© 2012 by Rebecca Dekker, PhD, RN, APRN
A few months ago, I had a conversation with some hospital adminstrators about their hospital’s policies for the labor and delivery unit. As I listened to them explain some policies to me (I believe we were talking about visitor policies while a woman is giving birth), I was struck by how many times they used the phrases, “We might let a woman do this,” or “In some cases, we might allow a patient to do this, but only if they did this beforehand.” I couldn’t listen to it anymore. I held up my hand to indicate that I wanted to speak, and I said (very politefully, I hope!):
“I hate to interrupt you. But something you keep saying is really jumping out at me. You keep saying, ‘We might let a woman do this,’ or ‘We might allow a patient to do this.’ Excuse me? I am the patient. This is MY birth. I choose what I want to do, you don’t ‘LET’ me do anything!”
They sat there, and their eyes got really wide, and they just looked at me and then at each other. They looked quite surprised. I wondered if this thought had never crossed their minds before.
In the past week, I’ve been thinking a lot about birth and the concept of patient-centered care, and I wanted to share my thoughts with you on this topic.
But what does patient-centered care have to do with evidence-based care? Isn’t the purpose of this blog to discuss evidence-based birth?
In my birth detective post at the top of this website (where I list my research questions for this blog), I said that I wanted to explore the question, “What is the importance of the individual woman’s values when it comes to evidence-based birth?” This article is my attempt to answer that question.
The definition of Evidence-based maternity care is healthcare that is based on the latest, highest-quality evidence while also taking into account an individual woman’s values.
(New addition to this article: For those of you who are curious, I formulated my definition of evidence-based practice from here: the American Medical Association. Also, I have received some critique that the care provider’s judgment is not included in my definition. That’s because “evidence” ranges from systematic meta-analyses to single randomized trials to the individual care provider’s experience. I don’t mean to ignore or devalue the care provider’s experience in this. It is an important type of evidence, although you may be surprised to know that the AMA ranks unsystematic clinical observations as the weakest form of evidence on their hierarchy of evidence).
So by its very definition, evidence-based care is patient-centered. In this article, let’s explore a little bit about what patient-centered care means.
What does patient-centered care have to do with maternity care in the U.S.?
Patient-centered care is not a new concept in healthcare. In 1996, JAMA (the Journal of the American Medical Association) published an important paper by Laine and Davidoff that discussed the history of medicine in the United States. In this paper, the authors talked about how there has been a gradual shift in medicine from physician-centered care to patient-centered care. This shift has taken place at different times for different medical specialties.
In the beginning of the paper, the author gives an example of what physician-centered care may have looked like many years ago.
“During the 1930s my grandmother saw a specialist about a melanoma on her face. During the course of the visit when she asked him a question, he slapped her face, saying, ‘I’ll ask the questions here. I’ll do the talking.’ Can you imagine such an event occurring today? Melanomas may not have changed much in the last fifty years, but the profession of medicine has.” (Cassell, 1985).
The scary thing is, yes, I can imagine a similar situation happening today in maternity care. Physician-centered care might not manifest as a slap on the face, but perhaps as not fully disclosing the risks of a procedure, or scheduling a non-medically indicated induction rather than waiting for spontaneous labor to occur, or starting Pitocin augmentation so that the care provider can make it to a meeting, or threatening to force a woman (in full-blown labor) out of the hospital unless she consents to an unnecessary procedure, or a implementing a practice-wide ban on doulas (yes, a doula ban is in place in an obstetrics practice in Columbus, Ohio). Physician or hospital-centered care manifests itself when women who want vaginal births after Cesareans are not allowed a vaginal birth by their doctors and hospitals. Would you call these things physician-centered, hospital-centered, or medico-legal-centered? I certainly would not call them patient-centered.
So what is patient-centered care?
According to the Institute of Medicine, patient-centered care takes into consideration patients’ personal preferences, cultural traditions, values, families, and lifestyles. Patient-centered care empowers patients to be responsible for their self-care. It reduces the use of healthcare interventions that are unwanted, inappropriate, or not needed.
