A simple question that embodies person-centered care is “what matters to you”, as opposed to “what’s the matter.”1 The origins of this concept were introduced in the Institute of Medicine’s Crossing the Quality Chasm publication in 20012, which defined patient-centered care as “providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.” As in other clinical settings, this concept prioritizes patient values in birthing care.
In a recent study in our journal, Van der Pijl and colleagues performed a national cross-sectional survey of persons who gave birth in the Netherlands within the previous 5 years, asking if and how consent was obtained for 10 obstetrical interventions. Importantly, the study also assessed the impact of obtaining consent (or not). While there was likely selection and recall bias in recruitment of subjects compared to the Dutch perinatal registry, the study highlights that a lack of consent (and therefore presumably, assent) for a variety of procedures can contribute to patient distress. The likelihood of giving consent varied by ethnicity and education, suggesting a disparity in the consenting process or experience by these individuals and highlighting the importance of incorporating individual values and cultures into our approaches to explaining and performing procedures.
Interestingly, home births in the Netherlands are performed at the highest rate of any developed country (12.7%), compared to 1.4% in the United States3, and even for the Netherlands, survey respondents had a higher-than-average rate of home births (20.4%). This sampling may have led to an underrepresentation of people having unfavorable experiences compared to not only the Dutch population but also those in other developed countries.
Obstetricians and midwives know there are obvious and intrinsic challenges to consent in labor and delivery, including acuity, rapidly evolving decision-making, unpredictable unit volume, and patient expectations. However, we pose that the latter – patient expectations – can be an opportunity (and not a barrier) for discussion on a shared vision of a “good” birth.
So, how do we, practically, improve consent in labor and delivery?
Perhaps the answer lies in starting with a simple prompt for a patient to imagine a “good” birth. This, in essence, is the goal of a birth plan. The birth plan is a guide to patient preferences and developed as part of childbirth education in 1980.4 The birth plan (or “preferences”) could provide a framework for improving our shared decision-making, and proactively walk patients and providers through the labor process. From the patient perspective, birth plans have shown high rates of endorsed satisfaction, feelings of control, being informed, and wishes being expressed. Providers often have different opinions however, with one study noting that 65% of providers perceived an increased risk of cesarean deliveries and poor outcomes5 for patients with birth plans, despite evidence to the contrary.6,7 Furthermore, patients have reported a high rate of clinicians not reading or being indifferent to their preferences.8
One quality improvement opportunity to facilitate a discussion around birth preferences would be standardizing the discussion antenatally. This might be achieved in different ways in different prenatal clinics – whether with “centering models” (where there is group prenatal care), as part of childbirth education, or in conversations with nurse educators. Subsequently, these preferences could be reviewed during admission to birthing centres.
To help facilitate the healthcare team remembering to address patient wishes, different tools can be created depending on what works for the facility. At our institution, a time-out is done right before vaginal birth where important medical conditions are addressed, and this time also could be utilized to review patient wishes. Similar to surgical time-outs where the desire for a Jehovah’s witness to not accept blood transfusions is essential information, all patient preferences could be integrated as part of our safety processes. Such ideas for change could be generated and tested in plan-do-study-act cycles to find methods that work for specific institutions. A goal set by the Institute for Healthcare Improvement in its “Idealized Model of Perinatal Care”9 is having 95% of patients reporting their wishes known to the entire team and respected. Examples cited include patients having the opportunity to express preferences for delivery, pain management, and the birth process. This metric could be measured immediately postpartum and provide a framework for improving person-centered care at our institutions.
Our healthcare system is centered around healthcare providers and what works for the system. We need to reimagine a system catered to the needs, values, and cultures of our patients. A shared decision-making model for birth processes individualized to patients should start in the antenatal period and continue through labor and delivery. We believe that by engaging patients as a partner in their birth processes, we can help create a safer, person-centered, equitable, and less traumatic place for birthing persons. Let’s approach our care through the eyes of our patients and start by asking the question, “what does a good birth look like for you?”
–Kathleen M. Zacherl, MD, & Luke A. Gatta, MD
Dr. Zacherl is a physician and an Assistant Professor at UConn Health in the Department of Obstetrics & Gynecology, where she serves as Vice Chair of Quality and Medical Director of Labor & Delivery.
Dr. Gatta is a physician in the Division of Maternal-Fetal Medicine and in the Center for Biomedical Ethics and Society at Vanderbilt University.
References
1. Barry M, Adgman-Levitan S. Shared decision making—The Pinnacle of Patient-Centered Care. NEJM 2012; 366; 9: 780-781.
2. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Washington DC: National Academy Press; 2001.
3. Gregory ECW, Osterman MJK, Valenzuela CP. Changes in home births by race and Hispanic origin and state of residence of mother: United States, 2019–2020 and 2020–2021. National Vital Statistics Reports; vol 71 no 8. Hyattsville, MD: National Center for Health Statistics. 2022. DOI: https://dx.doi.org/ 10.15620/cdc:121553.
4. Waller-Wise R. Birth Plans: Encouraging Patient Engagement. J Perinat Educ 2016;25(4):215-222. doi: 10.1891/1058-1243.25.4.215.
5. Grant R., Sueda A., & Kaneshiro B. (2010). Expert opinion vs. patient perception of obstetrical outcomes in laboring women with birth plans. Journal of Reproductive Medicine, 55(1–2), 31–35.
6. White-Corey S. (2013). Birth plans: Tickets to the OR? American Journal of Maternal Child Nursing, 38(5), 268–273.
7. Deering S. H., Zaret J., McGaha K., & Satin A. J. (2007). Patients presenting with birth plans: A case-control study of delivery outcomes. Journal of Reproductive Medicine, 52(10), 884–887.
8. Brown, S. J., & Lumley, J. (1998). Communication and decision-making in labour: Do birth plans make a difference? Health Expectations, 1, 106–116.
9. Cherouny PH, Federico FA, Haraden C, Leavitt Gullo S, Resar R. Idealized Design of Perinatal Care. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2005.