Facilitating functional decision making in midwifery: lessons from decision theory.
Supporting decision making is a core issue for midwifery practice. Midwives in New Zealand have an ethical and legal obligation to inform women of their choices and are in a position to influence the decisions that women make, by the way in which they convey this information. This paper takes a theoretical look at decision making, focusing on descriptive theory as one approach that midwives may find helpful. This approach posits four essential strategies that can be used to facilitate sound decision making in the context of cognition and information processing. These are: the utilisation of positive affect, the involvement of whanau/family, an understanding of modes of thinking and the use of narrative or storytelling.
Contextualising Midwives' Obligations to Women in Decision Making
Midwives engagement with women involves a complex interplay of factors. The transfer of clinical information and research evidence is only one of many areas that need to be considered when caring for women during the childbirth process. The ability to support informed decision making required at this time is reliant on the midwife having formed a trusting relationship with each woman. Within this context there are also key regulatory and professional frameworks related to information and decision making, which must be adhered to. These are the Code of Health and Disability Services Consumers' Rights (1996), the Health Practitioners' Competence Assurance Act (2003) and the New Zealand College of Midwives Code of Ethics and Standards of Practice (2005).
Midwives have a professional duty to 'uphold each woman's right to free, informed choice and consent throughout her childbirth experience' (New Zealand College of Midwives (NZCOM), 2005, p 10). This requires that a midwife 'facilitates the decision making process without coercion', 'respects the decisions made by the woman', and clearly states when 'professional judgement is in conflict with the decision or plans of the woman' (NZCOM, 2005, p 14).
The Code of Health and Disability Services Consumers' Rights Regulation 1996 (Health and Disability Commissioner Act, 1994) ensures the right of every woman to effective communication (Right 5), the right to be fully informed (Right 6) and the right to make an informed choice and to give informed consent (Right 7). These rights are fundamental to informed consent (Pearse, 1998), and the onus is on the midwife to create a 'functional partnership' relevant to a woman's decision making (Midwifery Council of New Zealand, 2004, p. 2).
Individualising the Decision Experience
What we do know as midwives is that although these statutory and regulatory requirements apply to all women, each woman is actually very different and inevitably the decisions that she makes will come from her own unique perspective. This need for an individualised approach to midwifery is a cornerstone of culturally safe care, which requires a midwife to respond to each woman on the basis of the woman's own cultural norms and values (New Zealand College of Midwives, 2005). Cultural safety is relevant to the decision experience of women as participation in decision making is a key contributor to a woman's positive birth experience (Lavender and Walkinshaw, 1999). Legislative and ethical frameworks in New Zealand require that all women receiving midwifery care will receive consistent information necessary to make informed decisions. Midwives need to balance this requirement with the need for an individual approach to each woman, remembering that information given should be accurate, and timely (Hibbard & Peters, 2003). Midwives also need to have insight into their own practice norms and attitudes, or midwifery culture, in order to recognise how they themselves might influence the decision process for women.
The Decision Process
Decision making is the cognitive process leading to the selection of a course of action among variations, and it is only after reaching a choice can women give their consent. Consent is closely associated with autonomy (Draper, 2004). In the context of midwifery assessments like urinalysis, blood pressure monitoring, abdominal palpation and vaginal examination, gaining consent before touching a woman's body, is a manifestation of respect for her autonomy, and giving consent to midwifery intervention is a woman's expression of autonomy (Draper, 2004).
When women are faced with choices that require them to compare two or more options on information provided (called comparative information), each choice is likely to make similar demands on the decision maker, because the information about each choice is likely to include technical terms and complex ideas, compare options, and require the decision-maker to differentially weight various factors according to individual values, preferences and needs (Hibbard and Peters, 2003). A typical example is choosing appropriate management for 3rd stage of labour, in which case a woman is faced with making a choice between options of active management or taking a physiological approach. Each option is likely to be important, but the information may be unfamiliar. Therefore, a woman has to interpret the information, identify the important factors to integrate into a decision, weight those factors in ways that match her individual needs and values, make trade-offs, and bring all the factors together into a choice. Although these may sound easy enough, they tend to be demanding cognitive tasks (Hibbard and Peters, 2003). The way information is framed and packaged will determine to a large degree what information is actually used in the final choice.
