2012 Summer Medical Editors Meeting: Carol Sakala

1. EXTENDING SHARED DECISION
MAKING TO MATERNITY CARE:
OPPORTUNITIES AND CHALLENGES
Carol Sakala
Director of Programs
Childbirth Connection
July 30, 2012

2. OPPORTUNITY:
GREAT POTENTIAL REACH
• Maternity care impacts
• everyone at the beginning of life
• 85% of women who give birth once or, mostly,
multiple times
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3. OPPORTUNITY:
FOCUSED ATTENTION & PREPARATION
• Well-defined episode of care, with 9 months
to
• make prenatal decisions
• prepare for birth, postpartum, and infant care
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4. OPPORTUNITY:
HIGHLY MOTIVATED POPULATION
• Pregnant and birthing women have
exceptional
• interest in supporting the well-being of their
fetus/newborn
• commitment to improving their own health
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5. OPPORTUNITY: NEW COMMUNICATION
CHANNELS & FUNCTIONALITY
• Communication options via Internet,
intranets: computers, mobile devices, apps,
EHRs, PHRs
• Potential to
• extend reach to more people and places
• incorporate interactivity, personalization
• Listening to Mothers III will identify practices,
options, and preferences
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6. OPPORTUNITY: A NEW GENERATION THAT
EMBRACES AND EXPECTS SDM?
• Following childbearing experiences, women
may demand SDM processes for
• their own care through the life course
• care of family members, over time and across
generations
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7. OPPORTUNITY:
RELATIVELY MATURE EVIDENCE BASE
• Iain Chalmers & colleagues’ major 1989
pregnancy & childbirth systematic review
publications
• inspired establishment of Cochrane Collaboration
• fostered 1000s of Cochrane and journal- and
agency-based pregnancy and childbirth SRs
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8. OPPORTUNITY: SDM AS RESOURCE FOR
EVIDENCE-PRACTICE GAPS
• Decision aids can address
• equipoise
• clinical uncertainty
• evidence-practice gaps, as documented in
Evidence-Based Maternity Care (2008)
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9. OPPORTUNITY: POTENTIAL FOR RAPID
GAINS IN QUALITY, OUTCOMES & VALUE
• Short- and long-term gains from high-quality
maternity care
• Wellness focus can prevent or delay chronic
disease
• Contrasts with challenges of chronic diseases
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10. OPPORTUNITY: UNPRECEDENTED COMMITMENT TO
HIGH-PERFORMING HEALTH SYSTEM
• Synergy through
• decision aids to engage women in obtaining high-
quality maternity care
• complementary improvement via payment and
delivery innovations, performance measurement,
quality collaboratives, harnessing health IT, etc.
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11. CHALLENGE: TWO INDIVIDUALS
RECEIVING CARE SIMULTANEOUSLY
• Differential effects of decisions on women and
fetuses/newborns
• Benefit/harm trade-offs often more complex
Solution:
• Use effective visual displays
• User test
• Provide good support for identifying and
weighing preferences
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12. CHALLENGE: TECHNOLOGY-INTENSIVE
PRACTICE STYLE, DOZENS OF DECISIONS
• Childbearing women face many decisions,
especially during relatively brief intrapartum period
• Challenge for development, updating
Solution:
• Strategically identify priority decisions
• Include decision support resources until other DAs
are available
• Limit to maternity care decisions
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13. CHALLENGE: HOW TO REACH WOMEN FOR
TWO CONSEQUENTIAL DECISIONS?
• Major implications of
• choice of maternity care provider
• choice of birth setting
• Unlikely to make shared decision with provider
Solution:
• Access Smart Decision Guide via, e.g., search
engines, social media, advocates, employers
• Change if initial decisions are not good fit
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14. CHALLENGE: HOW TO BRING BENEFITS OF
SDM TO WOMEN AROUND THE TIME OF BIRTH?
• Steady stream of decisions
• Rapid decision making often required
• Considerable physical & emotional demands
• Labor benefits from undisturbed limbic system
Solution:
• Anticipatory guidance, mobile app, engage
support team members (PCORI application)
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15. CHALLENGE:
MAKING DECISION IS JUST THE BEGINNING
• Well documented gaps between maternity care
preferences and care actually received
• Preferred care may be difficult or impossible to
find: e.g., VBAC, vaginal breech or twins
Solution:
• Smart Decision Guides have back-end support to
help women achieve their preferred care
• Prevention: e.g., focus on external version rather
than vaginal breech
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16. CHALLENGE: CHILDBIRTH AT
FOREFRONT OF DEMOGRAPHIC TRANSITION
• Culturally and linguistically diverse population
Solution:
• Optimize mix of backgrounds in focus groups
• Optimize mix of backgrounds in videos
*More targeted adaptations (e.g., Spanish) out
of reach at present
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17. CHALLENGE:
EXTENSIVE MEDICAID COVERAGE
• 2009 maternal hospitals stays
• private insurance: 47%
• Medicaid: 45%
• Medicaid programs have educational material
reading level requirements: typically, 6th grade
Solution:
• Seeking funding to pilot low-health-literacy
adaptations of 3 initial Smart Decision Guides
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18. CHALLENGE: SDM LARGELY NEW TO
U.S. MATERNITY CARE PROVIDERS
• SDM increasingly integrated into health care reform
and quality improvement
• Most existing maternity care decision aids
developed for use in other countries
Solution:
• Continuously raise awareness among clinicians,
policymakers, women, and other stakeholders
• Begin with high-demand topics
• Feature and pilot with early adopters
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