The World Health Organization (WHO) (2015a) estimates that in the UK, 24.9−29.1% of births are by caesarean section, despite evidence illustrating that caesarean section rates greater than 10% fail to achieve a reduction in maternal and newborn mortality rates (WHO, 2015b). Additionally, vaginal birth is associated with lower staffing and financial demands; potentially due to reduced need for pharmacological analgesia and longer hospital stays (Royal College of Obstetricians and Gynaecologists (RCOG), 2015; National Institute for Health and Care Excellence (NICE); 2019). Although there has been a focus for more than a decade on reducing unnecessary caesarean section by increasing vaginal birth after caesarean (VBAC) (Emmett et al, 2006), evidence suggests that this public health goal has not yet been realised (Macdonald and Loder, 2015; Miller et al, 2016). In an effort to engage women in the decision-making process, women who are clinically eligible for VBAC are routinely informed that successful VBAC after a single previous caesarean section is estimated at 72–75%, rising to 85–90% for those with a history of a previous vaginal birth, either before or after their caesarean section (RCOG, 2015). Yet despite this statistical evidence, some women's motivation and preference is still focused on a repeat caesarean section. This article introduces practitioners to a motivational systems-and-learning model to guide women through the shared decision-making process. It is proposed that, by providing practitioners with a practical guide to optimising the VBAC vs repeat caesarean section conversation, knowledge of how to promote VBAC through shared decision-making can be improved.
When promoting VBAC, shared decision-making is often considered the best approach (Sinclair et al, 2017), as evidence shows that when adults' autonomy and self-determination are respected, they are more likely to be averse to surgical intervention (Moulton and King, 2010; Barry and Edgman-Levitan, 2012; Stacey et al, 2014). Additionally, shared decision-making has many benefits, including a reduction in the decisional conflict associated with maternity care planning, increased maternal satisfaction with the birth experience, less depressive symptomology, and greater maternal-neonate attachment (Goldberg, 2009). However, implementing shared decision-making confidently through open discussion with an individual about their options, risks, probabilities and preferences is not easy for health professionals (Ammentorp et al, 2018), nor is it easy for women (Lundgren et al, 2012).
Shared decision-making seeks to enable women's confidence and involvement in decisions, while recognising their individual right to self-determination and autonomy (Elwyn et al, 2012; 2013; Lundgren et al, 2012; Horey et al, 2013). Different decision aids have demonstrated potential in assisting health professionals to achieve shared decision-making (Horey et al, 2013); however, person-centred discussions between a woman and her caring professional is still considered the most effective way of achieving shared decision-making (Ammentorp et al, 2018; Dugas et al, 2012). It is for this reason that the International Confederation of Midwives (2014) recommends that midwives spend time with women, educating them about their choices to enable their self-determination.
Behavioural change vs shared decision-making
To accommodate shared decision-making, midwives need to understand the differences between an interaction that aims to share a decision and one that aims to achieve a behavioural change. For example, when applying behavioural change tactics, the clinician's purpose and educational emphasis is on influencing the woman to set and sustain her goals, normally related to stopping an unhealthy and predefined behaviour, such as smoking during pregnancy. According to Michie et al (2011), there are a number of approaches that can encourage women to engage in behavioural change. One example is the creation of cognitive dissonance, where the midwife creates a feeling of discomfort through an honest and open discussion of a woman's past, beliefs, attitudes and behaviours (Festinger, 1957). Supported by her midwife, the woman is challenged to learn how to behave differently, and in doing so, reduces the tension. A key component of achieving behavioural change is the shared value that abandoning a well-defined, unhealthy behaviour is beneficial to the woman and her baby.
The purpose and emphasis of shared decision-making tactics differ in that they aim to motivate a woman to learn about the options and their relevance to her. The woman is therefore challenged to gain and use unfamiliar knowledge, and to collaborate with her practitioner, to decide which option is best for her. In the application of motivational theories, the health educational role of the midwife therefore also differs. For example, creating dissonance in a behavioural change context can provide the necessary driver for challenging an unhealthy behaviour; however, in a shared decision-making context, the creation of dissonance is theoretically more likely to lead to maternal stress, anxiety and dissatisfaction, which has a negative impact on the woman's autonomy, self-determination and optimal decision-making. It follows that while both behavioural change and shared decision-making draw on the same theories of motivation, volition, goal setting and achievement; the difference in their educational purpose has implications for how midwives implement them.
In an attempt to assist practitioners to manage the theoretical subtleties between behavioural change and shared decision-making, NICE (2018) recommends that health professionals learn to be health coaches. Newman et al (2016) point out that, although the purposes of shared decision-making and behavioural change are different, the coaching style provides the practitioner with a single platform for conversationally adjusting to the purpose of the discussion (to share a decision or to achieve a healthier behaviour).
