REPLAY: EBB 357 - Making Decisions about Elective Induction of Labor with Dr. Ann Peralta & Kari Radoff, CNM, from Partner to Decide

Hi everyone, on today's podcast, we're talking with Ann Peralta and Kari Radoff about how to decide if you want a labor induction or not. Welcome to the Evidence-Based Birth Podcast. My name is Rebecca Decker and I'm a nurse with my PhD and the founder of Evidence-Based Birth. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebberth.com slash disclaimer for more details. Hi everyone and welcome to today's episode of the EVV podcast. Today I'm so excited to welcome Dr. Ann Peralta and Kari Radoff who are here to talk about their nonprofit Partner to Decide and how you can decide if you want a labor induction or not. Dr. Ann Peralta is the founder and CEO of Partner to Decide, a nonprofit dedicated to improving decision-making and perinatal care. Ann has spent more than 15 years leading, innovating, and growing programs that support and power decision-making for families. She has a doctorate in public health and management, leadership, and policy, and a master's in public health and maternal and child health from Boston University School of Public Health. Ann is also a mom to two amazing kids and it was her own perinatal care journey that inspired Partner to Decide's first decision aid on routine induction of labor. Joining us also today is Kari Radoff. Kari is a certified nurse midwife and associate director of midwifery services at Boston Medical Center. She is an assistant professor of obstetrics and gynecology at Boston University School of Medicine. Ms. Radoff joined Boston University in 2012 after completing a Fulbright grant in Nicaragua. During her grant, she developed a radio-based pregnancy education intervention. Throughout her career, Ms. Radoff has advocated for patient-centered policies and interventions to promote physiologic birth. Kari has also created patient education materials in multiple languages to support pregnant people at a safety net hospital. Her research interests include patient-centered systems improvements that advance perinatal care experiences and outcomes in safety net populations. And Kari is a clinical consultant for Partner to Decide the Non-Profit. I just mentioned that we'll be talking about in more detail. Ann and Kari, welcome to the Evidence Space Birth Podcast. Thanks so much for having us. So I was wondering if you two could start us off by telling us what inspired the creation of a decision aid for labor induction and what were you hoping to achieve in filling this gap in care? Yeah, absolutely. So this is Ann. And I think first I'll just describe a little bit like what is this decision aid that we're talking about. And then I'll talk about what inspired me to start working on it. So a decision aid is a decision support tool that lays out options and balance pros and cons of all options and often helps someone think about what they most care about. So which of those pros and cons are most important to you? And in our case, the decision aid also has questions you might want to ask your provider and things like that. So in this case, this is on routine induction of labor, meaning induction without a medical reason. So any kind of induction when you don't have a medical reason for the induction like hypertension or something like that, anytime from an induction at 39 weeks to waiting beyond 42 weeks instead of having an induction. So I just want to say a little bit about that. There's a paper version that's sort of a static PDF and a more interactive web version on our website. So why did I create this? What prompted me to do this? So it was really my own experience. So when I was pregnant for the first time with my now 10 year old, she just turned 10, I was pregnant for the first time and I happened to be in my first semester during my pregnancy in that doctorate of public health program at BU. I was in the evenings in class listening to Dr. Jean DeClerc talk about induction rates and things like that. And my day job was I'm working in adolescent health and really focused on empowered decision making. So that's a little bit of the context in which I was pregnant. And then when I went past my due date with my daughter, Frida, a couple days after my due date, I had a standard appointment with my midwife and she said, you know, and we usually schedule inductions after 41 weeks, you know, they can be hard to schedule if you don't get them on the calendar. You know, you might want to have one just in case, you know, would you like Tuesday or Wednesday? And I thought to myself, like, I am not possibly going to be still pregnant next Tuesday or Wednesday. Wow. So I said, I'm not sure Wednesday and just kind of made an appointment, you know, sort of to appease the current conversation thinking I would definitely go into labor before then. And then the week went on and I did things like read evidence based birth summaries actually and Emily Oster's work around induction. And then as I got to the actual weekend, I was like, man, I need to really look into this. So as a doctoral student would, I read all of the research. I binge researched all weekend. I read the Cochran review, which is a summary of randomized control trials on the topic. I read individual studies. I just really, really deeply looked at this topic. And then the next week I was still pregnant, went back and now I was sort of, you know, into week 41. And my midwife said, you know, how are you feeling about your induction appointment? And I said, not great. I don't want an induction. I'm trying for an unmedicated birth. I really don't want a lot of interventions. I'm very healthy. This pregnancy has been going very well. I don't want it. It just feels arbitrary to me that one day you think I'm fine and the next day I'm not. And I read all the literature. It didn't convince me. And she said, well, and it's not arbitrary. Your risk of