180 Chapter 8 Woman-centredness during clinical decision-making (cause 3) Part of woman-centredness in maternity care is shared decision-making. Research has shown that the use of shared decision-making helps patients to take an active role in the decision-making process, which contributes to more positive experiences of their care. Decisions will then be made based on patient’s preferences, healthcare professionals’ expertise, the organisation of care and the best available evidence. When patients have an active role in the decision-making, different treatments are preferred compared to those with medical professionals’ judgement only (34,35). Up to now, most studies have explored the influence of shared decisionmaking on variation within hospitals and general practitioners practices (16,36). A comparable influence on practice variation in maternity care is likely when midwives use shared-decision making. Especially when uncertainty exist about the evidence on what is the best options, it creates room for women’s preferences. Variation within a midwifery practice is likely to increase when women’s preferences are taken into account using shared decision-making (15). If variation increases based on women’s preferences, within the boundaries of accepted care, this is not considered unwarranted variation. However, if this variation is caused by preferences of the midwife, it is considered to be unwarranted variation. As it seems that women informed through shared decision-making prefer more conservative options, another effect of shared decision-making may be a reduction in interventions during childbirth (15,37). In our interviews, participants described differences in communication skills. Midwives with a wait and see attitude seemed to use more communication skills that facilitated shared decision- making. Besides the use of instrumental communication to explain treatment options, these midwives showed additional attention to women’s need to feel known, by using more affective communication skills and gaining insight into women’s knowledge and motives (Chapter 5). The balance between instrumental and affective communication skills is necessary to invest in an effective partnership between woman and midwife and is in the line with the shared decision-making model (38–40). Shared decision-making means that a midwife explains the various options and their evidence base as well as exploring women’s preferences and what she knows. This makes clinical decision-making less dependent on the personal beliefs of the individual midwife (38), and leads to more awareness about appropriate use of interventions instead of standardised use. In practice, an informed consent approach can unjustly be mistaken for shared decisionmaking, because professionals ask for consent but there is no dialogue as a medium for the decision-making process (38). Research by Thomas et al. proposes changes in health education to develop the skills needed to be fully competent in shared decision-making (41). They suggest that education should, among other things, include teaching methods that involve more dialogue and the creation of moments of dissonance.
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