Although coaching offers a vehicle for shared decision-making, there is little advice about how to actually navigate an appropriate discussion with women. To achieve this, midwives need a working knowledge of motivation and volition, and need to be able to interpret and guide the woman's cognitive learning processing without minimising her autonomy, self-determination to learn and subsequent decision-making. Considering that service users present practitioners with a range of shared decision-making challenges (Attanasio et al, 2018), it is recommended that practitioners attend shared decision-making instructional programmes to learn communication skills and how to produce responsive dialogues (Elwyn et al, 2012; Ammentorp et al, 2018). This recommendation is based on the hypothesis that if health educators knew how to respond to women's motivation and volition, shared decision-making discussions would lead to lower rates of intervention. However, these courses are resource-intensive and not all midwives have access to this level of educational innovation. The aim of this article is to partially address this educational gap, by introducing an organisational system and learning model, the attention, relevance, confidence, and satisfaction (ARCS) model (Keller, 2010). This model aims to enable midwives to understand women's motivation and volition as they engage in shared decision-making discussions.
Introducing the ARCS-V motivational learning model
The ARCS learning model was first developed in 1979 and is underpinned by multiple motivational learning theories (Keller, 1979). The purpose of the model is to enable people who are not experts in the psychology of learning to design motivating and effective educational resources. Originally applied in schools, the model demonstrated validity and reliability (Keller, 2010). It was then transcribed into healthcare as a means of understanding women's motivations related to health education (Stockdale et al, 2011).
Motivation to learn refers to the energy that leads people to achieve their learning goals (Sansone and Harackiewicz, 2000). To stimulate and sustain motivation, the educator is challenged to design learning experiences by applying the four main components of the model (Keller, 2010):
Later, a fifth category, volition, was added to create the ARCS-V model (Keller, 2016). Once the educational environment is designed, the audience is more likely to feel motivated and will self-regulate their behaviour to achieve their goals. To illustrate how the ARCS-V could support shared decision-making, an introduction to the psychological basis of the four main components of the model (attention, relevance, confidence, satisfaction) is provided, with suggestions for how they could be implemented when educating women about VBAC vs repeat caesarean section.
The psychological basis for attention
People are more likely to generate meaningful knowledge when their attention is captured and held on the learning goals (Keller, 2010). Women want to know how their baby is going to be born (Shorten et al, 2015); however, not all women are conscious of the learning goals that enable them to engage in the shared decision-making process and achieve their optimal birth as a result. A key starting point for enabling maternal self-determination is therefore to draw and hold women's attention on what they need to know about VBAC and repeat caesarean section, so that they can choose. Women can also access courses such as the VBAC Birth Class or the VBAC Education Project online. While the content of courses may vary, most provide a structure that challenges women to explore and reflect on topics such as the risks and benefits of their options, and how to mentally and physically prepare for VBAC. This type of knowledge transfer meets women's need to feel sufficiently prepared for a vaginal birth (Nilsson et al, 2017). Women who have had a positive experience of caesarean section may not be spontaneously motivated to learn about VBAC, so routine access to midwifery continuity of care, support and information-sharing is essential (Fouruer et al, 2017).
To capture and hold attention during a conversation, the model recommends that educators draw on theories of information-seeking, curiosity and arousal, while avoiding information overload and boredom due to non-interactive communication (Keller, 2010). Carefully directing a shared decision-making conversation is a good way of stimulating maternal curiosity, which motivates women to engage in and self-regulate their information-seeking behaviours. However, if they are not curious, become bored or are overstimulated in terms of how much they are required to learn, their attention will be minimised, and so too their opportunity to achieve shared decision-making. The educational role of the midwife is therefore to guide the conversation so that the attention balance is achieved, as illustrated in Figure 1.
Conversational tactics that can be useful for achieving an attentional balance during a shared decision-making conversation include:
Sustaining attention is challenging, especially if a person places no value on the learning goals. The second ARCS-V component, relevance, aims to address this by connecting the learning goals with the individual's goals.
The psychological basis for relevance
While 19.8% of the general population are likely to experience general anxiety, the risk increases to 35% during pregnancy. Brunton et al (2019) suggest that pregnant women's susceptibility to anxiety is the result of the emotional challenges of pregnancy and upcoming birth. This is also a time when women desire emotional and behavioural control (McKenna and Symon, 2014; Nilsson et al, 2017).
