PHP: You successfully designed a shared decision-making tool for pregnant people. What is the purpose of the tool?
Ann Peralta: Patients often describe labor induction—offered when a pregnancy reaches week 41 or 42 of pregnancy–as a decision that is made for them and not with them, which is the opposite of what shared decision-making should be. Shared decision-making offers a full range of treatment options and keeps the person making the decision at the center. Many people are pressured to induce labor without evidence-based, balanced information about their options. This tool helps a person having a baby decide whether to have labor induced when there might be medical pros and cons for the induction.
How does this decision-making tool work? What choices are offered?
Prenatal care providers introduce the tool at a prenatal appointment and either talk about it immediately or let the patient take it home to review for future discussion. Most conversations begin between 36-39 weeks so the decision is not rushed. After reading and discussing the tool with their provider and any other people in their life, the patient tells their provider what they want: 1) to wait for labor to start on its own, 2) to schedule an induction between 41-42 weeks, or 3) to request an induction between 39-41 weeks.
The tool helps prompt a conversation for patients, allowing them to express their values with a provider by indicating the most and the least important considerations for making this decision.
What motivated your research focus on shared decision-making as it relates to pregnancy and maternal health?
When I was pregnant and past my due date, conversations about induction came up often. People would ask me, “Oh, when are you due? When’s your baby coming?” And I would say, “11 days ago.” And people who didn’t know me, like the barista or the ultrasound tech, would say things like, “Wow, how much longer are they going to let you go?” I think that “let you” language is this not-so-quiet piece of our culture that assumes that labor induction is not my decision.
We have this wider understanding that pregnant people aren’t entitled to make decisions about their pregnancy in the perinatal period. Once there’s a fetus, suddenly it’s not my body anymore in many aspects. But labor induction still is my decision. So shared decision-making and a decision aid seemed like a useful mechanism for focusing more on open conversations like, “Do you want this? Here’s why you might, and here’s why you might not.”
When you developed and tested your tool as part of a research study, what did you learn from patients that you didn’t already know?
Some people don’t know that they have choices or the risks and benefits of different medical decisions. I was surprised when people chose to say things like, “This gives me so much power.” I went into the project trying to solve a knowledge problem by creating access to options and knowledge, but I ended up also helping to solve a power problem.
I learned that many patients were not aware of how common it is to go past your due date. I was also made aware of how challenging time spent in the hospital can be for individual lives and schedules. Choosing to have an induction is a big factor when people learn it could take up to three days inpatient.
What did you learn from health care professionals that you didn’t already know?
Many providers admitted their bias about induction and how this tool was able to provide guidance for more balanced counseling. Beyond this, I did not expect providers to share they were having entirely different conversations with each patient before they were offered the structure of the decision aid tool. Conversations were often reliant on questions that patients brought up, how much time providers had, and even the language being spoken. Using a tool consistently should eliminate certain decision-making biases.
Now that your research project has concluded, where do you hope it will lead you next?
Many institutions have reached out to ask if they can also use it for their patients and are pleasantly surprised about the tool’s multiple language options. It’s free–so anyone can use it, print it, or share it online.
I finished this project in July 2022, just when the White House Maternal Health Blueprint came out. I was thrilled when I saw goal number two is to “ensure those giving birth are heard and are decisionmakers in accountable systems of care.” The blueprint specifically referenced induction as an example. The timing of this tool’s release has momentum, and I’m interested to see where else it can go.
Dr. Peralta’s shared decision-making tool can be found here.
Photo provided
This interview has been edited for length and clarity
