Women should be provided with evidence-based information when considering options for contraception and pregnancy management. When counseling about health conditions and available treatments, healthcare practitioners should employ strategies that encourage the incorporation of informed patient preferences into a shared decision-making process with the patient. To optimize the health of women at risk of experiencing adverse health outcomes during or after pregnancy, counseling should be a continuous process throughout the reproductive life course. The purpose of this Consult is to provide guidance for all healthcare practitioners about counseling reproductive-aged women who may be at high risk of experiencing maternal morbidity or mortality.
Key words
Introduction
Counseling women who are at an increased risk of medical complications of pregnancy is challenging for women and their healthcare practitioners.
1
,2
Although the evidence to inform these conversations is often limited,3
women should be provided with evidence-based information about the risks and treatment alternatives when considering options for contraception and pregnancy management. Healthcare practitioners counseling women about health conditions and available treatments should employ strategies that incorporate informed patient preferences into a shared decision-making process between the patient and healthcare practitioner.4
Strategies may include providing verbal and written information in the woman’s preferred language at an appropriate literacy level, incorporating decision support, minimizing bias in the framing of information, and empowering women to share their perspectives and values and integrating them in a nonjudgmental, encouraging manner.5
, 6
, 7
, 8
, 9
Counseling should be conducted with the goal of supporting reproductive justice, defined as “the human right to maintain bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.”10
SisterSong. Reproductive justice.
https://www.sistersong.net/reproductive-justice
Date accessed: January 3, 2021
For women who are not pregnant, counseling should include information regarding maternal health implications of pregnancy, ways to optimize maternal health and pregnancy outcomes through preventative care or treatment before pregnancy, and strategies to prevent or plan pregnancy through the use of contraception. This information may be provided either by a maternal-fetal medicine (MFM) subspecialist or through referral to another healthcare practitioner.
11
, 12
, 13
During the antepartum period, counseling should include information regarding maternal and fetal health risks resulting from a preexisting condition or a new-onset pregnancy-related condition, treatments for these conditions, and risk of recurrence or ways to reduce risks during future pregnancies.
14
,15
Postpartum counseling should include information about how pregnancy and delivery may affect a woman’s future pregnancies, her own health, and the health of the neonate, including long-term outcomes. Because women with preexisting medical conditions often see nonobstetrical healthcare practitioners before or during pregnancy, it is important for all medical professionals to be comfortable counseling women about the risks and benefits of contraception and pregnancy or to provide referrals to Complex Family Planning or MFM subspecialists as needed.16
,17
The purpose of this Consult is to provide guidance for all healthcare practitioners about counseling reproductive-aged women who may be at high risk of experiencing adverse maternal, fetal, or neonatal health outcomes during or after pregnancy.
What are the optimal communication strategies to ensure patient satisfaction and comprehension of risk?