stillbirth is three times higher if you go past 42 weeks. And I said, yes, three times higher. You're quoting me the Cochran review. Good job. That's a good evidence to be quoting me. But three times higher is also we're talking about at the time at that Cochran review, it was three in a thousand versus eight in a thousand. And that was beyond 42 weeks. So she was like, well, no one can say you're not informed. And she had to actually go and talk to other midwives on her team about sort of what they were going to do with me because I didn't want an induction and they sort of weren't used to people declining. And so she went and talked to her team, figured, you know, came to a, OK, if you go past 42 weeks, we want you to come in for monitoring every day. And I said, sure, monitor me away. Like, great. That's totally fine as a plan. And luckily I went into labor on my own at 41 weeks and six days just missing this deadline of constant monitoring. And I went on to have a really wonderful birth experience. I was able to have an unmedicated birth. I like, you know, it wasn't all pretty and beautiful, but it was a really empowering experience. And it felt like it started for me, given my preferences, with that being able to make that decision and be respected in that decision, that that's not what I wanted in terms of how my labor started. But that experience, both how positive and powerful it felt and the fact that looking back, right, all those little comments like, well, no one can say you're not informed, right? It sort of always bothered me that it felt like the ability to make that choice and have that choice respected seemed to really hinge on a lot of my identities, including being a doctoral student and being able to read that literature and argue about three times higher what is that, you know, what are those actual numbers. And the other thing that bothered me that I really wanted to work on and be a part of the solution is random people in the world like baristas and ultrasound techs. When I was very, very pregnant would say like as a really large pregnant person and they'd be like, wow, when are you do. And when I said like 10 days ago, 12 days ago, people would say, oh, wow, like how much longer are they going to let you go. And that let you language just really, really bothered me. And I think was, you know, really telling of our system in which we as a culture, not just within a medical setting, but as a culture wonder if it's really a pregnant person's decision, whether they should be induced or not. And I know I really appreciate you bringing up this respectful maternity care piece in your October podcast episode on the arrive trial because I think that is often that this piece of like, how do you make this choice? How do you have a good conversation between a provider and a patient is the gap that's that's missing here. We have all these guidelines saying that we should do this, but the reality is most people are not experiencing that. Yeah, wow, that paint such an interesting picture. I can almost like picture you in class like, you know, in your spare time, looking up the evidence based birth article on going past your due date. And it's so funny that was all happening on the same time. And you were in class with Dr. Eugene DeClerc, who's like one of the leading researchers on maternity care in the United States. It's so true though, what you said about how you were able to get your decision respected partly because of the privileges of where you were, who you were, and having a provider who was willing to listen to you, although they clearly were feeling hesitant about it. And that brings me to Kari as a clinician and a nurse midwife. You've been on the other side of that conversation, right? Where you're feeling pressures of the system to induce some risk management. You know, it's not just stillbirth, but there's other risks involved as well, you know, hypertension, other complications of pregnancy that increase as you go past your due date. So what has your clinical experience been like surrounding this whole induction decision? Yeah, yeah. This is Kari. Thanks so much for asking that question. When I think back to what we do as midwives in our training, we're taught about how shared decision making is really so critical to the work that we do. And we even call it one of the hallmarks of midwifery care. And that being said, and even though we've got these guidelines, these clinical position statements that come out of my organization, the American College of Nurse Midwives and then also from ACOG, the American College of Obstetricians and Gynecologists, nobody has really said, how do you actually achieve this shared decision making? Like, what are the tools that you integrate into your practice to ensure that you are having those respectful communications? And I always think about this kind of framework around person-centered care, where it's based on respect and communication and shared decision making. And many of us feel like we're excellent at shared decision making because we're good communicators. We respect the patients that we're with, but we're not always crossing that chasm and actually engaging in shared decision making. And I think that's what's also been borne out in the research as well. When we start listening to patients about or pregnant people about their experiences, and I think in particular, people of color, they tend to say, I wasn't engaged in shared decision making. I wasn't given the autonomy to have a choice. I was told what I was going to do or what I needed to do. And so I think what's been wonderful for me as a provider and working with Ann through the stages of this project is actually having like a very concrete tool that helps me do my job in a better way. And I feel like having these types of tools, this creates a bit of a roadmap that says, here's how you can do this as a clinician. Like, here's something that's really