Consensus Statement: Counseling Women at Increased Risk of Maternal Morbidity and Mortality

The Society for Maternal–Fetal Medicine recently released guidance for all health care practitioners about counseling reproductive-aged women who may be at high risk of adverse maternal, fetal or neonatal health outcomes during or after pregnancy.

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This summary presents highlights of the document, which was co-authored by Anjali J. Kaimal, MD, MAS, director of the Deborah Kelly Center for Clinical Research in the Department of Obstetrics and Gynecology at Massachusetts General Hospital, and published in the American Journal of Obstetrics & Gynecology.

Overarching Principles

• Although data are often limited, women at increased risk of medical complications of pregnancy should receive evidence-based information about their risks and treatment options
• An important goal of counseling is to support reproductive justice, which can be 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"
• The shared decision-making model is generally the optimal communication strategy, considering the impact of contraception and pregnancy on health, finances and quality of life

Improving Numeracy

"Individuating information," such as stories or anecdotes, tends to influence people more than statistics. People with a poor ability to interpret numeric health information (which is often independent of educational level) tend to give more weight to both their individual risks and the protective effect of interventions.

Similarly, self-perception of risk before a discussion has an anchoring effect that pulls the risk estimate in the direction of the patient's pre-formed opinion. Some strategies for improving numeracy are to:

• Use precise terms (e.g., 10% risk, not low risk)
• Use consistent denominator (e.g., compare risk as 4/1000 to 20/1000)
• Present both positive and negative outcomes
• Compare absolute risks, not relative risks
• Use visual aids and verbal descriptions of probabilities

Issues in Values Clarification

Faced with a challenging situation, patients frequently ask their clinician, "What would you do?" Health care professionals commonly deflect the question out of appropriate concern for patient autonomy. However, the patient may feel her needs are being disregarded. This question is a chance for clinicians to elicit the patient's values to help guide decision-making without necessarily disclosing personal opinions.

In some situations, women already have a clear idea of their preferences. In these cases, the clinician's role is simply to provide accurate, unbiased information.

When considering "what matters most" to them, patients need time to process information, ask questions, use decision-support resources and consult their family and other support systems. They should be offered more than one clinical contact (not necessarily face-to-face).

Counseling Throughout the Life Course

The consensus statement includes detailed recommendations about counseling according to the pregnancy stage. For example:

Women who are not pregnant and do not desire pregnancy in the next year should receive information about contraception, with the most effective option presented first. Clinicians should consult The United States Medical Eligibility Criteria for Contraceptive Use when counseling women at high risk to verify the safety and appropriateness of each option.

During the prenatal period, risk assessment should be performed continuously. Women at risk of maternal morbidity and mortality, including those living in adverse socio-economic and environmental conditions, should receive nondirective counseling about the potential risks and benefits of pregnancy continuation.

The initial discussion should address the potential for changes in risk status during pregnancy. Women must be aware that any follow-up discussions will be intended to consider the current risk-benefit ratio, not to question the woman's previous decision.

During the antepartum period, clinicians should counsel women about the risks and prevention of subsequent pregnancies whether or not they express a desire for future pregnancy. All women should be informed about the risks of a short interpregnancy interval, including increased risk of severe maternal morbidity and mortality.

Women who experienced complications during their pregnancy should be counseled in the immediate postpartum period about the risk of recurrence of these conditions in a subsequent pregnancy and strategies for mitigating the risks, if available. Counseling should also address how the physiologic changes of pregnancy may affect a woman's future quality of life based on her pre-pregnancy health status or complications experienced during or after pregnancy.

Facilitating Access to Care

The consensus statement cites evidence that non-obstetrical specialists caring for women with chronic conditions are likely to be uncomfortable with providing contraception, managing pregnancy and offering counsel about the option to terminate pregnancy. There is a need for specialty-specific evidence-based guidelines and better training during residency.

The document also notes that many federal, state and hospital policies limit clinicians' ability to counsel women about the full range of options available to manage a high-risk pregnancy. It specifically criticizes mandatory scripts, arbitrary waiting periods and bans on specific language and referrals because they interfere with the patient–provider relationship.

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Refer a patient to the Department of Obstetrics and Gynecology