanente, Washington, DC, USA
| | - Jeff Convissar
- MD, Medical Director Care Management Institute, Kaiser Permanente, Oakland, CA 94612, USA
| | - Scott S. Young
- MD, Executive Director & Senior Medical Director, Care Management Institute, Kaiser Permanente, Oakland, CA 94612, USA
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21
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Shorten A, Shorten B, Fagerlin A, Illuzzi J, Kennedy HP, Pettker C, Raju D, Whittemore R. A Study to Assess the Feasibility of Implementing a Web-Based Decision Aid for Birth after Cesarean to Increase Opportunities for Shared Decision Making in Ethnically Diverse Settings. J Midwifery Womens Health 2018; 64:78-87. [PMID: 30334330 DOI: 10.1111/jmwh.12908] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/22/2018] [Accepted: 06/28/2018] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Decision aids are central to shared decision making and are recommended for value-sensitive pregnancy decisions, such as birth after cesarean. However, effective strategies for widespread decision aid implementation, with interactive web-based platforms, are lacking. This study tested the feasibility and acceptability of implementing a Health Insurance Portability and Accountability Act-secure, web-based decision aid to support shared decision making about birth choices after cesarean, within urban, ethnically diverse outpatient settings. METHODS A before-and-after design was used to assess feasibility and acceptability for decision aid implementation. Measures included women's knowledge, decisional conflict, birth preferences, birth outcomes, decision aid use, decision aid acceptability ratings (content, features, and functions), and views on how the decision aid supported shared decision making. RESULTS Of the 68 women who participated, most were black (46.2%) or Hispanic (35.4%). Their knowledge scores increased by 2.58 points out of 15 (P < .001; d = 0.87), and decisional conflict score reduced by 0.45 points out of 5 points (P < .001; d = 0.69). Forty-four women (65.9%) attempted a vaginal birth after cesarean, of whom 29 (65.7%) succeeded. Women rated decision aid content, features, and functions as good or excellent. Most indicated they would recommend it to others. Health care providers recommended additional strategies to simplify decision aid access and integration into routine care. DISCUSSION Implementing web-based decision aids within ethnically diverse practice settings is potentially feasible and worthwhile. However, strategies are needed to improve women's access and to encourage timely decision aid usage to prepare them for decision discussions with health care providers. Sustained implementation will require seamless integration into clinic workflow, which could include health care provider tools (counselling guides) embedded within the electronic health record, along with continuing education to support and engage health care providers in their use.
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22
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Declercq ER, Cheng ER, Sakala C. Does maternity care decision-making conform to shared decision- making standards for repeat cesarean and labor induction after suspected macrosomia? Birth 2018; 45:236-244. [PMID: 29934981 DOI: 10.1111/birt.12365] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 05/18/2018] [Accepted: 05/18/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND In a national United States survey, we investigated whether crucial shared decision-making standards were met for 2 common maternity care decisions. METHODS Secondary analysis of Listening to Mothers III. A sequence of validated questions concerning shared decision-making was adapted to 2 maternity care decisions: to induce labor or wait for spontaneous onset of labor among women who were told their baby may be "getting quite large" (N = 349); and for women with 1 or 2 prior cesareans (N = 393), the decision to have a repeat cesarean. RESULTS Almost half (N = 163; 47%) of women who were told their baby might be large reported engaging in a discussion concerning possible labor induction vs waiting for labor, while a large majority (N = 321; 82%) of women with a prior cesarean discussed the option of a repeat cesarean or a planned vaginal birth after cesarean (VBAC). Women who engaged in discussions received disproportionate information about having the interventions and were more likely to experience the interventions (68% induction, 87% repeat cesarean) than women who did not. After adjustment, women who reported that their provider recommended scheduling a repeat cesarean were 14 times more likely to give birth via cesarean compared with those whose providers recommended planning VBAC (AOR 14.2; 95% CI: 3.2, 63.0). CONCLUSION Our findings suggest that, for the decisions in question, established standards of shared decision-making are not being reliably implemented in maternity care despite opportunities to do so. Provider recommendations and the disproportionate conveyance of reasons for an intervention appear to be related to higher levels of intervention.
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Affiliation(s)
- Eugene R Declercq
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
| | - Erika R Cheng
- Children's Health Services Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Carol Sakala
- National Partnership for Women and Families, Washington, DC, USA
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Molenaar J, Korstjens I, Hendrix M, de Vries R, Nieuwenhuijze M. Needs of parents and professionals to improve shared decision-making in interprofessional maternity care practice: A qualitative study. Birth 2018; 45:245-254. [PMID: 30051527 DOI: 10.1111/birt.12379] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 06/22/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Shared decision-making (SDM) is a critical but challenging component of high quality maternity care. In co-creation with parents and professionals, we are developing an intervention to improve SDM. As a first step we aimed to explore the experiences and needs of parents and professionals regarding shared decision-making in interprofessional antenatal, natal, and postnatal care. METHODS We organized 11 focus groups in the Netherlands in November and December 2016. Parents, primary care midwives, hospital-based midwives, obstetricians, obstetric nurses, and maternity care assistants participated. RESULTS Parents and professionals recognized the SDM steps of introducing a decision (choice talk) and discussing options (option talk), but most parents did not seem to discuss preferences and weigh options with professionals before making their final decision (decision talk). Barriers to SDM were often related to interprofessional collaboration, while good communication skills of parents and professionals facilitated SDM. An intervention to improve SDM would need to: (a) increase awareness and offer insight into the SDM process and roles and responsibilities of parents and professionals, (b) develop good communication skills, and (c) encourage interprofessional collaboration. The preferred design of the intervention was online, interactive, and practical. CONCLUSIONS Parents and professionals will benefit from an intervention designed to improve SDM. A practical e-learning for all maternity care providers and e-health information for parents seems most appropriate. Key elements for the e-learning are raising awareness of the roles and responsibilities of parents and professionals, developing good communication skills and encouraging interprofessional collaboration. This requires a variety of educational strategies.