Another definition has been offered by Donald Berwick, the President of the Institute for Healthcare Improvement:
Patient centered-care includes transparency, individualization, recognition, respect, dignity, and choice in all matters– no exceptions– related to one’s person, circumstances, and relationships in health care. In other words, it is care that is wanted and needed provided at a time when it is wanted and needed.
I would argue that because the majority of pregnant women are not sick, they are not patients. Technically we should be talking about “woman-centered” care or “family-centered” maternity care. But for the purposes of simplicity, I will be using the medical term “patient-centered.”
What are the main components of patient-centered care?
In his classic speech on patient-centered care, Donald Berwick argued that patient-centered care can be boiled down to 3 simple principles:
- The needs of the patient come first.
- Nothing about me without me.
- Every patient is the only patient.
Let’s look at each one of these principles. How might they be violated in a Labor and Delivery setting?
1. The needs of the patient come first.
This principle would be violated if a woman desires to go into spontaneous labor, but her doctor pressures her into a (not medically indicated) induction at 40 weeks and 3 days. The woman later finds out that her doctor was planning a vacation for later that week. Whose needs came first?
2. Nothing about me without me.
This principle is a little bit harder to understand. It basically means that nothing should be going on with regard to my health and my body without my involvement or consent. When a woman enters a hospital labor and delivery unit, she frequently must submit to rigid rules. These rules are not negotiable and they are not open for discussion. “You are not allowed to eat or drink.” “We will not let you get out of bed now that your water has broken.” “You must wear the continuous electronic fetal monitor.” “You must have a saline lock in case of an emergency.” With these rigid rules, women in labor have lost control over basic bodily functions– including the ability to eat, drink, move, and sometimes even go to the toilet. There is a lot that is being done to her and about her without her.
3. Every patient is the only patient.
This principle is violated with “cookie cutter” obstetrical care. Upon entering a labor and delivery unit, a woman might be told to change into a hospital gown (thus labeling her as a “patient”) and restricted to hospital policies and procedures (many of which are not evidence-based). Her unique culture, values, and reasons for doing things are ignored. One example might be a woman who feels really strongly that she would like delayed cord clamping, but hospital routine prohibits it. Or a couple does not want to have their infant receive a bath right away, but the nurses take the baby away and do it anyways. Their reason for doing so? “Because that’s the way we always do things.” Or, “We have a rule that it has to be done this way.” Is that treating every patient like the only patient?
I looked at my hospital’s website. They say they provide “patient-centered care.” What does that mean?
Be cautious about hospitals that advertise themselves as providing patient-centered care. Just because they advertise it doesn’t always mean that is what they do. Of course there are some hospitals that provide excellent patient-centered maternity care. However, there are many others that use this term as a marketing ploy. They say, “At our hospital, the patient comes first!” but what they really mean is, “At our hospital, the patient comes first, but only after the hospital, doctors, midwives, nurses, residents, students, nursing assistants, cleaning staff, dietary workers, unit secretaries, billing clerks, lawyers, medical records personnel, security staff, and parking attendants.”
How can I tell if my chosen care provider or hospital provides patient-centered maternity care?
In an article on KevinMD.com, a former hospital administrator says that your care provider might provide patient-centered care if he or she:
- Knows your name
- Actively seeks, listens, and honors your opinion whenever humanly possible
- Treats you as the most important member of your health care team
- Educates you on how you can contribute to the overall success of your pregnancy and birth
- Sees you as someone who is actively involved in your own care and birth
- Other women tell you that this care provider really, truly listened to what they had to say
Of course, no matter how patient-centered your care provider is, you still have to deal with the place you are giving birth. Clues that your chosen place of birth might be patient-centered include (* items indicate those that have been endorsed by ACOG plus 6 other professional groups):
- There are no restrictions on how many visitors you have, except for restrictions chosen by you
- You are allowed to determine what you eat and drink and what clothing you wear in the hospital (to the extent that your health status allows)
- You are allowed freedom of mobility (to the extent that your health status allows)
- You participate in shared decision making, which means that you and your care team work together as partners to make fully informed decisions about your care*
- Decisions about interventions take into account your personal values and preferences and are made only after you have been given enough information to make an informed choice, in partnership with your care team*
Why don’t more care providers practice patient-centered maternity care?
