Improving Communication during Perinatal Care to Eliminate Preventable Maternal Morbidity and Mortality
Year: 2025
Type: editorial
Abstract: Improving communication during perinatal care is foundational to eliminating preventable maternal morbidity and mortality. Transparent, evidence-based communication allows for the provision of person-centered care. The collective goal of the health care team is that every person has a positive birth experience, devoid of trauma, and characterized by respectful maternity care (Runyon et al., 2023). Clinicians should provide sufficient, clear, and unbiased information to facilitate individual choice, a concept central to reproductive justice (Julian et al., 2020; Ross, 2017; Scott et al., 2019). Public health programs and interventions have been created to highlight and facilitate this work. For example, the Centers for Disease Control and Prevention (CDC) created the Hear Her campaign to increase awareness of the importance of listening to childbearing patients' concerns and outline the importance of addressing urgent maternal warning signs (CDC, 2022). Birth plan or preferences sheets have been created to help facilitate and document conversations with pregnant people about their preferences for their birth, including pain management, and their desires for labor support and during their newborns transition (Ahmadpour et al., 2022; DeBaets, 2017; Mirghafourvand et al., 2019). Despite ongoing efforts, the concerns of childbearing women are often overlooked by the health care team, resulting in possibly negative and/or traumatic experiences within the health care system (Kasaye et al., 2023; Vedam et al., 2019). The purpose of this editorial is to provide definitions for the following terms: trauma informed care, respectful maternity care, autonomy, and shared decision-making (Table 1). I will also offer thoughts on these terms are interrelated in a hierarchy of communication (Figure 1) and that each is only possible when there is an emotionally safe environment for the patient and the health care team to communicate and act within the health care system (Figure 2). For example, a health care team can provide safe, quality, and equitable care only within an emotionally and psychologically safe environment where they feel comfortable to share concerns and problems, and challenges are addressed to improve care. To this end, respectful maternity care can only be offered when care is trauma informed. Shared decision-making is only possible when the tenets of respectful and autonomous care are present and honored. This hierarchy of communication is necessary to achieve equitable and person-centered care throughout the perinatal continuum. TABLE 1. - Definitions for Improved Communication and the Communication Hierarchy Term Definition Trauma informed care An approach that: Realizes the widespread impact of trauma Recognizes the signs and symptoms of trauma in patients, families, and staff Integrates knowledge about trauma into policies, procedures, and practices Actively avoids re-traumatization (SAMHSA, 2014) Respectful maternity care An approach that: Honors the dignity, personhood, autonomy, and preferences of birthing people Prevents disrespect, mistreatment, or abuse toward individuals who are utilizing maternal care services Provides a practical paradigm for the delivery and receipt of peripartum care through a rights- and reproductive justice-based framework. (Cantor et al., 2024) Autonomy Allows for the person to have the ability to make decisions using Control Agency Independence Ethical reasoning (Hirani & Olson, 2016; Tesfaye et al., 2022) Shared decision-making An approach where clinicians and childbearing families: Share and discuss the best available evidence in conjunction with the individual's personal beliefs and values with all options in making clinical decisions during perinatal care. Acknowledges individuals have their own values and priorities. Unbiased, evidence-based, and complete information on risks and benefits of all options and alternatives is shared between the birthing person and the healthcare team. Birthing patients may request or refuse care because of their values, preferences, and priorities. (Breman et al., 2024) Emotional safety Occurs when: There is a commitment to safety for both healthcare staff and patients at all levels of the organization. Reinforcement of a safe, ethical environment. Staff feel safe to make mistakes and discuss problems without fear of retribution or punishment. It is easy for staff to ask for help or support when needed. (Gallo, 2023; Lyndon et al., 2023) FIGURE 1.: Hierarchy of communication.FIGURE 2.: Safe Health Care Work Environment for Good Communication.Trauma informed care (TIC) recognizes the widespread impact of trauma (Substance Abuse and Mental Health Services Administration [SAMHSA], 2023). Organizations and individuals that use a trauma informed approach, seek to recognize the signs and symptoms of trauma, address trauma, and actively avoid re-traumatization. As a part of trauma informed and respectful communication, the patient must also have autonomy over their body and their care. Their voice must be valued and heard by the health care team (Moore, 2016; Vedam et al., 2019). When these three foundational concepts are met, shared decision-making is possible. This hierarchy of communication is illustrated in Figure 1. Shared decision-making (SDM) is “An approach where clinicians and childbearing families share and discuss the best available evidence as well as the individual's personal beliefs and values to weigh all options when faced with the task of making clinical decisions for labor and childbirth. Shared decision making is founded in an ethical framework that acknowledges that individuals have their own values and priorities. Unbiased, evidence-based, and complete information on the risks and benefits of all options and alternatives is shared. In maternity care, this complex process can involve various stakeholders, including the pregnant patient; obstetricians or midwives; anesthesiologists; nurses; partners; and support persons, which might include a doula. Pregnant patients may request or refuse care that fits within their values, preferences, and priorities.” (Breman et al., 2024, p. 96) Shared decision-making is particularly relevant to maternity care because patents are highly engaged and want to actively participate in decision-making about their pregnancy, labor, birth, and care of their newborn (Watkins et al., 2022). Birth is a transformative experience, as the birth of a child is a shift in identity from person to parent. To prevent birth trauma, health care professionals have a responsibility to provide evidence-based information about interventions available, including transparent discussions on the risks and benefits of each intervention that is suggested. For example, when considering the use of continuous fetal monitoring versus intermittent auscultation, how often do patients receive information about the risks and benefits of each method? Consider information about I.V. fluids and use of oxytocin after the expulsion of the placenta; how often do patients even know they are being medicated at that time and why? If the health care team does not provide this information, are respectful maternity care, autonomy, and shared decision-making occurring? As frontline caregivers, nurses are often the first to observe situations where the tenets of TIC, respect, autonomy, and SDM are violated in practice in the United States. According to Runyon et al. (2023), nurses may inadvertently perpetuate trauma and obstetrical violence by acting as bystanders. In these situations, a nurse may or may not advocate for the inclusion of the pregnant patient's birth preferences in discussions about care decisions. The nurse's choice to advocate or not has the potential to affect the patient's emotional safety during their care (Lyndon et al., 2023). This begs the question as perinatal care professionals: how can we improve communication with patients and their families so that every birth experience is as positive as possible, and ensure that traumatic birth, disrespect, and mistreatment of patients does not occur. Understanding the hierarchy of communication is central to providing person-centered maternity care. Nurses play a key role in supporting patients and in advocating for transparent communication that is respectful and supports patient autonomy and SDM.
Author: Rachel Blankstein Breman
Institution: University of Maryland, Baltimore
Language: English
Subfield: Obstetrics and Gynecology
Field: Medicine
Domain: Health Sciences
Open Access status: green
Award: G3399072519
OpenAlex ID: W4410089468