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Affiliation(s)
- Joyce Molenaar
- Research Centre for Midwifery Science Maastricht, Zuyd University, Maastricht, The Netherlands
| | - Irene Korstjens
- Research Centre for Midwifery Science Maastricht, Zuyd University, Maastricht, The Netherlands
| | - Marijke Hendrix
- Research Centre for Midwifery Science Maastricht, Zuyd University, Maastricht, The Netherlands
| | - Raymond de Vries
- Research Centre for Midwifery Science Maastricht, Zuyd University, Maastricht, The Netherlands.,CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Marianne Nieuwenhuijze
- Research Centre for Midwifery Science Maastricht, Zuyd University, Maastricht, The Netherlands
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24
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Hicklin KT, Ivy JS, Wilson JR, Cobb Payton F, Viswanathan M, Myers ER. Simulation model of the relationship between cesarean section rates and labor duration. Health Care Manag Sci 2018; 22:635-657. [PMID: 29995263 DOI: 10.1007/s10729-018-9449-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 06/13/2018] [Indexed: 11/25/2022]
Abstract
Cesarean delivery is the most common major abdominal surgery in many parts of the world, and it accounts for nearly one-third of births in the United States. For a patient who requires a C-section, allowing prolonged labor is not recommended because of the increased risk of infection. However, for a patient who is capable of a successful vaginal delivery, performing an unnecessary C-section can have a substantial adverse impact on the patient's future health. We develop two stochastic simulation models of the delivery process for women in labor; and our objectives are (i) to represent the natural progression of labor and thereby gain insights concerning the duration of labor as it depends on the dilation state for induced, augmented, and spontaneous labors; and (ii) to evaluate the Friedman curve and other labor-progression rules, including their impact on the C-section rate and on the rates of maternal and fetal complications. To use a shifted lognormal distribution for modeling the duration of labor in each dilation state and for each type of labor, we formulate a percentile-matching procedure that requires three estimated quantiles of each distribution as reported in the literature. Based on results generated by both simulation models, we concluded that for singleton births by nulliparous women with no prior complications, labor duration longer than two hours (i.e., the time limit for labor arrest based on the Friedman curve) should be allowed in each dilation state; furthermore, the allowed labor duration should be a function of dilation state.
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Affiliation(s)
- Karen T Hicklin
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.
| | - Julie S Ivy
- Edward P. Fitts Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, NC, 27695, USA
| | - James R Wilson
- Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, NC, 27695, USA
| | - Fay Cobb Payton
- College of Management, North Carolina State University, Raleigh, NC, 27695, USA
| | | | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, 27710, USA
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25
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Attanasio LB, Kozhimannil KB, Kjerulff KH. Factors influencing women's perceptions of shared decision making during labor and delivery: Results from a large-scale cohort study of first childbirth. PATIENT EDUCATION AND COUNSELING 2018; 101:1130-1136. [PMID: 29339041 PMCID: PMC5977392 DOI: 10.1016/j.pec.2018.01.002] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 11/30/2017] [Accepted: 01/04/2018] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To examine correlates of shared decision making during labor and delivery. METHODS Data were from a cohort of women who gave birth to their first baby in Pennsylvania, 2009-2011 (N = 3006). We used logistic regression models to examine the association between labor induction and mode of delivery in relation to women's perceptions of shared decision making, and to investigate race/ethnicity and SES as potential moderators. RESULTS Women who were Black and who did not have a college degree or private insurance were less likely to report high shared decision making, as well as women who underwent labor induction, instrumental vaginal or cesarean delivery. Models with interaction terms showed that the reduction in odds of shared decision making associated with cesarean delivery was greater for Black women than for White women. CONCLUSIONS Women in marginalized social groups were less likely to report shared decision making during birth and Black women who delivered by cesarean had particularly low odds of shared decision making. PRACTICE IMPLICATIONS Strategies designed to improve the quality of patient-provider communication, information sharing, and shared decision making must be attentive to the needs of vulnerable groups to ensure that such interventions reduce rather than widen disparities.
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Affiliation(s)
- Laura B Attanasio
- Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA.
| | - Katy B Kozhimannil
- Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Kristen H Kjerulff
- Department of Public Health Sciences and Department of Obstetrics and Gynecology, College of Medicine, Penn State University, Hershey, PA, USA
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26
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Gietel-Habets JJG, de Die-Smulders CEM, Derks-Smeets IAP, Tibben A, Tjan-Heijnen VCG, van Golde R, Gomez-Garcia E, van Osch LADM. Support needs of couples with hereditary breast and ovarian cancer during reproductive decision making. Psychooncology 2018; 27:1795-1801. [PMID: 29644780 DOI: 10.1002/pon.4729] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 02/23/2018] [Accepted: 03/20/2018] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Reproductive decision making for couples with hereditary breast and ovarian cancer (HBOC) is complex and can result in decisional conflict or regret. This study investigated couples' support needs and aimed to identify vulnerable couples. Ultimately, we should strive to develop a clear standard of care guideline regarding reproductive decision support. METHODS Mixed methods were used for data collection. A focus group study was conducted among 18 couples (N = 35) with HBOC who had made a reproductive decision after reproductive counselling. Subsequently, 129 similar couples (N = 258) were invited to complete a cross-sectional survey based on the focus group study. RESULTS Clinical and practical aspects of reproductive counselling were positively evaluated in the focus group study, although couples indicated a need for additional support with emotional and social concerns in which their relationship, social environment, and the way they picture their desired family were key elements. The survey was completed by 86 participants. Making a reproductive choice was experienced as (very) difficult by 43%, and 69% showed a need for additional support during decision making. Younger participants and those who opted for a natural pregnancy experienced more difficulty with reproductive decision making, and partners showed a higher need for psychological support than carriers. CONCLUSIONS Couples with HBOC who need to make a reproductive decision have specific needs for guidance and support, of which the desired content and methods can vary. It is therefore important to identify vulnerable couples and to attune counselling to couples' needs.