One of the reasons I think we don’t see more patient-centered care in maternity care is because many care providers don’t really understand what patient-centered care is. When I was doing my research for this article, I found this essay by Dr. Kilpatrick, who is chairperson of OB/GYN at Cedars-Sinai in California, a large hospital that provides care for many birthing women. In her essay, she asks, “What does patient-centered care mean? Hasn’t the patient always been the focus of our attention?” She then goes on to say,
“If that is what patient-centered care means, I am all for it. The admission to labor and delivery is about her: We are there to take care of her, listen to her, talk to her, explain to her and her family the management plan because we made the management plan using our knowledge, our best judgment, and our compilation of the facts, and we incorporated her input in the process.” (italics mine)
She also states, “Most patients did not go to medical school and do a residency; most do not have
years of experience in taking care of other patients and of seeing bad and good
Donald Berwick, President of the Institute of Healthcare Improvement, calls this type of viewpoint the classic “profession” perspective of patient care. People who adhere to this perspective think that we should give authority to the physician because they are the professional who always knows what is best for us. In other words, we should heed the physician when he or she says, “Trust me, I am a doctor, I know best what will help you.” But this perspective is not true patient-centered care, because it forgets that a woman knows herself, her values, her body, and her preferences far better than her doctor ever will. This perspective forgets that women are experts on themselves.
On the opposite side of the spectrum is the consumer-oriented perspective on patient care. In the consumer-oriented perspective, it is the patient, not the provider, who has all the authority. Sounds great, right? Well, not really. For example, consumer-oriented care would include giving a woman a vast menu of choices about birth. “You can decide– do you want to do an elective induction at 36, 37, 38, 39, or 40 weeks? Or do you want to wait to go into spontaneous labor? Or do you want a scheduled C-section?” This offering of unnecessary interventions (many of which could potentially cause harm) is not true patient-centered care.
In the end, true patient-centered care lies somewhere in the middle of these 2 extremes. In the middle, you will find Mr. Berwick’s summary of patient-centered care, which is “They give me exactly the help I need and want exactly when I need and want it.” This means that true patient-centered care is both necessary care and wanted care. You should never do something to a patient that they didn’t want. You should also never do something to a patient if they didn’t need it. The idea of patient-centered care is to put the patient and the provider on the same level. The patient and the provider are team players. They have different skills and different sets of expertise, but they are equals, nonetheless.
Unfortunately, many care providers equate “patient-centered care” with the “consumer-oriented” care. No wonder they don’t want to provide patient-centered care! Who would want to give up complete control of their medical practice? Who would want to be completely subservient to any and every patient demand? On the other hand, many care providers think that patient-centered care is similar to the “profession” perspective of patient care. In their case, they already believe they are practicing patient-centered care, when in fact their philosophy is not in line with true patient-centered care. But they don’t know that. They think that they are already providing patient-centered care. So why should they change?
In the end, perhaps if more care providers and hospitals understood the true meaning of patient-centered care and were trained in it, they wouldn’t be so opposed to implementing it.
So, in summary, what does patient-centered care have to do with evidence-based maternity care?
It has everything to do with evidence-based maternity care!
So what do you think? Tell us about some of your birth settings. Can you give any examples of when you received patient-centered care?
- Berwick, D. M. (2009). “What ‘patient-centered’ should mean: confessions of an extremist.” Health Affairs 28(4): w555-565.
- Cassell, E. J. (1985). ”Talking with Patients.” In: The Theory of Dotor-Patient Communication (Vol.1). Cambridge, Mass: The MIT Press.
- Laine, C. and F. Davidoff (1996). “Patient-centered medicine. A professional evolution.” Jama 275(2): 152-156.
- Institute of Medicine, Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century: National Academies Press. Access the e-book for free here: http://books.nap.edu/openbook.php?record_id=10027.