To understand the complexity of decision making, preference construction is used to cope cognitively with information. This theory posits that when people are faced with a situation that is complex and unknown, they are likely to not have fixed ideas, but will 'think up' or construct an answer for a moment in time (Hibbard & Peters, 2003). The following is a hypothetical scenario about Carli which demonstrates this.
Carli is pregnant with her first baby and at 12 weeks gestation she meets a midwife, Bea, for the first time. Carli has an expectation that Bea will do home visits because she has read an information booklet from Bea's practice, which lists home visits as an option. Bea and her colleagues have framed their practice information as if home visiting is an option for women. In reality, they prefer to, and do, conduct antenatal checks at their clinic. On hearing this, Carli responds to Bea's framing of her practice by constructing an answer that conforms to their practice approach. Carli agrees to go to clinic visits, despite the fact this is not consistent with her desire or expectation.
Information and communication form the basis of gaining consent and it is important that information reflects actual practice, and that the potential for mixed messages or miscommunication is reduced. This begins at the first point of contact between a midwife and a woman, when the midwife must negotiate her role and clarify expectations and/or needs.
Time constraints and pressures on midwives, may result in midwives having a lack of discussion with women about their choices in maternity care. One reason might be acute or emergency situations when the midwife prioritises attention to clinical responsibilities. But time constraints may also affect midwives who have a caseload that is so significant, they have little or no time dedicated to informing women about basic midwifery assessments.
Hibbard and Peters (2003) suggest that the simple provision of information alone does not improve decision making. To make informed decisions and navigate the complex maternity system, including research evidence, women, they say, need to have access to accurate and timely information. Though women may have all information deemed relevant by the midwife, it does not necessarily follow that they use the information or that they will consent. (Paterson, 2003).
A good example of this is found in the work of O'Cathain, Walters, Nicholl, Thomas, and Kirkham, (2002). They conducted a randomised controlled trial in 13 maternity units in Wales, to assess the effect of informed choice leaflets on the exercise of informed choice regarding the use of maternity services. They found that there was no change in the proportion of women who reported that they exercised informed choice. Stapleton, Kirkham & Thomas, (2002) concluded, from the same study, that the potential for leaflets as evidence based decision aids was reduced, because the way in which leaflets were distributed supported existing normative practice. This ensured informed compliance rather than informed choice.
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Various authors have offered different descriptions of factors that affect decision making. Bekker, et al. (1999), for example, propose that there are three major components (Figure 1). These components consist of the context in which the decision is made, the decision maker and environmental influences.
In this model, a woman's own life experiences inform decision making because she will draw on her past experiences to estimate the likelihood of a decision outcome according to options available. Many decisions in childbirth have a clinical context. For example, the decision of a woman to have a blood transfusion or not following a post partum haemorrhage, is likely to be considered against whether she is symptomatic or not and her own feelings about having a transfusion. Midwives can be seen as having an environmental influence on decisions as they are the major providers of maternity services and have a close relationship with women. Other influences include whanau/family, friends, other health professionals and the media.
Carolan and Hodnett (2007) take a slightly different approach and suggest that choices and decisions in childbirth are determined by a woman's knowledge about care models, by the local availability of services and perceptions of risk, both on the part of the woman and of the midwife. A comprehensive knowledge of the maternity system and the major players or practitioners and what they offer, increases a woman's choices and thus she is more able to look for a practice that most closely fits her view of the type of care she needs. This assumes that women understand differences in models or approaches to care. In reality, this 'information is accessed principally by well-educated and well-resourced' women (ibid, 2007, p 142). The Internet for example, is a major source of health information (Brodie et al., 2000) and New Zealand has one of the highest rates of internet access in the world (Statistics New Zealand, 2004). Women who have reduced socio economic resources are less likely to participate in the current information environment, accessed mainly through the internet.
The availability of maternity services in New Zealand is largely determined by the size and needs of the population geographically (Ministry of Health, 2000). Rural services, for example, cater for fewer people, and recruitment and retention of health practitioners to rural areas is problematic due to there being less colleagial support and opportunities for professional development (Health Workforce Advisory Committee, 2001). This in turn, contributes to a reduction in choices for women in rural areas.