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Affiliation(s)
- J J G Gietel-Habets
- Department of Clinical Genetics, Maastricht University Medical Centre+, Maastricht, The Netherlands.,GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - C E M de Die-Smulders
- Department of Clinical Genetics, Maastricht University Medical Centre+, Maastricht, The Netherlands.,GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - I A P Derks-Smeets
- Department of Clinical Genetics, Maastricht University Medical Centre+, Maastricht, The Netherlands.,GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - A Tibben
- Centre for Human and Clinical Genetics, Leiden University Medical Centre, Leiden, The Netherlands
| | - V C G Tjan-Heijnen
- GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Department of Internal Medicine, Division of Medical Oncology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - R van Golde
- GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Department of Obstetrics and Gynaecology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - E Gomez-Garcia
- Department of Clinical Genetics, Maastricht University Medical Centre+, Maastricht, The Netherlands.,GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - L A D M van Osch
- Department of Clinical Genetics, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Department of Health Promotion/CAPHRI, Maastricht University, Maastricht, The Netherlands
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Sanders RA, Crozier K. How do informal information sources influence women's decision-making for birth? A meta-synthesis of qualitative studies. BMC Pregnancy Childbirth 2018; 18:21. [PMID: 29316887 PMCID: PMC5761120 DOI: 10.1186/s12884-017-1648-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 12/28/2017] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Women approach birth using various methods of preparation drawing from conventional healthcare providers alongside informal information sources (IIS) outside the professional healthcare context. An investigation of the forms in which these informal information sources are accessed and negotiated by women, and how these disconnected and often conflicting elements influence women's decision-making process for birth have yet to be evaluated. The level of antenatal preparedness women feel can have significant and long lasting implications on their birth experience and transition into motherhood and beyond. The aim of this study was to provide a deeper understanding of how informal information sources influence women's preparation for birth. METHODS Seven electronic databases were searched with predetermined search terms. No limitations were imposed for year of publication. English language studies using qualitative methods exploring women's experiences of informal information sources and their impact upon women's birth preparation were included, subject to a quality appraisal framework. Searches were initiated in February 2016 and completed by March 2016. Studies were synthesised using an interpretive meta-ethnographic approach. RESULTS Fourteen studies were included for the final synthesis from Great Britain, Australia, Canada and the United States. Four main themes were identified: Menu Birth; Information Heaven/Hell; Spheres of Support; and Trust. It is evident that women do not enter pregnancy as empty vessels devoid of a conceptual framework, but rather have a pre-constructed embodied knowledge base upon which other information is superimposed. Allied to this, it is clear that informal information was sought to mitigate against the widespread experience of discordant information provided by maternity professionals. CONCLUSION Women's access to the deluge of informal information sources in mainstream media during pregnancy have significant impact on decision making for birth. These informal sources redefine the power dynamic between women and maternal healthcare providers, simultaneously increasing levels of anxiety and challenging women's pre-existing ideations and aspirations of personal birth processes. A lack of awareness by some professionals of women's information seeking behaviours generates barriers to women-centred support, leaving an experience expectation mismatch unchecked. TRIAL REGISTRATION CRD42016041491 17/06/16.
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Affiliation(s)
- Ruth A. Sanders
- Norfolk & Norwich, University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk NR4 7UY UK
- Norwich Norfolk, UK
| | - Kenda Crozier
- University of East Anglia, Norwich Research Park, Norwich, Norfolk NR4 7TJ UK
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28
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Munro S, Dewar K, Wilcox E, Klein MC, Janssen PA. Evaluation of a Patient Education Pamphlet for Women Considering Vaginal Birth After Cesarean. J Perinat Educ 2017; 26:37-48. [PMID: 30643376 DOI: 10.1891/1058-1243.26.1.37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We evaluated a patient education pamphlet on vaginal birth after cesarean (VBAC). Focus groups with 17 women in 4 communities involved a 5-item knowledge pretest and question on intention to plan VBAC, reading the pamphlet, a knowledge posttest, and a moderated discussion. Forming a preference for birth after cesarean was characterized by (a) consolidating information from social sources, (b) seeking certainty in your next birth, and (c) questioning your ability to have a vaginal birth. Participants preferred vaginal birth, but all feared the uncertainty of labor. Knowledge scores increased for all participants, but intentions to plan a VBAC did not change. Our findings may encourage the development of interventions to reduce women's fear of vaginal birth.
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29
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Lee S, Ayers S, Holden D. Decision-making regarding place of birth in high-risk pregnancy: a qualitative study. J Psychosom Obstet Gynaecol 2016; 37:44-50. [PMID: 26984582 DOI: 10.3109/0167482x.2016.1151413] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Women consider factors including safety and the psychological impact of their chosen location when deciding whether to give birth in hospital or at home. The same is true for women with high-risk pregnancies who may plan homebirths against medical advice. This study investigated women's decision-making during high-risk pregnancies. Half the participants were planning hospital births and half were planning homebirths. METHODS A qualitative study using semi-structured interviews set in a hospital maternity department in the UK. Twenty-six participants with high-risk pregnancies, at least 32 weeks pregnant. Results were analysed using systematic thematic analysis. RESULTS Three themes emerged: perceptions of birth at home and hospital; beliefs about how birth should be; and the decision process. Both groups were concerned about safety but they expressed different concerns. Women drew psychological comfort from their chosen birth location. Women planning homebirths displayed faith in the natural birth process and stressed the quality of the birth experience. Women planning hospital births believed the access to medical care outweighed their misgivings about the physical environment. DISCUSSION Although women from both groups expressed similar concerns about safety they reached different decisions about how these should be addressed regarding birth location. These differences may be related to beliefs about the birth process. Commitment to their decisions may have helped reduce cognitive stress.