Utilizing shared decision-making
Discussing the benefits and harms of treatment interventions and understanding patient preferences and priorities are central to good clinical practice and the provision of high-quality, patient-centered care.![Figure thumbnail gr1]()
18
Models for medical decision-making and counseling exist on a continuum of degrees of control over decision-making. A provider-driven approach offers the least control to the patient, whereas the autonomous model offers the greatest patient control with the least provider guidance.19
The shared decision-making model recognizes the central roles of both the patient and healthcare practitioner in reaching a decision based on the best medical evidence and the patient’s preferences and values (Figure).19
, 20
, 21
Because the shared decision-making model has been shown to increase knowledge, confidence, and active participation from patients, it is considered the optimal approach, particularly for decisions regarding contraception and pregnancy, which have health, financial, and quality of life implications. One survey of 345 patients undergoing contraceptive counseling reported that those who engaged in shared decision-making had significantly greater satisfaction with the decision-making process than those who engaged in either the autonomous or provider-driven model (96% vs 88% and 63%, respectively; both P<.05).22
FigureA shared decision-making model
20
Tabled
1Key to the figure
| Deliberation | A process where patients become aware of choice, understand their options and have the time and support to consider ‘what matters most to them’: may require more than one clinical contact not necessarily face-to-face and may include the use of decision support and discussions with others. |
| Choice talk | Conveys awareness that a choice exists – initiated by either a patient or a clinician. This may occur before the clinical encounter. |
| Option talk | Patients are informed about treatment options in more detail. |
| Decision talk | Patients are supported to explore ‘what matters most to them’, having become informed. |
| Decision Support | Decision support as designed in two formats: I) brief enough to be used by clinician and patient together and 2) more extensive, designed to be used by patients either before or after clinical encounters (paper, DVD, web). |
| Initial Preferences | Awareness of options leads to the development of initial preferences, based on existing knowledge. The goal is to arrive at informed preferences. |
| Informed Preferences | Personal preferences based on ‘what matters most to patients’, predicated on an understanding of the most relevant benefits and harms. |
Society for Maternal-Fetal Medicine. SMFM Consult Series #55: Counseling women at increased risk of maternal morbidity and mortality. Am J Obstet Gynecol 2021.
Addressing language and numeracy barriers
Because both the patient and the healthcare practitioner play essential roles in the shared decision-making process, accurate exchange of information is critical. Reducing language barriers is key, as demonstrated in a study comparing knowledge and beliefs about gestational weight gain after prenatal counseling in Spanish- and English-speaking women. Researchers found that Spanish-speaking women were significantly more likely than English-speaking women to report that they did not know whether they received advice on the recommended amount of weight to gain during pregnancy (27.8% vs 9.2%; odds ratio [OR], 3.1; 1.4–6.5); how to gain weight with a healthy diet and exercise programs (19.4% vs 8.1%; OR, 2.5; CI, 1.1–5.8); or appropriate amounts of exercise (16.7% vs 5.1%; OR, 2.9; CI, 1.1–7.7) after counseling on these topics. These findings suggest that language may have been a barrier to effectively conveying this information.
23
There are many known biases in the way that humans conceptualize and interpret numbers and risk. Employing strategies to mitigate these cognitive biases will help to optimize consideration of treatment options. For example, people tend to be more influenced by “individuating information,” such as stories or anecdotes, rather than statistical information.
24
This tendency stems in part from differences in the ability to interpret numeric health information, referred to as health literacy or numeracy, which is a skill set that is often independent of educational level.25
Furthermore, people with low numeracy tend to give more weight to both their individual risks and the protective effect of interventions, and they are more likely to be affected by mood.26
Interpretation of risk also can be affected by the attitude of the participants before the discussion and the way that the discussion is framed. Self-perception of risk before a discussion has an “anchoring effect” that pulls the risk estimate in the direction of the patients’ preformed opinion.27
Labeling a result as positive or negative or reporting the likelihood of having a complication rather than the likelihood of having an uncomplicated course can impact not only the patient’s perception of risk but also her likelihood of choosing to proceed with treatment. Making numbers more transparent by using a consistent denominator, presenting information graphically, comparing risks in terms of absolute risk difference rather than relative risk, and being mindful of anchoring and framing effects may mitigate some of these biases (Box).28
,29
Box
Strategies for addressing numeracy issues
Avoid using exclusively descriptive terms (eg, “low” risk as opposed to 10% risk).
Use consistent denominator (eg, compare risk as 4/1000 to 20/1000).
Present both positive and negative outcomes.
Compare absolute risks.
Use visual aids and verbal descriptions of probabilities.
Data from Paling
28
and Edwards et al.29
Society for Maternal-Fetal Medicine. SMFM Consult Series #55: Counseling women at increased risk of maternal morbidity and mortality. Am J Obstet Gynecol 2021.