Risk is another factor that Carolan and Hodnett believe influences choice. Skinner (2005) commented that midwives are both constrained by and act in resistance to risk. Hansson (2005) describes risk as referring to situations in which a decision is made, from which consequences depend on the outcomes of future events having known probability. However, humans are not exact measurement instruments, and there is an incompatibility in calculating the risk of human behaviour as a mathematical equation on the basis of probability, and applying this to the natural physiological phenomenon of childbirth for which unexpected outcomes can occur. An example of how decisions related to the perception of risk can be effected by context is illustrated in the 2004 study of Mead and Kornbrot.
They found that midwives who worked in maternity units with higher rates of intervention, perceived birth as more risky than their colleagues who worked in units with lower intervention rates. These midwives under-estimated the ability of women to progress normally through their labour and overestimated the advantages of interventions, particularly epidural analgesia. The researchers concluded that workplace culture significantly influences midwives' perception of risk, and that decisions associated with risk perception can often be inaccurate. They commented : 'If midwives' perception of risk is at odds with reality, irrespective of the level of intra-partum intervention, it is likely that the information provided to women will be biased towards labour being presented as more risky than it actually is' (Mead & Kornbrot, 2004, pg 69). The possibility for midwives varying their information to women on the basis of risk perception, gives rise to a question of whether all women do receive the same information within the context of decision making. Insight into decision theory and human information processing can assist midwives understand how they might utilise such knowledge to facilitate their role in the decision process.
The theoretical approaches to decision theory can be broadly categorised as taking three approaches--normative, prescriptive and descriptive (Bekker et al., 1999). Normative theory describes what people ought to do if they want to be rational decision makers. This approach is dominated by scientific inquiry to illustrate how rational thinking is achieved. Using this approach decisions are seen to be made using mathematical and statistical standards of proof (Bekker et al., 1999). In contrast to the empirical normative approach, rational normative theory emphasises the authority of human reason and conscience (Mautner, 2000). Human beings are motivated by their own desires and goals, and their decisions are infleunced by social phenomena and institutions (Mautner, 2000).
Prescriptive theory assumes that human beings can make poor decisions and therefore proposes that decision aids are necessary to assist the decision process. This is in order to make decisions seem more objective and quantifiable (Nassar, Roberts, Raynes-Greenow, & Barratt, 2007; Wong, Thornton, Gbolade, & Bekker, 2006). Take for example the information leaflets about nuchal translucency scans. If a woman is considering nuchal translucency, she needs information about the technology and the evidence that supports its use in pregnancy. She needs to identify her reason for wanting the scan, the benefits, the clinical risks, any costs and what the actual procedure involves. Whether a nuchal translucency scan goes ahead or not is irrelevant, because a women needs to be satisfied with the outcome of her decision, and an information leaflet can help bridge the knowledge gap while seeming objective.
The descriptive approach to decision making, on the other hand is concerned with cognitive phenomena and how humans actually think and process information. Decision making using this approach is understood to be a sophisticated cognitive activity, sensitive to how complex a task is, the pressure of time, how the task is framed and what reference points are used in order to make the decision (Lichenstein & Slovic, 2006). It is this descriptive approach to decision theory that is emerging as an important discourse in midwifery practice (Raynor, Marshall, & Sullivan, 2005).
Descriptive Decision Theory
An exploration into descriptive theory offers some insights into the relevance of cognition to decision making in childbirth. Known features of human information processing are that humans have a limited span of working memory, they have limited exactness in quantitative measurement, and they have a tendency for error and contradiction (Larichev, 1999; Hansson, 2005). Each of these features has consequences and these are discussed using vignettes to demonstrate their implications for practicing midwives.
Limited Span of the Working Memory Human capacity to process information is limited and the simple provision of more information does not necessarily improve decision making. The great body of empirical work to date suggests that we are "boundedly rational". In other words, 'although we are capable of great feats of intellect, our intellectual capacity is nonetheless limited' (Hibbard & Peters, 2003, p. 416). Integrating different information and different variables into a decision is a very complex cognitive process, and the complexity of clinical decision making is a well reported phenomenon (Raynor, Marshall, & Sullivan, 2005). Too much information can become an impediment to decision-making and this can lead to attempts to problem solve by reducing cognitive effort (taking mental shortcuts) or 'heuristics'. Tversky & Kahneman's seminal work (1974) on heuristics and biases is the dominant school of thought in considering subjective judgements. Heuristics refers to methods of problem solving by experimentation or 'trial and error' and this means that the task of assessing the probability of a situation is reduced to an intuitive judgement (Tversky & Kahneman, 1974). For example, in representative heuristics, the chance that a first time mother will have a long labour is based on the degree to which she is representative of other first time mothers.
