Decision Making and Consumer Choice: Problems and System Goals


Lack of access to comprehensible information from trustworthy sources

Consumers often receive conflicting information from diverse sources. They may not be confident in their ability to make decisions or may use unreliable information. The childbirth education system is not meeting the needs of contemporary women. Childbirth education affiliated with hospitals can compromise the independence of childbirth educators and interfere with women’s access to unbiased information.

Few national standardized performance measures exist for maternity care, and none address the adequacy of processes for informed decision making. Existing measures are neither widely collected and reported, nor easily understood by consumers.

Women do not currently have access to comprehensible performance reporting about maternity care providers and facilities to help them choose a caregiver and place of birth. They lack ready access to full, balanced information on risks, benefits, and alternatives associated with various options for childbirth.

Poor processes and insufficient opportunities for shared decision making

All too often, women are not full partners with caregivers in decision making, but rather experience care paths based on the decisions of others. Established institutional routines create barriers to informed and shared decision making. Health professionals may ask women to consent to procedures without providing them with adequate help to understand benefits and harms of recommendations and alternatives. To complicate the process further, many choices are complex, with multiple, sometimes incommensurable trade-offs, and decision making during labor is subject to many pressures.

Cultural mistrust of birth and pervasive climate of doubt

The current cultural emphasis on the pain, fear, and risks associated with childbirth, coupled with a strong emphasis on medical technology and interventions for childbirth seriously limit awareness of other ways of understanding birth and giving birth. The prevailing culture of maternity care and popular media representations of childbirth make it difficult for women to approach childbirth in a ‘‘climate of confidence’’ (Boston Women’s Health Collective, 2008).

Limited care options and lack of choice

Women do not currently have access to a wide range of choices about where to give birth, how to give birth, and with whom to give birth. Factors that constrain their choices include institutional policies (e.g., disallowance of VBAC), provider preferences (e.g., routine cesarean delivery of twins), loss of clinical skills (e.g., vaginal breech birth), and reimbursement policies (e.g., no reimbursement for home birth).

System Goals

  • Activated and informed consumers foster maternity care quality improvement and system performance.
  • Valid, unbiased, easily understood information about risks, benefits, and alternatives is accessible to support women’s informed decision making.
  • Women have access to a wide range of safe and effective maternity care options that enable them to realize their carefully considered choices.


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Boston Women’s Health Book Collective. (2008). Approaching birth with confidence. In: Our bodies, Ourselves: Pregnancy and birth. Boston: Simon and Schuster.