The use of decision tools is another strategy that may combat language or numeracy barriers to comprehension. These paper- or computer-based instruments are designed to augment and support the shared decision-making process. They can include information about treatment options, present risks, incorporate values clarification, and provide guidance for deliberation and communication. They can be used independently by the patient or mediated by an external party, such as a peer counselor in preparation for a visit, or shared between the patient and healthcare practitioner during a visit.
3
A systematic review evaluating the effectiveness of decision aids for individuals making decisions about pregnancy and childbirth found that these tools increased knowledge, decreased anxiety, and decreased decisional conflict.6
Because decision tools do not exist for many of the decisions faced by women at high risk of pregnancy complications, future research and development are needed in this area.Prioritizing patient values
In addition to sharing accurate information, it is important to ensure that both the patient and the healthcare practitioner understand what risks and benefits matter most to the patient, because one of the goals of these discussions is to support reproductive justice.
10
Values clarification methods provide an opportunity to address this goal. These are defined as “methods to help patients think about the desirability of options or attributes of options within a specific decision context, in order to identify which option [they] prefer.”SisterSong. Reproductive justice.
https://www.sistersong.net/reproductive-justice
Date accessed: January 3, 2021
30
Values clarification methods may involve identifying management options, which can include generating new options or limiting a set of options under consideration, identifying aspects of the options that are most important, and making comparisons between options either in a holistic way or based on attributes or consequences of each decision that may be traded off.31
In challenging clinical settings, patients frequently ask healthcare practitioners, “What would you do?” It can be complex to respond to such questions, and qualitative studies indicate that healthcare practitioners may not directly answer but rather deflect the question out of appropriate concern for patient autonomy.
32
, 33
, 34
However, avoiding the question may leave patients feeling that their needs are being disregarded. The “what would you do” question can be a chance for healthcare practitioners to elicit a patient’s values to help guide decision-making without necessarily disclosing personal opinions.34
Facilitating a values-based decision will lead not only to improved decision satisfaction for these women but also improved long-term outcomes, including coping and grief resolution.35
In some situations, women may have a clear idea of their preferences, in which case respect for patient autonomy is critical. A qualitative study of 36 women who underwent second-trimester termination found that most participants very clearly knew whether they wanted to undergo dilation and evacuation or induction for this procedure.
35
A study of 5109 women seeking an abortion found similar results: 87% of women in this study already had high confidence in their decision about seeking this procedure before counseling.36
An autonomous decision-making model may be best suited for these types of situations, in which the healthcare practitioner serves primarily as a resource for providing accurate, unbiased information while providing their patients an opportunity to express their preferences.Each healthcare practitioner brings a wealth of experience and biases to any discussion of risks and benefits. Each patient also has a unique set of beliefs, understanding of medical care, and level of trust in the medical system. Even when patients and healthcare practitioners have a shared understanding of the advantages and disadvantages of a certain strategy, their experience of medical care and complications differs in quantity and quality. If these differences are not acknowledged, the patient and healthcare practitioners may interpret information discordantly, complicating the shared decision-making process. Healthcare practitioners should practice active listening and self-reflection to identify any differences, ensure their biases do not cloud their ability to provide neutral counseling, and speak with a judgment-free and respectful tone and language.
37
Healthcare practitioners should also be aware of their patient’s cultural background and how that may impact their preferences regarding shared decision-making, including involving support individuals in this process.38
Finally, many factors contribute to the decisions women make about their pregnancies,36
including many outside their control. Healthcare practitioners should allow time for patients to process information, ask questions, and consult with their support system, which may require making a plan for follow-up discussions depending on the circumstances.4
For women at an increased risk of pregnancy complications who are not pregnant, what essential information should be included in prepregnancy counseling?
During counseling before pregnancy, women should be informed about both maternal and fetal health risks of pregnancy and strategies to prevent or reduce these risks. These risks may be related to a woman’s preexisting health conditions; the medications used in the treatment of a health condition; personal, family, or genetic history; physical environment; or health behaviors.