To achieve this through the shared decision-making process, the midwife aims to support women emotionally and motivationally, by getting them to concentrate on their own personal needs and wishes (Preis et al, 2018). Relevance is achieved when a person perceives the learning content to be in alignment with their values (intrinsic value), and is useful to their experiences (instrumental value) (Keller, 2010). Although underpinned by multiple psychological theories, three dynamic concepts provide the opportunity to enhance the motivational impact of health education from a relevance perspective (Figure 2).
Clinically, enabling goal choice can be challenging, as women cannot be given a 100% guarantee that a VBAC will be successful (Bonzon et al, 2017). Nonetheless, in addition to providing evidence related to the likely outcomes, the midwife can respect a woman's goal choice by enabling her to think through her feelings towards her options. Tolman (1932) proposed that people's choices to behave in a particular way was always purposeful and directed towards or away from some preconceived outcome(s). The more self-determined women's choosing is, the less likely they are to choose intervention.
A key tactic for enabling goal choice is to encourage a woman to talk through her past caesarean section experience, as there will be aspects that she will either be keen to repeat or avoid (Stockdale et al, 2014). This process can give the midwife an insight into the woman's preferences, in order to match the relevant knowledge to the woman's learning needs. Referred to as ‘motive-matching’, this purposeful listening and responding enables the timing and framing of key information to be adapted to the woman's experiences and values. Encouraging women to connect with others who have similar, successful experiences (Konheim-Kalkstein et al, 2015) creates a sense of familiarity, which can make learning more effective.
It is important to remember, however, that women vary in their goal orientation and in the degree to which they feel the need to achieve. Some women will have perforamce-orientated goals, placing their emphasis on the end outcome in terms of their success to have a VBAC; while other women will have mastery or learning-orientated goals, focusing on the process of learning about their options. Dweck (1986) demonstrated that there are many advantages to being mastery-orientated learner, as they are more likely to accept a challenge and believe they can learn the skills to achieve. Encouraging women to stay focused on learning about their options for the upcoming birth is therefore another tactic to motivate women to value and expect to succeed in their optimal birth experience.
The psychological basis for confidence
The impact of maternal confidence on women's intention and experience of vaginal birth is well documented (Ip et al, 2008), with health researchers continuing to develop and test antenatal educational services that influence women's belief that they can succeed (SerÇekus and Baskale, 2016). In a shared decision-making context, the role of the midwife as an educator is to influence women's confidence to learn about their options (learning goals), keeping in mind that if women learn confidently, they are more likely to choose optimally. Miller and Holdaway (2019) found that women were more likely to adopt VBAC instead of repeat caesarean section as their goal when health professionals:
Optimising the style of communication is important; nevertheless, there are other aspects of confidence-building communication that are required for women to learn with self-efficacy and decide.
Multiple theories and concepts underpin the confidence component of the ARCS-V model. As there is already an accepted evidence base related to maternal self-efficacy and birth, Table 1 outlines some simple suggestions for maternal confidence-building as they relate to a few of the underpinning theories of the ARCS-V model.
| Underpinning theories | Suggestions for implementation |
|---|---|
| Locus of control theory: People differ in the degree to which they believe they can control the outcome of their learning experience | Inviting a woman to set the learning pace and how she prefers to learn about VBAC and RCS can help her feel in control of the learning process. Emphasising mastery-orientation related to relevancy will also contribute to her perceived control |
| Self-efficacy theory: Each woman will ask herself: ‘Am I capable of doing what is necessary for success? Developing a plan for success? Persisting long enough to be successful?’ | To feel confident, women must be supported to explore and plan for the potential experiences that she will encounter, especially those she hasn't experienced before. For example, women need clear information about what to do if labour spontaneously commences. Developing a VBAC/RCS plan with a woman is a completely different to a woman presenting her own birth plan. Plans guided by professionals should have coping strategies |
| Attribution theory: People vary in their assessment of why they succeeded or failed | Listen for low expectancy for success statements such as: ‘I tried it the last time, I couldn't do it, I don't think I can do it this time either’. Explore these statements further, returning to the motive-matching (relevance) process, where the learning goals that address the woman's lack of confidence come to the fore. Understanding why a woman has had a previous caesarean section and discussing the probability of it happening again is important to build her confidence to birth this next timefor her next birth. Classification models related to the probability of a successful VBAC may be useful for guiding this aspect of the conversation |
| Educator self-efficacy: Educators who have belief in their ability to teach will apply more effort, support learning better and are willing to give the person more learning autonomy | Taking time to reflect on your ability to encourage shared decision-making, and share information in an effective and confident way, is essential to women's confidence. To increase self-efficacy, educators can tap into shared resources, discuss educational ideas with other midwives and midwife educators, be challenged to learn more about motivation to learn, and have the courage to try new instructional ideas |
VBAC: vaginal birth after caesarean; RCS: repeat caesarean section
The psychological basis for satisfaction
Women's satisfaction with shared-decision making is directly linked to their satisfaction with their experience of birth; therefore research into maternal satisfaction tends to focus on the birth outcome (Gungor et al, 2012; Fleming et al, 2016; Attanasio et al, 2018). However, evidence also demonstrates that as people gain relevant knowledge, their decision-making self-efficacy is affected (Scaffidi et al, 2014). Briefly exploring some of the theories related to the satisfaction component of the ARCS-V model is therefore useful in understanding how to optimise women's decision-making satisfaction (Figure 3).
