Factors influencing women’s perceptions of shared decision making during labor and delivery: Results from a large-scale cohort study of first childbirth

Highlights

• Few studies have examined shared decision making in the childbirth context.

• Obstetric procedure use was associated with less shared decision making.

• Shared decision making was less common among lower-SES women and women of color.

• Black women who delivered by cesarean had strikingly low shared decision making.

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.

Introduction

Nearly 4 million women give birth in the U.S. each year; 32% deliver by cesarean, and at least 22% give birth following an induction of labor [[1], [2]]. There is broad agreement that cesarean delivery is currently overused in the U.S., given that maternal and neonatal morbidity and mortality have not decreased as cesarean delivery has become more common [3]. Furthermore, cesarean delivery is a major abdominal surgery and carries increased risk of complications for the mother and baby, as well as increased risk of placenta problems in future pregnancies compared to vaginal delivery [[3], [4]]. There is less consensus on whether labor induction is overused, but the major concern is that induction of labor when it is not medically necessary may lead to a higher risk of delivering by cesarean [[3], [5], [6], [7]]. Despite these concerns about overuse of obstetric procedures, little is known about how procedure utilization in childbirth relates to women’s involvement in decision making during labor.

Shared decision making, a process in which clinicians and patients work together to make choices about screening, treatment, and other aspects of care, is a dimension of patient-centered care and a key aspect of care quality [8]. While studies have found mixed results of the effects of shared decision making on outcomes [9], some U.S. research has linked shared decision making with higher quality care in a variety of contexts, including depression treatment [10], diabetes management [11], and cancer treatment [12]. Shared decision making in maternity care could have benefits such as reducing decisional conflict, increasing satisfaction with the delivery experience, and generating more positive feelings toward the newborn and fewer depressive symptoms [13], and some maternity care providers have called for more attention to shared decision making as part of increasing the provision of patient-centered care. Advocates of patient-centered care have noted that not all patients may wish to participate in decision-making to the same degree. Although no studies that we are aware of have assessed women’s desire for shared decision making in maternity care specifically, the proportion of patients reporting a desire for shared decision-making in general has been increasing over time [14]. Additionally, some research has shown that patients who participate in decision making report better quality of care and higher quality physician communication regardless of their stated preferences for decision making role [[15], [16]].

Research on decision making in the context of maternity care has focused on women with a prior cesarean delivery and “elective” or “maternal request” cesarean delivery, and found that decision aids or formal counseling programs can increase knowledge and reduce decisional conflict [[17], [18], [19], [20], [21]]. One study conducted at two northern California hospitals found no relationship between women’s perceptions of shared decision making during prenatal care and odds of delivering by cesarean [22]. However, despite the fact that women are actively involved in decisions during the clinical management of labor, no previous research that we are aware of has examined predictors of shared decision making during the intrapartum period of labor and childbirth.

The quality of clinician-patient communication and shared decision making vary by the race/ethnicity and socioeconomic status (SES) of the patient. High-quality communication may be a necessary prerequisite for patients to be involved in making decisions about their care, and racial/ethnic minority patients and lower-SES patients tend to experience poorer-quality communication with clinicians [[23], [24], [25]]. White patients are more likely to experience shared decision making compared to racial/ethnic minority patients [[26], [27], [28], [29], [30]]. Lower-SES patients may have lower levels of health literacy, which can be a barrier to engaging in shared decision making [31]. There are several potential reasons for these disparities in the quality of clinician-patient interaction. For example, there may be greater social separation between clinicians and racial/ethnic minority patients, given that only about 4% of U.S. physicians identify as Black or African American [32]. Greater social separation may contribute to a greater imbalance of power in the patient-clinician relationship, which has been identified as a barrier to shared decision making [33]. Implicit bias among clinicians may also be a factor in communication quality and decision-making style [34]. Minority and lower-SES patients are more likely to be seen in low-resource settings where time pressures may be more intense, which is another barrier to shared decision making [33].

To better understand the relationship between procedure use in childbirth, race/ethnicity and SES, and shared decision making, this study aimed to 1) characterize the association between race/ethnicity, SES and shared decision making during childbirth, 2) examine whether shared decision making varies by use of obstetric procedures such as labor induction and cesarean delivery, and 3) assess whether the relationship between obstetric procedure use and shared decision making is different depending on the woman’s race/ethnicity or SES.