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Affiliation(s)
- Suzanne Lee
- a School of Health Sciences, City University London , Northampton Square , London , UK and
| | - Susan Ayers
- a School of Health Sciences, City University London , Northampton Square , London , UK and
| | - Des Holden
- b Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital , Canada Avenue, Redhill , Surrey , UK
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30
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How women with high risk pregnancies perceive interactions with healthcare professionals when discussing place of birth: A qualitative study. Midwifery 2016; 38:42-8. [DOI: 10.1016/j.midw.2016.03.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Revised: 02/23/2016] [Accepted: 03/17/2016] [Indexed: 11/22/2022]
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Stevens G, Miller YD, Watson B, Thompson R. Choosing a Model of Maternity Care: Decision Support Needs of Australian Women. Birth 2016; 43:167-75. [PMID: 26661139 DOI: 10.1111/birt.12212] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Access to information on the features and outcomes associated with the various models of maternity care available in Australia is vital for women's informed decision-making. This study sought to identify women's preferences for information access and decision-making involvement, as well as their priority information needs, for model of care decision-making. METHODS A convenience sample of adult women of childbearing age in Queensland, Australia were recruited to complete an online survey assessing their model of care decision support needs. Knowledge on models of care and socio-demographic characteristics were also assessed. RESULTS Altogether, 641 women provided usable survey data. Of these women, 26.7 percent had heard of all available models of care before starting the survey. Most women wanted access to information on models of care (90.4%) and an active role in decision-making (99.0%). Nine priority information needs were identified: cost, access to choice of mode of birth and care provider, after hours provider contact, continuity of carer in labor/birth, mobility during labor, discussion of the pros/cons of medical procedures, rates of skin-to-skin contact after birth, and availability at a preferred birth location. This information encompassed the priority needs of women across age, birth history, and insurance status subgroups. CONCLUSIONS This study demonstrates Australian women's unmet needs for information that supports them to effectively compare available options for model of maternity care. Findings provide clear direction on what information should be prioritized and ideal channels for information access to support quality decision-making in practice.
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Affiliation(s)
- Gabrielle Stevens
- School of Psychology, The University of Queensland, Brisbane, Qld, Australia
| | - Yvette D Miller
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Qld, Australia
| | - Bernadette Watson
- School of Psychology, The University of Queensland, Brisbane, Qld, Australia
| | - Rachel Thompson
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH, USA
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Stevens G, Thompson R, Watson B, Miller YD. Patient decision aids in routine maternity care: Benefits, barriers, and new opportunities. Women Birth 2016; 29:30-4. [DOI: 10.1016/j.wombi.2015.08.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 06/12/2015] [Accepted: 08/05/2015] [Indexed: 12/20/2022]
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Jou J, Kozhimannil KB, Johnson PJ, Sakala C. Patient-Perceived Pressure from Clinicians for Labor Induction and Cesarean Delivery: A Population-Based Survey of U.S. Women. Health Serv Res 2015; 50:961-81. [PMID: 25250981 PMCID: PMC4545342 DOI: 10.1111/1475-6773.12231] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To determine whether patient-perceived pressure from clinicians for labor induction or cesarean delivery is significantly associated with having these procedures. DATA SOURCES/STUDY SETTING Listening to Mothers III, a nationally representative survey of women 18-45 years who delivered a singleton infant in a U.S. hospital July 2011-June 2012 (N = 2,400). STUDY DESIGN Multivariate logistic regression analysis of factors associated with perceived pressure and estimation of odds of induction and cesarean given perceived pressure. PRINCIPAL FINDINGS Overall, 14.8 percent of respondents perceived pressure from a clinician for labor induction and 13.3 percent for cesarean delivery. Women who perceived pressure for labor induction had higher odds of induction overall (adjusted odds ratio [aOR]: 3.51; 95 percent confidence interval [CI]: 2.5-5.0) and without medical reason (aOR: 2.13; 95 percent CI: 1.3-3.4) compared with women who did not perceive pressure. Those perceiving pressure for cesarean delivery had higher odds of cesarean overall (aOR: 5.17; 95 percent CI: 3.2-8.4), without medical reason (aOR: 6.13; 95 percent CI: 3.4-11.1), and unplanned cesarean (aOR: 6.70; 95 percent CI: 4.0-11.3). CONCLUSIONS Patient-perceived pressure from clinicians significantly predicts labor induction and cesarean delivery. Efforts to reduce provider-patient miscommunication and minimize potentially unnecessary procedures may be warranted.
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Affiliation(s)
- Judy Jou
- Address correspondence to Judy Jou, M.A., Division of Health Policy and Management, University of Minnesota School of Public Health, 420 Delaware St. SE, MMC 729, Minneapolis, MN 55455; e-mail:
| | - Katy B Kozhimannil
- Katy B. Kozhimannil, Ph.D., M.P.A., is with the Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN
- Pamela Jo Johnson, Ph.D., M.P.H., is with the Center for Spirituality & Healing and the Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN
- Carol Sakala, Ph.D., is with the National Partnership for Women and Families, Washington, DC
| | - Pamela Jo Johnson
- Katy B. Kozhimannil, Ph.D., M.P.A., is with the Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN
- Pamela Jo Johnson, Ph.D., M.P.H., is with the Center for Spirituality & Healing and the Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN
- Carol Sakala, Ph.D., is with the National Partnership for Women and Families, Washington, DC
| | - Carol Sakala
- Katy B. Kozhimannil, Ph.D., M.P.A., is with the Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN
- Pamela Jo Johnson, Ph.D., M.P.H., is with the Center for Spirituality & Healing and the Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN
- Carol Sakala, Ph.D., is with the National Partnership for Women and Families, Washington, DC
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Beckmann M, Cooper C, Pocock D. INFORMed choices: Facilitating shared decision-making in health care. Aust N Z J Obstet Gynaecol 2015; 55:294-7. [DOI: 10.1111/ajo.12343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 03/19/2015] [Indexed: 01/29/2023]
Affiliation(s)
- Michael Beckmann
- Department of Obstetrics and Gynaecology; Mater Health Services; Brisbane Queensland Australia
- Mater Research Institute, University of Queensland; Brisbane Queensland Australia
- School of Medicine; University of Queensland; Brisbane Queensland Australia
| | - Catherine Cooper
- Mater Education Centre; Mater Health Services; Brisbane Queensland Australia
| | - Daniel Pocock
- Clinical Safety and Quality Unit; Mater Health Services; Brisbane Queensland Australia
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Nieuwenhuijze MJ, Korstjens I, de Jonge A, de Vries R, Lagro-Janssen A. On speaking terms: a Delphi study on shared decision-making in maternity care. BMC Pregnancy Childbirth 2014; 14:223. [PMID: 25008286 PMCID: PMC4104734 DOI: 10.1186/1471-2393-14-223] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 06/27/2014] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND For most women, participation in decision-making during maternity care has a positive impact on their childbirth experiences. Shared decision-making (SDM) is widely advocated as a way to support people in their healthcare choices. The aim of this study was to identify quality criteria and professional competencies for applying shared decision-making in maternity care. We focused on decision-making in everyday maternity care practice for healthy women. METHODS An international three-round web-based Delphi study was conducted. The Delphi panel included international experts in SDM and in maternity care: mostly midwives, and additionally obstetricians, educators, researchers, policy makers and representatives of care users. Round 1 contained open-ended questions to explore relevant ingredients for SDM in maternity care and to identify the competencies needed for this. In rounds 2 and 3, experts rated statements on quality criteria and competencies on a 1 to 7 Likert-scale. A priori, positive consensus was defined as 70% or more of the experts scoring ≥6 (70% panel agreement). RESULTS Consensus was reached on 45 quality criteria statements and 4 competency statements. SDM in maternity care is a dynamic process that starts in antenatal care and ends after birth. Experts agreed that the regular visits during pregnancy offer opportunities to build a relationship, anticipate situations and revisit complex decisions. Professionals need to prepare women antenatally for unexpected, urgent decisions in birth and revisit these decisions postnatally. Open and respectful communication between women and care professionals is essential; information needs to be accurate, evidence-based and understandable to women. Experts were divided about the contribution of professional advice in shared decision-making and about the partner's role. CONCLUSIONS SDM in maternity care is a dynamic process that takes into consideration women's individual needs and the context of the pregnancy or birth. The identified ingredients for good quality SDM will help practitioners to apply SDM in practice and educators to prepare (future) professionals for SDM, contributing to women's positive birth experience and satisfaction with care.