Reflecting on satisfaction brings the shared decision-making journey full circle, in that satisfaction is directly related to how well women's intrinsic and self-determination (relevance), interest (attention) and competency (confidence) to achieve their goals, is respected and encouraged. Understanding the theories of equity, balance and cognitive evaluation adds further meaning to the phenomenon of maternal satisfaction. The relationships that midwives can build with women provide the best opportunity for making each woman feel that health professionals are investing in them (equity). As continuity of carer (McInnes et al, 2018; Kildea et al, 2018) becomes common practice, midwives are strategically placed to ensure maternal equity, and optimise women's shared decision-making and overall birth experiences.
This relational basis for achieving maternal self-determination also provides a platform for woman's attitudes and goals, which should be balanced with those of her midwife. Balance theory proposes that people strive for consistency in their attitudes as a result of their person-environment interactions (Heider, 1958). This could be shown in a midwifery context by examining the role of the midwife in terms of consistency of carer and dissonance related to openness to learning. This relational basis for maternal self-determination also provides a platform for woman's attitudes and goals to emerge, which should be balanced with those of her midwife. When a difference in attitudes persists, the resulting dissonance is uncomfortable but, if a good relationship exists, both partners will be motivated to work towards reducing this (Heider, 1958). However, it takes time for a woman and her midwife to work through this learning process, to discover the best option for the woman (attention) and to plan for her optimal experience.
Satisfaction is nonetheless influenced by the woman's subjective view of the outcome and how it related to her expectations and social comparisons (cognitive evaluation). Key to achieving satisfaction is remaining open and honest about the options available to each woman and what her experience is likely to entail, so that she sets realistic expectations (Gungor and Beji, 2012).
Without a satisfying shared decision-making experience, women are more likely to experience anxiety, which can manifest itself in a range of symptoms. These include cognitive disturbance, (poor concentration, impending thoughts of doom or irritability, sleep disturbance) and automatic arousal (sweating, dry mouth and/or palpations, hyperventilation) (Pilgrim, 2017).
Conclusion
The UK has a high rate of unnecessary caesarean section, despite the evidence that VBAC offers the opportunity to achieve better maternal and newborn outcomes (RCOG, 2015; WHO, 2015b; NICE, 2019). Maternal motivation is regulated by complex contributing factors and is central to how women with a previous caesarean section decide on their preferred birth. However, to be self-determined, women need to learn about their options and be supported in their decision-making process. When women feel unsupported, or coerced into a particular decision, it is more likely that they will experience anxiety. Coaching is a goal-focused technique of ‘containing anxiety’ (Western, 2012: 175), that is recommended for health professionals encouraging optimal behaviours (Newman et al, 2016).
The majority of advice about how to implement coaching is focused on behavioural change and not shared decision-making. This makes it difficult for midwives to direct the shared decision-making conversation so that women remain self-determined to choose VBAC. This article provides midwives with an introduction to the ARCS-V model (Keller, 2010) as one way of understanding and responding to women's motivation and volition to share the decision about VBAC vs repeat caesarean section. As an organisational model, it provides midwives with direction about how to guide shared decision-making conversations by capturing and holding women's attention on what they need to learn; matching the learning content to women's goals (relevance); building women's confidence to achieve their optimal birth; and ensuring that they are satisfied with their overall experience of learning. It is only when these four educational conditions are met that women will learn about their options and choose optimally.
Limitations
Implementing theory into practice is challenging and requires health professionals to continue to learn and practise the shared decision-making conversation. Although useful, this introduction of the ARCS-V model is limited, in that focuses on only a few examples of the key theories underpinning each of the components and how they relate to shared decision-making. A fuller and more systematic approach to learning how to implement the ARCS-V as an organisational model for promoting shared decision-making is therefore required, ahead of further testing and developing of the motivational system and learning design model in maternity care.