11
The information provided during counseling before pregnancy will differ depending on a woman’s pregnancy intention. Therefore, the first step should be to assess a woman’s reproductive life plan.
39
If a woman does not desire pregnancy in the next year, counseling regarding appropriate contraception options is recommended. Counseling should include information on safety, effectiveness, accessibility, affordability, and acceptability of the range of options, presented with the most effective option first.40
,41
Healthcare practitioners should consult The United States Medical Eligibility Criteria for Contraceptive Use when counseling high-risk women with preexisting conditions to verify the safety and appropriateness of each option.42
It is important to provide balanced information about all options to reduce the likelihood of reproductive coercion.19
If a woman is ambivalent or does desire pregnancy in the next year, counseling should include a discussion of her risks, including risks of adverse pregnancy outcome, risks to short- and long-term maternal health, and risks to the fetus and neonate. For example, women with heart disease should be counseled about the risk of mortality based on their modified World Health Organization classification; women with class III or IV are at a substantially higher risk than women with class I or II heart disease.
16
,43
Healthcare practitioners should review available strategies to reduce risks before pregnancy and should refer women to relevant subspecialists and social services.11
,39
For most women at an increased risk, referral to an MFM subspecialist is also appropriate.44
Nonobstetrical specialists who manage women with conditions such as lupus or diabetes mellitus should be prepared to counsel reproductive-aged patients about the potential risks of pregnancy complications resulting from their condition, medications used to treat their condition, factors that may modify these risks, and medication changes that may be necessary.45
These healthcare practitioners also should expect to coordinate with MFM subspecialists and obstetrician-gynecologists throughout the care of a high-risk pregnancy.44
All women should receive counseling about optimal nutrition, physical activity, and health behaviors, such as cessation of substance use,46
because these are highly modifiable risk factors. Finally, fetal risks should be assessed by evaluating the family history, including the outcomes of previous pregnancies, and eliciting any history of termination for fetal anomalies. All women should also be offered carrier screening.47
How should pregnant women who are at an increased risk of complications be counseled about the risks of pregnancy, labor, and delivery during the prenatal period?
Women at risk of maternal morbidity and mortality during pregnancy include those with preexisting chronic conditions, new-onset pregnancy-related conditions including fetal and obstetrical complications, and adverse socioeconomic and environmental conditions.
43
These women should receive nondirective counseling regarding the potential risks and benefits of pregnancy continuation, including the short- and long-term implications of expectant management or medical intervention for the condition placing her at an increased risk, and the risks and benefits of pregnancy termination. When indicated during pregnancy, counseling regarding pregnancy termination should be performed as expeditiously as possible to optimize choices and outcomes.43
Because of the potential for rapid changes in health status during pregnancy and logistical and legal barriers to providing the full range of reproductive health services, risk assessment and subsequent counseling should be performed continuously. The initial discussion should include information about the potential for changes during pregnancy that may impact the risk-benefit calculus so that women are aware that follow-up discussions are not intended to question a previous discussion and decision but to ensure that they are moving forward based on accurate information. If there are changes in a woman’s risk status, counseling should be reinitiated to determine whether her decision to continue or terminate the pregnancy has changed and to elicit her preferences regarding ongoing counseling throughout the remainder of the pregnancy.Women at an increased risk of pregnancy-related complications should be provided with the following information during counseling: short- and long-term maternal health risks of her condition; short- and long-term health risks and benefits of pregnancy; and treatment options in the setting of ongoing pregnancy or termination of pregnancy, including the health risks and any potential benefit of termination of pregnancy.