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Affiliation(s)
- Marianne J Nieuwenhuijze
- Research Centre for Midwifery Science, Faculty Midwifery Education & Studies, Zuyd University, Universiteitssingel 60, 6229 ER Maastricht, the Netherlands
| | - Irene Korstjens
- Research Centre for Midwifery Science, Faculty Midwifery Education & Studies, Zuyd University, Universiteitssingel 60, 6229 ER Maastricht, the Netherlands
| | - Ank de Jonge
- Midwifery Science/EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands
| | - Raymond de Vries
- Research Centre for Midwifery Science, Faculty Midwifery Education & Studies, Zuyd University, Universiteitssingel 60, 6229 ER Maastricht, the Netherlands
- CAPHRI, University Maastricht, Universiteitssingel 60, 6229 ER Maastricht, the Netherlands
| | - Antoine Lagro-Janssen
- Department of General Practice, Women Studies Medicine, Radboud University Medical Center, Geert Grooteplein-Zuid 10, 6525 GA Nijmegen, the Netherlands
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Cox KJ. Counseling women with a previous cesarean birth: toward a shared decision-making partnership. J Midwifery Womens Health 2014; 59:237-45. [PMID: 24773588 DOI: 10.1111/jmwh.12177] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Pregnant women who had a previous cesarean birth must choose whether to have a repeat cesarean or to attempt a vaginal birth. Many of these women are candidates for a trial of labor. Current practice guidelines recommend that women should be thoroughly counseled during prenatal care about the benefits and harms of both a trial of labor after cesarean (TOLAC) and an elective repeat cesarean delivery and be offered the opportunity to make an informed decision about mode of birth in collaboration with their provider. The purpose of this article is to improve the process of counseling, decision making, and informed consent by increasing health care providers' knowledge about the essential elements of shared decision making. Factors that affect the decisions to be made and concepts that are critical for effective counseling are explored, including clinical considerations, women's perspectives, decision-making models, health literacy and numeracy, communicating risk, and the use of decision aids. Issues related to birth sites for TOLAC are also discussed, including access, safety, refusal of surgery, and clinical management.
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Rossignol M, Chaillet N, Boughrassa F, Moutquin JM. Interrelations between four antepartum obstetric interventions and cesarean delivery in women at low risk: a systematic review and modeling of the cascade of interventions. Birth 2014; 41:70-8. [PMID: 24654639 DOI: 10.1111/birt.12088] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2013] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To critically appraise the literature on the relations between four intrapartum obstetric interventions-electronic fetal monitoring (EFM), epidural analgesia, labor induction, and labor acceleration; and two types of delivery-instrumental (forceps and vacuum) and cesarean section. METHODS This review included meta-analyses published between January 2000 and April 2012 including at least one randomized clinical trial published after 1995 and presenting results on low-risk pregnancies between 37 and 42 weeks of gestation, searched in the databases Medline, Cochrane Library, and EMBASE with no language restriction. RESULTS Of 306 documents identified, 8 fulfilled the inclusion criteria and presented results on women at low risk. EFM at admission (vs intermittent auscultation) was associated with cesarean delivery (odds ratio [OR] = 1.20, 95% confidence interval [CI] 1.00-1.44) and epidural analgesia (OR = 1.25, 95% CI 1.09-1.43). Epidural on request was associated with cesarean delivery (OR = 1.60, 95% CI 1.18-2.18), instrumental delivery (OR = 1.21, 95% CI 1.03-1.44), and oxytocin use (OR = 1.20, 95% CI 1.01-1.43) when compared with epidural on request plus nonpharmacological labor pain control methods such as one-to-one support, breathing techniques, and relaxation. Induction and acceleration of labor showed heterogeneous patterns of associations with cesarean delivery and instrumental delivery. CONCLUSIONS Complex patterns of associations between obstetric interventions and modes of delivery were illustrated in an empirical model. Intermittent auscultation and nonpharmacological labor pain control interventions, such as one-to-one support during labor, have the potential for substantially reducing cesarean deliveries.
