Carol SakalaDirector of Programs

Childbirth ConnectionJuly 30, 2012

O P P O RT U N I T I E S A N D C H A L L E N G E S

EXTENDING SHARED DECISION MAKING TO MATERNITY CARE:

OPPORTUNITY:GREAT POTENTIAL REACH

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•Maternity care impacts• everyone at the beginning of life• 85% of women who give birth once or,

mostly, multiple times

OPPORTUNITY:FOCUSED ATTENTION & PREPARATION

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•Well-defined episode of care, with 9 months to• make prenatal decisions• prepare for birth, postpartum, and infant

care

OPPORTUNITY:HIGHLY MOTIVATED POPULATION

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• Pregnant and birthing women have exceptional• interest in supporting the well-being of

their fetus/newborn• commitment to improving their own

health

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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OPPORTUNITY: A NEW GENERATION THAT EMBRACES AND EXPECTS SDM?

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• 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

OPPORTUNITY:RELATIVELY MATURE EVIDENCE BASE

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• 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

OPPORTUNITY: SDM AS RESOURCE FOR EVIDENCE-PRACTICE GAPS

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•Decision aids can address• equipoise• clinical uncertainty• evidence-practice gaps, as documented

in Evidence-Based Maternity Care (2008)

OPPORTUNITY: POTENTIAL FOR RAPID GAINS IN QUALITY, OUTCOMES & VALUE

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• Short- and long-term gains from high-quality maternity care•Wellness focus can prevent or delay chronic disease• Contrasts with challenges of chronic diseases

OPPORTUNITY: UNPRECEDENTED COMMITMENT TO HIGH-PERFORMING HEALTH SYSTEM

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• 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.

CHALLENGE: TWO INDIVIDUALSRECEIVING CARE SIMULTANEOUSLY

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• 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

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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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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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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CHALLENGE:MAKING DECISION IS JUST THE BEGINNING

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•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

CHALLENGE: CHILDBIRTH ATFOREFRONT OF DEMOGRAPHIC TRANSITION

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• 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

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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CHALLENGE: SDM LARGELY NEW TOU.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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