Bias is another human behaviour, commonly explained as a byproduct of the limitations of processing information, and it is difficult to quantify because it is based on human experience and social perception (Haselton, Nettle, & Andrews, 2005).
Anchoring or focalism, a form of cognitive bias describes the common human tendency to rely too heavily, or "anchor," on one trait or piece of information when making decisions (Tversky & Kahneman, 1974). Take the example of a woman who chooses to artificially feed her baby, stating that it is the best feed for her baby. She conveys this message to her midwife, despite evidence which attempts to dispel those views. Her hypothesis is based, or anchored on her perception that breastfeeding is painful. A consequence of this anchoring is that all incoming information is not considered seriously, and the woman favours her original hypothesis. Unless the midwife is alert to anchoring, taking time to explore the source of the woman's opinion, then the woman may hold to her hypothesis. Her perception of breastfeeding as a painful experience will persist. In addition, the midwife herself needs to recognise her own bias and how she can contribute to a woman's perception of breastfeeding. This can happen through direct or indirect communication. Direct communication includes verbal information sharing and the midwife's own body language, and indirect communication can include such things as entries in midwifery notes.
Limited Exactness in Quantitative Measurement
Tversky (1969) the pioneer of cognitive science, observed that individuals make inconsistent choices even in the absence of changes in their preferences. This reflects the fact that cognitive behaviour is not underpinned by an exact science (Larichev, 1999). Alternative options are eliminated in preference for a single 'dominant' factor that most reflects an individual's preference at any point in time.
Imagine a scenario involving Jay, who is healthy and in her 2nd trimester of pregnancy. Jay has told her midwife that she wants to have her baby at the local hospital rather than in the birth centre, so 'everything is there if something goes wrong'. Jay's view has been influenced by a close friend who had a caesarian section for fetal distress. Jay anticipates that she may need a caesarian and she has neglected to consider information about the risks of caesarian section or the benefits of birth centre care, because 'fetal distress' has become the dominating factor for her. The implication for midwives is the need to identify the dominating factor in order to acknowledge and explore, in this case, Jay's concern.
A Tendency for Human Errors and Contradictions
'To err is human' is a quote that is no less true of humans when processing information. The reasons for human error are numerous and can include such things as weariness and a lack of attention that can result from illness, grief, concentration span or boredom (Hibbard & Peters, 2003). A lack of attention often has a root cause, affecting a person's behaviour and judgement. Imagine a scenario involving Brenda who is 38 weeks pregnant with her first baby. She last saw her midwife at 32 weeks when her baby was lying in a breech position. Brenda has missed several visits from midwife Janet including the last three, and Janet is frustrated by not being able to meet with Brenda to discuss ongoing care. Unbeknown to Janet, Brenda and her partner are having serious relationship problems. She has not had the strength or courage to tell Janet, so she is avoiding meeting her where conversation about her partner might come up.
Continuity of care by one midwife enables the midwife to get to know a woman. The midwife is better able to detect changes in the woman's wellbeing and is better placed to make judgements about the woman's preparedness to receive information. The midwife might also make judgements about what to tell women and at what time. The implication for midwives is the need to identify barriers for women's participation in decision making.
Strategies For Practice
Through knowledge of decision theory and cognitive processes, midwives can be in a stronger position to identify ways to facilitate their role in providing information to women. Two key ideas found within the theoretical approaches are reducing cognitive effort, and making information contextually relevant to individual women. The challenge for midwives is not merely to communicate accurate information to women, but to understand how to present and target that information so that it is usable (Hibbard & Peters, 2003). This next section considers four strategies that might assist midwives facilitate the decision process.
Using Positive Affect
The first of these is the use of positive affect (feelings, emotions). A growing body of research indicates that the use of such positive affect can influence everyday thought processes and do so on a regular basis (Isen, 2001; 1997). For example the presence of positive feelings may cue positive material in memory, making access to such thoughts easier and thus making it more likely that positive material will "come to mind" (Isen, 1997). According to Isen, positively remembered material is organised and accessible, and particularly important in that it has been found to improve both efficiency and thoroughness in decision making.
