Shared decision-making in a medicalized birth environment: mixed-methods exploratory study, Cyprus

BACKGROUND: Maternity care practices are not always supportive of participation in decision-making; a fundamental pillar of the WHO Respectful Maternity Care framework. With the highest caesarean section (C/S) rate in the EU (>60%), high episiotomy rates (70.9%) etc, the medicalised birth environment in Cyprus raises questions about Informed Choice. METHODS: Following focus groups (N = 12) with pregnant women and new mums (N = 62), an online survey was shared via the Baby Buddy Cyprus webapp. Women responded to the Maternal Autonomy in Decision-Making (MADM) scale along a battery of scales, including perceived efficacy in patient-provider interaction (PEPPI) and Kim Alliance Scale (KAS). RESULTS: Based on MADM classification, 54.3% of 387 participants (64% primiparas, 42% C/S, 80% private sector) were classified as having high autonomy, while one in five were classified as low or very low. There were lower scores among primiparous women (p = 0.02) and higher among those receiving care in the private sector (p < 0.001). Perceived efficacy in interaction was related to educational attainment (p-value for trend=0.02). In regression models, KAS (b coeff= 1.25 95%CI 1.06, .1.45; p < 0.001) and PEPPI (b coeff = 0.38 95%CI 0.24, 0.52; p < 0.001) were independently associated with MADM after adjusting for socio-demographic and pregnancy characteristics. Consistently, having a “confident voice” in an ‘unsupportive system’ where the ‘art of communication’ is often left to the women themselves emerged as themes from the qualitative study. CONCLUSIONS: Participation in decision-making among pregnant women in Cyprus is problematic. Given that reduction of C/S, most classified as elective by maternal request, was identified as national Public Health priority, further research is necessary. Continuous professional training along with population-level interventions to promote self-agency may be needed, especially since childbirth rights were further compromised during the COVID-19 pandemic. KEY MESSAGES: • Against physician dominance in communication, birthing women in Cyprus do not rate participation in decision-making favourably. • Further research is needed around Informed Choice, including educational and population-level interventions targeted at healthcare providers as well as women.