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Affiliation(s)
- Michel Rossignol
- Institut national d'excellence en santé et en services sociaux (INESSS), QC, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
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Weiniger CF, Spencer PS, Weiss Y, Ginsberg G, Ezra Y. Reducing the cesarean delivery rates for breech presentations: administration of spinal anesthesia facilitates manipulation to cephalic presentation, but is it cost saving? Isr J Health Policy Res 2014; 3:5. [PMID: 24564984 PMCID: PMC3936937 DOI: 10.1186/2045-4015-3-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 01/09/2014] [Indexed: 11/25/2022] Open
Abstract
Background External cephalic version (ECV) is infrequently performed and 98% of breech presenting fetuses are delivered surgically. Neuraxial analgesia can increase the success rate of ECV significantly, potentially reducing cesarean delivery rates for breech presentation. The current study aims to determine whether the additional cost to the hospital of spinal anesthesia for ECV is offset by cost savings generated by reduced cesarean delivery. Methods In our tertiary hospital, three variables manpower, disposables, and fixed costs were calculated for ECV, ECV plus anesthetic doses of spinal block, vaginal delivery and cesarean delivery. Total procedure costs were compared for possible delivery pathways. Manpower data were obtained from management payroll, fixed costs by calculating cost/lifetime usage rate and disposables were micro-costed in 2008, expressed in 2013 NIS. Results Cesarean delivery is the most expensive option, 11670.54 NIS and vaginal delivery following successful ECV under spinal block costs 5497.2 NIS. ECV alone costs 960.21 NIS, ECV plus spinal anesthesia costs 1386.97 NIS. The highest individual cost items for vaginal, cesarean delivery and ECV were for manpower. Expensive fixed costs for cesarean delivery included operating room trays and postnatal hospitalization (minimum 3 days). ECV with spinal block is cheaper due to lower expected cesarean delivery rate and its lower associated costs. Conclusions The additional cost of the spinal anesthesia is offset by increased success rates for the ECV procedure resulting in reduction in the cesarean delivery rate.
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Affiliation(s)
- Carolyn F Weiniger
- Department of Anesthesiology and Critical Care Medicine Hadassah-Hebrew, University Medical Center, Ein Kerem, Jerusalem 91120, Israel.
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Steel A, Adams J, Sibbritt D, Broom A, Gallois C, Frawley J. Managing the pain of labour: factors associated with the use of labour pain management for pregnant Australian women. Health Expect 2013; 18:1633-44. [PMID: 24304970 DOI: 10.1111/hex.12155] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2013] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Despite high rates of women's use of intrapartum pain management techniques, little is known about the factors that influence such use. OBJECTIVE Examine the determinants associated with women's use of labour pain management. DESIGN Cross-sectional survey of a substudy of women from the 'young' cohort of the Australian Longitudinal Study of Women's Health (ALSWH). SETTING AND PARTICIPANTS Women aged 31-35 years who identified as being pregnant or recently given birth in the 2009 ALSWH survey (n = 2445) were recruited for the substudy. The substudy survey was completed by 1835 women (RR = 79.2%). MAIN VARIABLES STUDIED Determinants examined included pregnancy health and maternity care [including complementary and alternative medicine (CAM)] for their most recent pregnancy and any previous pregnancies. Participants' attitudes and beliefs related to both CAM and maternity care were also included in the analysis. MAIN OUTCOME MEASURES The outcome measures examined were the use of both pharmacological and non-pharmacological pain management techniques (NPMT). RESULTS Differences were seen in the effects of demographics, health service utilization, health status, use of CAM, and attitudes and beliefs upon use of intrapartum pain management techniques across all categories. The only variable that was identified as a determinant for use of all types of pain management techniques was a previous caesarean section (CS). DISCUSSION AND CONCLUSIONS The effect of key determinants on women's use of pain management techniques differs significantly, and, other than CS, no one determinant is clearly influential in the use of all pain management options.
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Affiliation(s)
- Amie Steel
- Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), Faculty of Health, UTS, Ultimo, NSW, Australia
| | - Jon Adams
- Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), Faculty of Health, UTS, Ultimo, NSW, Australia
| | - David Sibbritt
- Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), Faculty of Health, UTS, Ultimo, NSW, Australia
| | - Alex Broom
- School of Social Science, University of Queensland, St Lucia, QLD, Australia
| | - Cindy Gallois
- School of Psychology, University of Queensland, St Lucia, QLD, Australia
| | - Jane Frawley
- Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), Faculty of Health, UTS, Ultimo, NSW, Australia
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Norum J, Heyd A, Hjelseth B, Svee T, Mürer FA, Erlandsen R, Vonen B. Quality of obstetric care in the sparsely populated sub-arctic area of Norway 2009-2011. BMC Pregnancy Childbirth 2013; 13:175. [PMID: 24034451 PMCID: PMC3847544 DOI: 10.1186/1471-2393-13-175] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 09/11/2013] [Indexed: 12/02/2022] Open
Abstract
Background It is challenging to obtain high quality obstetric care in a sparsely populated area. In the subarctic region of Norway, significant distances, weather conditions and seasonable darkness have called for a decentralized care model. We aimed to explore the quality of this care. Methods A retrospective study employing data (2009–11) from the Medical Birth Registry of Norway was initiated. Northern Norwegian and Norwegian figures were compared. Midwife administered maternity units, departments at local and regional specialist hospitals were compared. National registry data on post-caesarean wound infection (2009–2010) was added. Quality of care was measured as rate of multiple pregnancies, caesarean section, post-caesarean wound infection, Apgar score <7, birth weight <2.5 kilos, perineal rupture, stillbirth, eclampsia, pregnancy induced diabetes and vacuum or forceps assisted delivery. There were 15,586 births in 15 delivery units. Results Multiple pregnancies were less common in northern Norway (1.3 vs. 1.7%) (P = 0.02). Less use of vacuum (6.6% vs. 8.3%) (P = 0.01) and forceps (0.9% vs 1.7%) (P < 0.01) assisted delivery was observed. There was no difference with regard to pregnancy induced diabetes, caesarean section, stillbirth, Apgar score < 7 and eclampsia. A significant difference in birth weight < 2.5 kilos (4.7% vs. 5.0%) (P < 0.04) and perineal rupture grade 3 and 4 (1.5% vs. 2.3%) (P < 0.02) were revealed. The post-caesarean wound infection rate was higher (10.5% vs. 7.4%) (P < 0.01). Conclusion Northern Norway had an obstetric care of good quality. Birth weight, multiple pregnancies and post-caesarean wound infection rates should be further elucidated.