The implication for midwives is that there is opportunity to draw on positive affect in a way that may enhance a woman's decision experience. For a woman who has already had a baby, for example, this might involve reflection on her experience of labour or parenting, in order to identify positive factors that may help to influence her decision making for her current pregnancy.
The word 'woman' promoted by the midwifery profession in New Zealand includes the woman's baby/partner/whanau/family (New Zealand College of Midwives Inc, 2005). Social structures akin to whanau/ family have a significant influence on attitudes to health decisions (Hoddinot & Pill, 1999). For example, role modelling of breastfeeding by family members and the embodied knowledge women gain from observing the practical skill of breastfeeding within their own family, have a more profound positive influence on a woman's decision to breastfeed than theoretical knowledge (Hoddinot & Pill, 1999). Many midwives may have observed how women consult their close relatives, partners or friends at some stage during their childbearing. Decisions are rarely made alone, and the people closest to a woman can be important for relaying the message the midwife wants to promote, and for interpreting the message in a way that is culturally fitting. For example, a whanau/family that has a history of artificially fed babies may find that one woman amongst them decides that breastfeeding is best for her baby. In this case, the midwife may need to target education to the whanau/family, in order to advocate and support an individual woman's choice.
Appealing to Modes of Thinking
Information in decision making appears to be processed using two different modes of thinking: analytic and experiential (Hibbard & Peters, 2003). The analytic mode is conscious, deliberative, reason-based, verbal and relatively slow, and it is this mode of thinking that we as midwives tend to consider in our attempts to inform choices. The experiential mode is intuitive, automatic, associative and fast. It is based on affective (emotional) feelings, and one of its primary functions is to highlight information important enough to warrant considerations. When information is provided without consideration for emotional meaning, it cannot be given appropriate attention in decision making (Hibbard & Peters, 2003). It is here where midwives can be influential and proactive in influencing socially constructed attitudes to childbirth as it is experiential thinking that gives meaning to relevant information.
To demonstrate the application of modes of thinking in practice, consider the subject of vaginal examination. Any discussion with a woman about vaginal examination assumes that a midwife will carry out this procedure as necessary. The fundamental purpose of a vaginal examination is to gain information about the progress of labour, and it is generally a universally accepted procedure by women and health professionals as one of the main methods of assessment in labour. The intimacy involved in carrying out a vaginal examination is, in a way, a separate issue from the purpose of a vaginal examination by a midwife, and these two interrelated issues will require the midwife appealing both to a woman's analytic and experiential thinking as part of the process of informing her about the procedure. All aspects of midwifery care will involve engaging analytic and experiential thinking.
Narratives or stories about someone else's experience can help a decision maker who has never experienced the consequences of some choice and may not be able to predict its impact on their life. Narrative helps move the decision maker closer to the actual experience, and 'may help render even unfamiliar information evaluable, salient, and easily imaginable through the use of concrete descriptors and images'. (Satterfield, Slovic, & Gregory, 2000; Hibbard & Peters, 2003, p. 424). The key ingredient is sharing and talking, and this can happen in a range of forums such as at antenatal classes, on the marae, at church, family gatherings, support groups, through one-on-one or group activities. The implication for midwives is that if a woman is isolated or has little or no contact with other women, she will not be in a position to hear other women's stories to imagine how she would think or feel in the same situation.
New Zealand legislation provides for women, the right to effective communication, and the right to be fully informed and to give their informed consent. Such rights are supported by midwives' professional standards and regulation. Midwives play a key role in giving women information and in supporting the decision process. Knowledge of decision theory and cognitive processes can be useful for midwives in facilitating a woman's decision making. This also requires midwives to have some insight into factors within their own practice context that may inhibit, influence or enhance women's choice. This includes perceptions of risk, time and information overload. Various strategies can be used by midwives to enhance fulfilment of their professional obligations and this paper has discussed four strategies--positive affect, support from whanau/family, utilising modes of thinking and narrative.
Accepted for publication in March 2008
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Ngai Tamanuhiri, Ngai Te Ragnihouhiri, Ngai Tahu
PhD Candidate Public Health (Maori)
Casual Employed and Self Employed Midwife