Decision Making and Consumer Choice: Recommendations and Action Steps

1. Expand the opportunities and capacity for shared decision making processes, and tools and resources to facilitate informed choices in maternity care.

  • Summarize research evidence, fill priority research gaps in how best to support maternity care decision making, and incorporate results into resources and tools for shared decision making and informed choice.
  • Create a national coalition of public and private entities that provide educational materials for childbearing women and families to identify, develop, refine, and foster access to the shared decision-making tools.
  • Identify nationally recognized producers of independent, consumer-friendly information on quality and evidence in maternity care, provide support for their work, and foster broad access to these credible sources of information.
  • Fund the development of a set of electronic decision-support tools that present probability data on expected shorter term and downstream benefits and harms of common maternity interventions. Pilot the tools with diverse audiences to evaluate and refine them. Publish results, make the tools freely available, and foster their integration into the health system and use by childbearing women. Include individualized decision aids that solicit a woman’s preferences and values and feedback options most compatible with what that woman deems important, a promising decision support strategy in preliminary studies.
  • With support from consumer and advocacy groups, develop templates for ‘‘maternity care plans’’ that encompass the full episode of pregnancy, birth, and the postpartum period to encourage women to clarify their values and preferences before actual decision points. Advance directives, living wills, and other forms of end-of-life planning are models for this work.
  • Develop electronic maternity care records that systematically incorporate and make readily accessible information about a woman’s maternity care preferences to help ensure that caregivers honor her choices across settings and throughout her full episode of maternity care.
  • Support the development of performance measures of consumer involvement in maternity care, including informed decision making, and adapt for maternity care the generic CAHPS Provider, Facility and Health Plan surveys to measure experiences of childbearing women.
  • Encourage health plans and Medicaid programs to provide beneficiaries ready access to meaningful information about all potential maternity caregivers:
    • Identify as maternity caregivers and include name, clinical discipline, languages spoken, photograph, and contact information for all obstetricians, family physicians and midwives whose maternity services the plan would cover.
    • Develop standardized national guidelines for presentation of information about heath plan maternity caregiver panel members to beneficiaries.

2. Design system incentives that reward provider and consumer behaviors that lead to healthy pregnancies and high-quality outcomes.

  • Create financial incentives for caregivers to engage in patient education and shared decision making and to support appropriate low-intervention choices of childbearing women such as practices that support physiologic labor and spontaneous full-term birth. (See the Blueprint section on Payment Reform to Align Incentives with Quality.)
  • Offer incentives that motivate women to select providers who have demonstrated consistent adherence to evidence-based practice and/or exceptional achievement of outcomes. These could include co-insurance reductions, health savings account contributions, and co-pay waivers.

3. Revive and broaden the reach of childbirth education through expanded models and innovative teaching modalities.

  • Investigate the current role of formal childbirth education in women’s decision making and the ways they obtain and use information about pregnancy and childbirth.
  • Implement and evaluate several models of education for childbearing women:
    • Independent, community-based education that fosters taking responsibility for informed maternity care decision making
    • Peer education with ‘‘good birth ambassadors’’ serving as change agents in local communities
    • Alternate media for childbirth education, such as web-based formats and podcasts.
  • Seek reimbursement for childbirth education models of demonstrated effectiveness.
  • Engage National Priorities Partnership (NPP) members in piloting the various educational strategies and implementing effective ones in fulfillment of their focus on better engaging patients and families in managing their health and making decisions about their care.

4. Promote a cultural shift in attitudes toward childbearing.

  • Explore the model of cultural transformation around end-of-life care that the death-and-dying movement has pursued and apply similar strategies to change the culture of childbirth. Promote awareness that childbirth is a meaningful process that can be profoundly transformative for women and families, and is not just a clinical event.
  • Partner producers of mass media with advocacy and professional groups to develop and carry out ways to improve the image of childbirth in the media.
  • Conduct national and local ‘‘childbirth literacy campaigns’’ to inform women of maternity care options and convey positive messages about childbearing processes. Collaborate with state and local public health agencies and staff of the Title V programs. Target women’s magazines and other popular media and outreach on college campuses.
  • Conduct regular national surveys of women’s childbearing experiences, like the Listening to Mothers surveys (available:, to ensure that women’s voices are included in the discourse.

Lead Responsibilities

A broad range of stakeholders share fundamental responsibilities for improving decision making and consumer choice. Key stakeholders include consumers and their advocates, researchers and epidemiologists, health professionals, administrative leaders, public and private payors and purchasers, federal and state agencies, and the NPP.


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