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Affiliation(s)
- Jan Norum
- Northern Norway Regional Health Authority trust, Bodø, N-8038, Norway.
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Horey D, Kealy M, Davey MA, Small R, Crowther CA. Interventions for supporting pregnant women's decision-making about mode of birth after a caesarean. Cochrane Database Syst Rev 2013:CD010041. [PMID: 23897547 DOI: 10.1002/14651858.cd010041.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Pregnant women who have previously had a caesarean birth and who have no contraindication for vaginal birth after caesarean (VBAC) may need to decide whether to choose between a repeat caesarean birth or to commence labour with the intention of achieving a VBAC. Women need information about their options and interventions designed to support decision-making may be helpful. Decision support interventions can be implemented independently, or shared with health professionals during clinical encounters or used in mediated social encounters with others, such as telephone decision coaching services. Decision support interventions can include decision aids, one-on-one counselling, group information or support sessions and decision protocols or algorithms. This review considers any decision support intervention for pregnant women making birth choices after a previous caesarean birth. OBJECTIVES To examine the effectiveness of interventions to support decision-making about vaginal birth after a caesarean birth.Secondary objectives are to identify issues related to the acceptability of any interventions to parents and the feasibility of their implementation. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2013), Current Controlled Trials (22 July 2013), the WHO International Clinical Trials Registry Platform Search Portal (ICTRP) (22 July 2013) and reference lists of retrieved articles. We also conducted citation searches of included studies to identify possible concurrent qualitative studies. SELECTION CRITERIA All published, unpublished, and ongoing randomised controlled trials (RCTs) and quasi-randomised trials with reported data of any intervention designed to support pregnant women who have previously had a caesarean birth make decisions about their options for birth. Studies using a cluster-randomised design were eligible for inclusion but none were identified. Studies using a cross-over design were not eligible for inclusion. Studies published in abstract form only would have been eligible for inclusion if data were able to be extracted. DATA COLLECTION AND ANALYSIS Two review authors independently applied the selection criteria and carried out data extraction and quality assessment of studies. Data were checked for accuracy. We contacted authors of included trials for additional information. All included interventions were classified as independent, shared or mediated decision supports. Consensus was obtained for classifications. Verification of the final list of included studies was undertaken by three review authors. MAIN RESULTS Three randomised controlled trials involving 2270 women from high-income countries were eligible for inclusion in the review. Outcomes were reported for 1280 infants in one study. The interventions assessed in the trials were designed to be used either independently by women or mediated through the involvement of independent support. No studies looked at shared decision supports, that is, interventions designed to facilitate shared decision-making with health professionals during clinical encounters.We found no difference in planned mode of birth: VBAC (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.97 to 1.10; I² = 0%) or caesarean birth (RR 0.96, 95% CI 0.84 to 1.10; I² = 0%). The proportion of women unsure about preference did not change (RR 0.87, 95% CI 0.62 to 1.20; I² = 0%).There was no difference in adverse outcomes reported between intervention and control groups (one trial, 1275 women/1280 babies): permanent (RR 0.66, 95% CI 0.32 to 1.36); severe (RR 1.02, 95% CI 0.77 to 1.36); unclear (0.66, 95% CI 0.27, 1.61). Overall, 64.8% of those indicating preference for VBAC achieved it, while 97.1% of those planning caesarean birth achieved this mode of birth. We found no difference in the proportion of women achieving congruence between preferred and actual mode of birth (RR 1.02, 95% CI 0.96 to 1.07) (three trials, 1921 women).More women had caesarean births (57.3%), including 535 women where it was unplanned (42.6% all caesarean deliveries and 24.4% all births). We found no difference in actual mode of birth between groups, (average RR 0.97, 95% CI 0.89 to 1.06) (three trials, 2190 women).Decisional conflict about preferred mode of birth was lower (less uncertainty) for women with decisional support (standardised mean difference (SMD) -0.25, 95% CI -0.47 to -0.02; two trials, 787 women; I² = 48%). There was also a significant increase in knowledge among women with decision support compared with those in the control group (SMD 0.74, 95% CI 0.46 to 1.03; two trials, 787 women; I² = 65%). However, there was considerable heterogeneity between the two studies contributing to this outcome ( I² = 65%) and attrition was greater than 15 per cent and the evidence for this outcome is considered to be moderate quality only. There was no difference in satisfaction between women with decision support and those without it (SMD 0.06, 95% CI -0.09 to 0.20; two trials, 797 women; I² = 0%). No study assessed decisional regret or whether women's information needs were met.Qualitative data gathered in interviews with women and health professionals provided information about acceptability of the decision support and its feasibility of implementation. While women liked the decision support there was concern among health professionals about their impact on their time and workload. AUTHORS' CONCLUSIONS Evidence is limited to independent and mediated decision supports. Research is needed on shared decision support interventions for women considering mode of birth in a pregnancy after a caesarean birth to use with their care providers.
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Affiliation(s)
- Dell Horey
- Faculty of Health Sciences, La Trobe University, Bundoora, Australia.
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Romano AM. Continuing education module transforming maternity care: implementing the blueprint for action. J Perinat Educ 2013; 21:145-8. [PMID: 23730125 DOI: 10.1891/1058-1243.21.3.145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
In January 2010, Women's Health Issues published two direction-setting reports from the Transforming Maternity Care (TMC) Project: "2020 Vision for a High-Quality, High-Value Maternity Care System" and "Blueprint for Action: Steps Toward a High-Quality, High-Value Maternity Care System." This guest editorial summarizes highlights of the implementation phase of what is now known as the TMC Partnership. Major progress has been made in elevating maternity care quality to a national policy priority, increasing the availability and use of maternity care performance measures, and developing shared decision making tools for childbearing women.