4
Women should be made aware of the risks and what to expect in the course of the chosen management strategy to optimize their ability to make an informed choice. One study of women who underwent pregnancy termination after the diagnosis of a fetal anomaly or pregnancy complication found that women defined satisfaction with their decision to terminate based on receiving adequate information about termination options and having the autonomy to decide on the method of termination consistent with their personal values and their preference for how to cope with the loss.35
Finally, if a woman elects to terminate her pregnancy, postabortion counseling should be provided to normalize her feelings, positive or negative, and identify supportive resources for helping her cope.7
Importantly, there is very limited evidence on best practices for counseling this specific population and system-level barriers that may impede optimal counseling practices, such as reimbursement policies and scheduling practices.
14
Ideally, MFM and Complex Family Planning subspecialists and obstetrician-gynecologist specialists should collaborate to develop evidence-based recommendations and strategies to facilitate their implementation in this area.How should pregnant women at an increased risk of complications be counseled about their health status and ongoing management after pregnancy?
Two-thirds of maternal deaths occur in the year after delivery,
48
and an estimated 50,000 women experience some form of severe maternal morbidity during this time.49
Cardiovascular conditions represent the greatest proportion of morbidity and mortality,50
followed by infection and other medical conditions.48
To reduce maternal morbidity and mortality after delivery, counseling should address a woman’s physical health after pregnancy. Counseling should include signs and symptoms of both immediately life-threatening conditions, such as hemorrhage and sepsis, and common but less severe physical changes, such as incontinence and fatigue.14
,51
A large proportion of women also experience morbidity and mortality due to mental health conditions after delivery, largely from depression and substance use disorder.
52
However, many women report that healthcare practitioners devote more attention to physical rather than mental health.15
Healthcare practitioners should counsel women about postpartum depression, anxiety, and substance use and connect them to community resources as appropriate.14
Beginning in the antepartum period, healthcare practitioners should counsel women about risks and prevention of subsequent pregnancies, whether they express a desire for a future pregnancy or not. All women should be informed about the risks of a short interpregnancy interval, including the increased risks of severe maternal morbidity and mortality.
53
Women with chronic conditions such as diabetes mellitus, hypertension, and obesity should receive counseling about the management of these conditions during the interpregnancy period if they desire a future pregnancy and as a means of optimizing their future health.54
Women who experienced complications during their pregnancy, such as preeclampsia or congenital anomalies, should be counseled starting in the immediate postpartum period about the risk of recurrence of these conditions in a subsequent pregnancy and strategies for mitigating these risks, if available.54
Counseling should also include how the physiological changes of pregnancy may impact a woman’s future quality of life based on her prepregnancy health status or complications experienced during or after pregnancy. For instance, women with hypertensive disorders of pregnancy have an increased risk of future cardiovascular disease, chronic hypertension, heart failure, and stroke compared with women with normotensive pregnancies.11
All women should receive contraception counseling that addresses the safety, effectiveness, accessibility, affordability, and acceptability of the full range of options beginning in the prenatal period.
42
,54
Postpartum long-acting reversible contraception is highly effective, and counseling regarding this option should be patient centered, avoid coercion, and include the alternative options of sterilization and short-acting methods.54
If a woman desires sterilization, she should be counseled using a patient-centered model about the risks and benefits and the permanence of the procedure, availability of the procedure at a local institution, and alternatives to sterilization.54
Women encounter many barriers to accessing postpartum care and counseling during this time. Therefore, counseling for postpartum health, contraception, and future pregnancy risks should be initiated during pregnancy and continued throughout the interpregnancy period.
14
,15
,54
,55
What strategies facilitate access to care, services, and the continuation of care?
To fully optimize care of women at an increased risk of pregnancy complications, changes to training, healthcare policies, and norms around collaboration with the nonphysician community may be needed. Because nonobstetrical healthcare practitioners are likely to encounter reproductive-aged women with chronic conditions in their practice, they should be prepared to provide these women with counseling or referrals for contraception or abortion. However, several studies have shown that nonobstetrical specialists, such as rheumatologists and primary care physicians, do not routinely offer counseling regarding the option of termination for women with an unintended pregnancy and are reluctant to provide contraception or manage pregnancies.
