The Mother’s Autonomy in Decision Making (MADM) scale: Patient-led development and psychometric testing of a new instrument to evaluate experience of maternity care

Abstract

Shared decision making (SDM) is core to person-centered care and is associated with improved health outcomes. Despite this, there are no validated scales measuring women’s agency and ability to lead decision making during maternity care.ObjectiveTo develop and validate a new instrument that assesses women’s autonomy and role in decision making during maternity care.DesignThrough a community-based participatory research process, service users designed, content validated, and administered a cross-sectional quantitative survey, including 31 items on the experience of decision-making.Setting and participantsPregnancy experiences (n = 2514) were reported by 1672 women who saw a single type of primary maternity care provider in British Columbia. They described care by a midwife, family physician or obstetrician during 1, 2 or 3 maternity care cycles. We conducted psychometric testing in three separate samples.Main outcome measuresWe assessed reliability, item-to-total correlations, and the factor structure of the The Mothers’ Autonomy in Decision Making (MADM) scale. We report MADM scores by care provider type, length of prenatal appointments, preferences for role in decision-making, and satisfaction with experience of decision-making.ResultsThe MADM scale measures a single construct: autonomy in decision-making during maternity care. Cronbach alphas for the scale exceeded 0.90 for all samples and all provider groups. All item-to-total correlations were replicable across three samples and exceeded 0.7. Eigenvalue and scree plots exhibited a clear 90-degree angle, and factor analysis generated a one factor scale. MADM median scores were highest among women who were cared for by midwives, and 10 or more points lower for those who saw physicians. Increased time for prenatal appointments was associated with higher scale scores, and there were significant differences between providers with respect to average time spent in prenatal appointments. Midwifery care was associated with higher MADM scores, even during short prenatal appointments (<15 minutes). Among women who preferred to lead decisions around their care (90.8%), and who were dissatisfied with their experience of decision making, MADM scores were very low (median 14). Women with physician carers were consistently more likely to report dissatisfaction with their involvement in decision making.DiscussionThe Mothers Autonomy in Decision Making (MADM) scale is a reliable instrument for assessment of the experience of decision making during maternity care. This new scale was developed and content validated by community members representing various populations of childbearing women in BC including women from vulnerable populations. MADM measures women’s ability to lead decision making, whether they are given enough time to consider their options, and whether their choices are respected. Women who experienced midwifery care reported greater autonomy than women under physician care, when engaging in decision-making around maternity care options. Differences in models of ca...

A Rapid Review of Available Evidence to Inform Indicators for Routine Monitoring and Evaluation of Respectful Maternity Care

“…[14][15][16] In addition, 2 additional scales have been validated in Canada for measuring respect and autonomy in high-resource settings. 17,18 These scales include items that extend the work on women's experiences beyond measuring D&A to measuring various positive aspects of women's childbirth experiences. The questions in these scales, as well as questions in various prior questionnaires for surveys and birth observations on women's experiences, provide useful indicators for evaluating interventions to improve women's childbirth experiences.…”

Bearing witness: United States and Canadian maternity support workers’ observations of disrespectful care in childbirth

“…This study, fielded prior to Bohren et al's publication, examines six types of disrespectful care, among three typologies: Verbal abuse , including threats of poor outcomes, racially demeaning comments, and sexually degrading remarks; Stigma and discrimination in the form of extra procedures because of race/ethnicity; and Failure to meet professional standards of care by failing to secure fully informed consent or by performing procedures explicitly against a woman's wishes . Clinicians, health organizations, and childbirth advocates recognize the growing problem of disrespectful care in childbirth; and recent efforts to develop patient‐reported metrics on these phenomena show promise to better measure this critical quality issue …”

I felt so much conflict instead of joy: An analysis of narratives from pregnant people in British Columbia who declined care recommendations

“…Pregnancy, childbirth, and the postpartum period are a critical emotional and transitional period in a person's life. Evidence con rms that a lack of involvement in decision-making about care results in negative patient experiences (19,20). These ndings suggest that both what is offered and the way it is being communicated are equally valuable to childbearing people.…”

“…Midwives, family physicians, obstetricians, and nurses can provide respectful maternity care by ensuring client autonomy is supported through engaging in a person-centered decision-making process (20).…”

“…How pregnant people experience care when they make choices outside of community standards or against their provider's recommendations is not well understood. By analyzing open-ended responses from an online survey from the Changing Childbirth in BC Study (3,4), we describe experiences of people who declined their care provider's recommendations during pregnancy, birth, and/or the postpartum period. Increased knowledge in this area may assist care providers in supporting autonomous decisionmaking and providing respectful care to all pregnant people, regardless of their choices.…”