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Sakala C, Yang YT, Corry MP. Maternity care and liability: most promising policy strategies for improvement. Womens Health Issues 2013; 23:e25-37. [PMID: 23312711 DOI: 10.1016/j.whi.2012.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 11/02/2012] [Accepted: 11/07/2012] [Indexed: 01/05/2023]
Abstract
BACKGROUND The present liability system is not serving well childbearing women and newborns, maternity care clinicians, or maternity care payers. Examination of evidence about the impact of this system on maternity care led us to identify seven aims for a high-functioning liability system in this clinical context. Herein, we identify policy strategies that are most likely to meet these aims and contribute to needed improvements. A companion paper considers strategies that hold little promise. METHODS We considered whether 25 strategies that have been used or proposed for improvement have met or could meet the seven aims. We used a best available evidence approach and drew on more recent empirical legal studies and health services research about maternity care and liability when available, and considered other studies when unavailable. FINDINGS Ten strategies seem to have potential to improve liability matters in maternity care across multiple aims. The most promising strategy--implementing rigorous maternity care quality improvement (QI) programs--has led to better quality and outcomes of care, and impressive declines in liability claims, payouts, and premium levels. CONCLUSIONS A number of promising strategies warrant demonstration and evaluation at the level of states, health systems, or other appropriate entities. Rigorous QI programs have a growing track record of contributing to diverse aims of a high-functioning liability system and seem to be a win-win-win prevention strategy for childbearing families, maternity care providers, and payers. Effective strategies are also needed to assist families when women and newborns are injured.
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Affiliation(s)
- Carol Sakala
- Childbirth Connection, New York, New York 10016, USA.
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Rapaport S, Leshno M, Fink L. A design process for using normative models in shared decision making: a case study in the context of prenatal testing. Health Expect 2012; 17:863-75. [PMID: 23033887 DOI: 10.1111/hex.12004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2012] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Shared decision making (SDM) encourages the patient to play a more active role in the process of medical consultation and its primary objective is to find the best treatment for a specific patient. Recent findings, however, show that patient preferences cannot be easily or accurately judged on the basis of communicative exchange during routine office visits, even for patients who seek to expand their role in medical decision making (MDM). OBJECTIVE The objective of this study is to improve the quality of patient-physician communication by developing a novel design process for SDM and then demonstrating, through a case study, the applicability of this process in enabling the use of a normative model for a specific medical situation. DESIGN Our design process goes through the following stages: definition of medical situation and decision problem, development/identification of normative model, adaptation of normative model, empirical analysis and development of decision support systems (DSS) tools that facilitate the SDM process in the specific medical situation. CASE STUDY This study demonstrates the applicability of the process through the implementation of the general normative theory of MDM under uncertainty for the medical-financial dilemma of choosing a physician to perform amniocentesis. DISCUSSION The use of normative models in SDM raises several issues, such as the goal of the normative model, the relation between the goals of prediction and recommendation, and the general question of whether it is valid to use a normative model for people who do not behave according to the model's assumptions.
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Affiliation(s)
- Sivan Rapaport
- Department of Industrial Engineering and Management & Telekom Innovation Laboratories, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Barbadoro P, Chiatti C, D’Errico MM, Di Stanislao F, Prospero E. Caesarean delivery in South Italy: women without choice. A cross sectional survey. PLoS One 2012; 7:e43906. [PMID: 23028476 PMCID: PMC3444483 DOI: 10.1371/journal.pone.0043906] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 07/26/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In spite of the World Health Organization's recommendations to maintain caesarean delivery (CD) between 5% and 15% of total births, the rates of CD continue to rise in countries with routine access to medical services. As in Italy CD rate reached 38% in 2008, the highest at EU level, we evaluated socioeconomic and clinical correlates of "elective" and "non programmed" CD in the Country. We performed a stratified analysis in order to verify whether the effect of such correlates differed among women with an "a priori" preference for natural and caesarean delivery respectively. METHODS AND FINDINGS We analyzed cross-sectional data from the Italian National Statistics Institute (ISTAT) survey on health condition. Socio-demographic variables, information on maternal care services use and health conditions during pregnancy, as well as maternal preferences on delivery, were available for a representative sample of 2,474 primiparous women. After an initial bivariate analysis, we used logistic regressions to evaluate factors associated to the study outcomes. Overall CD accounted for 35.5% of the total births in our sample (CI 33.6-37.4%); moreover, 30.7% (CI 28.6-32.6%) of women preferring natural delivery actually delivered with a CD. Elective CD rate is higher among women over 35 years (22.9%, CI 18.8-27.4%), and those living in the South (26.2%, CI 23.0-29.6%). The multivariate analysis showed that, even adjusting for several confounders, women in the South, receiving care in the private sector had higher chances of CD, also in case of preference for natural delivery. CONCLUSION Policy interventions are required to reduce the rate of undesired CD, e.g. increasing women knowledge regarding delivery in order to favour aware choices. An effective strategy to reduce CD rate should address the Southern Regions, as women here appear to have a very limited control over the delivery, in spite of a widespread preference for natural delivery.
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Affiliation(s)
- Pamela Barbadoro
- Department of Biomedical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Carlos Chiatti
- Department of Biomedical Sciences, Università Politecnica delle Marche, Ancona, Italy
| | | | | | - Emilia Prospero
- Department of Biomedical Sciences, Università Politecnica delle Marche, Ancona, Italy
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Sakala C. Letter from North America: rapidly evolving national maternity care landscape in the United States. Birth 2012; 39:263-5. [PMID: 23281909 DOI: 10.1111/j.1523-536x.2012.00556.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Carol Sakala
- Director of Programs at Childbirth Connection; New York; United States of America
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Emeis CL. Current resources for evidence-based practice July/August 2012. J Obstet Gynecol Neonatal Nurs 2012; 41:519-28. [PMID: 22804958 DOI: 10.1111/j.1552-6909.2012.01389.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Cathy L Emeis
- School of Nursing, 3455 SW US Veterans Hospital Rd., Oregon Health & Science University, Portland, OR 97239-2941, USA.
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Emeis CL. Current Resources for Evidence‐Based Practice, July/August 2012. J Midwifery Womens Health 2012. [DOI: 10.1111/j.1542-2011.2012.00193.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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