56
,57
A lack of evidence-based guidelines and inadequate training during residency have been reported as barriers to providing these services by nonobstetrical healthcare practitioners.56
,58
When such practitioners do receive training in how to counsel patients regarding options for pregnancy termination, they report greater self-efficacy and intention in providing such counseling.58
,59
Expanding healthcare practitioner education on counseling for contraception and pregnancy options for high-risk women may be beneficial.In addition, education of nonobstetrical healthcare practitioners should emphasize that referrals to obstetrician-gynecologist specialists and MFM and Complex Family Planning subspecialists should be made as quickly as possible when a patient presents in pregnancy or if a reproductive-aged woman is seen so that options for pregnancy management and contraception can be reviewed. If a patient desires standard reproductive services that the counseling provider cannot or will not provide, referral to another healthcare practitioner or facility should be made in a timely manner. In an emergency in which referral is not possible or might negatively affect a patient’s physical or mental health, healthcare practitioners have an obligation to provide medically indicated and requested care regardless of the healthcare practitioner’s moral objections.
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Currently, federal, state, and hospital policies often limit healthcare practitioners’ ability to counsel women about the full range of options available to manage a high-risk pregnancy. Changes to these laws and policies are necessary to help women achieve their reproductive health goals. In terms of counseling, state policies with mandatory scripts, bans on specific language and referrals, and arbitrary waiting periods should be permanently enjoined because they interfere with the patient-provider relationship.
61
A recent survey of directors of obstetrics and gynecology residency programs revealed that hospital policies are often more restrictive than state laws,Society for Maternal-Fetal Medicine
Access to pregnancy termination services.
Access to pregnancy termination services.
https://s3.amazonaws.com/cdn.smfm.org/media/1269/Access_to_Pregnancy_Termination_Services.pdf
Date: 2017
Date accessed: August 21, 2019
62
suggesting that advocacy at this level may also be necessary. For women in regions with limited access to healthcare practitioners, counseling through telemedicine has been shown to be equally as acceptable and safe as in-person counseling and may serve as a strategy to reduce some of these logistical barriers.63
Achieving continuity of care for women at high risk of maternal morbidity and mortality will involve collaboration with medical professionals in many specialties and with individuals outside the medical profession. This may include engaging with community health workers, doulas, and others to support women during prenatal care and labor and delivery. Connecting women with social services and community resources through a case manager may help address factors in their social context that may increase their risk of complications. Alleviating stressors surrounding housing instability, food access, and employment may improve a woman’s overall health.
52
Conclusion
Women should be provided with accurate, comprehensible, evidence-based information about the risks and treatment alternatives when considering options for contraception and management in pregnancy. To optimize the health of women at risk of experiencing adverse maternal, fetal, or neonatal health outcomes during or after pregnancy, counseling should be a continuous process throughout the reproductive life course. Before pregnancy, women should be informed about maternal and fetal health risks of pregnancy and strategies to prevent or reduce these risks. During pregnancy, women should receive counseling regarding the potential risks and benefits of pregnancy continuation and termination and counseling for postpartum health, contraception, and future pregnancy risks. Shared decision-making is the optimal counseling approach, and healthcare practitioners should utilize strategies that reduce barriers to informative, unbiased communication, prioritize patient values, and empower patients to make the best reproductive health choices for them.
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Article info
Publication history
Published online: December 09, 2020
Footnotes
This publication was developed following a workshop held at the 39th Annual Pregnancy Meeting of the Society for Maternal-Fetal Medicine in Las Vegas, NV, February 11-12, 2019.
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- Blackwell S.
- Louis J.M.
- Norton M.E.
- et al.
Reproductive services for women at high risk for maternal mortality: a report of the workshop of the Society for Maternal-Fetal Medicine, the American College of Obstetricians and Gynecologists, the Fellowship in Family Planning, and the Society of Family Planning.
Am J Obstet Gynecol. 2020; 222: B2-B18
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