Extending Shared Decision Making to Maternity Care: Opportunities and Challenges


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2012 Summer Medical Editors Meeting: Carol Sakala

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Extending Shared Decision Making to Maternity Care: Opportunities and Challenges

  1. 1. EXTENDING SHARED DECISIONMAKING TO MATERNITY CARE: OPPORTUNITIES AND CHALLENGES Carol Sakala Director of Programs Childbirth Connection July 30, 2012
  2. 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 2
  3. 3. OPPORTUNITY: FOCUSED ATTENTION & PREPARATION• Well-defined episode of care, with 9 months to • make prenatal decisions • prepare for birth, postpartum, and infant care 3
  4. 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 4
  5. 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 5
  6. 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 6
  7. 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 7
  8. 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) 8
  9. 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 9
  10. 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. 10
  11. 11. CHALLENGE: TWO INDIVIDUALS RECEIVING CARE SIMULTANEOUSLY• Differential effects of decisions on women and fetuses/newborns• Benefit/harm trade-offs often more complexSolution:• Use effective visual displays• User test• Provide good support for identifying and weighing preferences 11
  12. 12. CHALLENGE: TECHNOLOGY-INTENSIVE PRACTICE STYLE, DOZENS OF DECISIONS• Childbearing women face many decisions, especially during relatively brief intrapartum period• Challenge for development, updatingSolution:• Strategically identify priority decisions• Include decision support resources until other DAs are available• Limit to maternity care decisions 12
  13. 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 providerSolution:• Access Smart Decision Guide via, e.g., search engines, social media, advocates, employers• Change if initial decisions are not good fit 13
  14. 14. CHALLENGE: HOW TO BRING BENEFITS OFSDM 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) 14
  15. 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 twinsSolution:• 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 15
  16. 16. CHALLENGE: CHILDBIRTH ATFOREFRONT OF DEMOGRAPHIC TRANSITION• Culturally and linguistically diverse populationSolution:• Optimize mix of backgrounds in focus groups• Optimize mix of backgrounds in videos*More targeted adaptations (e.g., Spanish) out of reach at present 16
  17. 17. CHALLENGE: EXTENSIVE MEDICAID COVERAGE• 2009 maternal hospitals stays • private insurance: 47% • Medicaid: 45%• Medicaid programs have educational material reading level requirements: typically, 6th gradeSolution:• Seeking funding to pilot low-health-literacy adaptations of 3 initial Smart Decision Guides 17
  18. 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 countriesSolution:• Continuously raise awareness among clinicians, policymakers, women, and other stakeholders• Begin with high-demand topics• Feature and pilot with early adopters 18