Optimizing Autonomy-Supportive Consultation: An investigation in the context of prenatal consultations in maternity care

IIntroduction Consultations in maternity care have become more complex; options regarding preferred care, diagnostics and lifestyle interventions have increased. Supporting patients’ decision-making process places high demands on the interaction skills of maternity care professionals. Despite additional training, research shows that professionals focus primarily on providing information instead of involving patients in decision-making. At the same time, active patient participation is necessary to enable them to make their own choices. In the context of maternity care, the effect is that some patients are disappointed, mainly due to experiencing poor communication and freedom of choice. Autonomy-supporting consultation (ASC) can help professionals support patients' decision-making by using an autonomy-supportive interaction style to meet patients' basic psychological needs. ASC is based on the self-determination theory, which states that people become more autonomously motivated and self-regulated when their basic psychological needs, autonomy, competence, and relatedness are met. To lay a foundation for developing training to help professionals optimise their interactions and decision-making support during consultations. The broad research question of this thesis was: “How can professionals in maternity care optimise their interaction so that patients are more autonomously motivated and more self-regulating and can make their own choices regarding their health?”. Methods This was investigated in five studies in the context of prenatal consultations in maternity care in the Netherlands. Both obstetrics and midwives in hospital and midwifery practices were included. First, a realist review provided the theoretical framework for the concept of ASC. Subsequently, an observation tool was adapted and validated for maternity care to facilitate a quantitative observation study. This quantitative observation study examined the autonomy-supportive and autonomy-thwarting interactions professionals use during prenatal consultation and patients' perceptions of the consultation climate. A qualitative observation study was conducted to gain insight into the interactions between professionals and patients, specifically during decision-making. Finally, a qualitative survey study explored what professionals consider to be core elements of good counselling. Summary of Results The realist review offers a theoretical framework in which shared decision-making and motivational interviewing concepts were integrated with autonomy-supportive consultation. The quantitative and qualitative observation studies show that professionals provide space and freedom of choice to meet patients’ autonomy. They scarcely use interactions that invite patients to participate actively. Professionals meet patients’ competence by providing information and explanations. Professionals hardly use interactions to give structure to patients to meet their need for competence. Creating a warm and comfortable consultation climate meets patients’ need for relatedness. Focusing on agreement, using humour, and minimising language strengthens the relationship between professional and patient. The effect is that the interaction could stay somewhat superficial, and discomfort and difficulties are avoided. The findings align with the core components of good counselling, according to professionals. They named Freedom of choice and providing information essential aspects of good counselling. Discussion and Conclusion With this thesis, we have laid a foundation for developing training to facilitate maternity care professionals' optimisation of interactions and decision-making support during prenatal consultations. The thesis also offers suggestions on how professionals could optimise their autonomy-supportive interactions. To meet patients’ need for autonomy, professionals should be aware that supporting patients in exploring their values, standards, expectations, fears, and wishes is necessary. In addition, support with professional advice is essential. To fulfil patients’ need for competence, it is vital to support knowledge development. Prerequisites for this are a 'brave space' consultation climate. In a 'brave space,' difficult and sometimes even painful topics can be discussed with the certainty that there is always support and respect. Although o