practical that you can use to make sure that you're having these conversations. And I think having those conversations in a really consistent way with anyone who comes in front of you. So whether that is the individual who doesn't speak the same language as you in a safety net hospital versus somebody like Ann who might come in, armed with all of the research and knowing what her decision already was without even talking with her provider. So I think that that's like the gap that's being filled here. And I think truly as a provider, like I've had shared decision making conversations or I've had conversations around induction of labor, but this is really laid it out in a way that's easy for me. It fits into my clinical workflow. And I really feel like I am having that high level communication that I want to have with my patients and providing them those risks and benefits in a way that sets it up before them so that they can have everything to make that informed choice. Yeah, it sounds like both of you are really big proponents of informed choice and autonomy, but also like accurate information. And what role does personal values, preferences or even intuition play in this process of just making a major decision like this? I mean, it's really built all of those are built into the tool again to make it easy for a provider to not skip that part. So there's a section on both the paper and the web based tool. The web based, it's a little cooler. It's a quiz, but on the paper based tool, it's sort of an insert and it walks through statements and sort of asks you as a pregnant person to reflect on how important is this to you? Is this, you know, for example, is it, you know, are you really anxious for your baby to come or not plenty patient? Are you already planning to use an epidural? So, you know, if there's a slight increase in pain medication use with an induction like that's not going to affect your decision most likely. And then there's a cultural and personal reasons element of that because this is a topic that has very deep preferences, right? Some people are like really want an induction and have really strong feelings about that for whatever reason. And other people who really don't want an induction and have really strong feelings about that. So there is the, the evidence pieces and things to consider of like how much did these, you know, risks matter or not to you and how much of your decision are they going to be? You know, like I like to say, you know, I wasn't compelled by the the small increase in risk to, you know, about stillbirth and perinatal death for me personally. So, but that is my own risk tolerance. And the fact that I had, you know, I don't have any bad experiences. I don't have any wonderfully loved ones who have lost a baby. That might have been very different if I had a different feeling about that or something had scared me in my pregnancy. I might have seen that same difference in risk and been like, nope, absolutely not, will not take any elevated risk. So I think this decision aid and the values piece is what can help the patient and provider have a higher quality conversation about like, why do they really want an induction? Why do they really don't not want an induction? And like those pieces are really important and just as valid as right, my reading of the literature, like, right, that's why that comment bothered me so much is like, well, no one can say it weren't informed. Right. I had the right reasons. I said that in air quotes for people only listening. But, you know, all reasons are valid reasons, whether you want an induction or not, especially when there's no medical reason for the induction. Okay, that makes sense. And I want to get into like how your team developed this tool, which is located at partner2decide.org. But before we do that, I'd like you to define a word for me. You mentioned the word safety net hospital a couple of times. Could you like just tell us what that means for listeners who haven't heard that term before? Yeah, thanks. Thanks for asking that. So a safety net hospital is a hospital that tends to have a majority of publicly insured individuals. And so at our hospital, we have about 80% of our patients are insured on mass health insurance. And at our hospital, we also have high level of diversity. We have individuals coming from all over the world and speaking all different languages. And we're caring for that population. Okay, so Anne or Kari, whichever one of you wants to talk about, like, how did you start? You know, you had this idea that you wish you would have had something like this when you were pregnant, Anne, but how did you go about developing it? I'll start off. And I know Anne was really the visionary on this. And she spent a lot of time just even drafting this and coming up with the imagery around it and going into the Cochrane reviews and pulling that evidence for the evidence base that went into this tool. And then it really was this iterative process where we were working with a team of providers and that team of providers was really diverse. So it included physicians, obstetricians, family medicine doctors, nurses, nurse practitioners and nurse midwives. And so there was really diversity of healthcare belief systems that went into this or philosophies, I should say. And then there was a lot of engagement of pregnant people and the pregnant people that were working with us were basically reviewing the tool. They were providing feedback so that we could update, adapt it and improve it so that it was really meeting the needs of our community. And the testing for this tool primarily happened at Boston Medical Center in some of our community health centers. And within this hospital system, as we mentioned, we have many individuals who spoke different languages. And so this tool was translated from the beginning in Spanish and Haitian Creole. And so we were able to interview those individuals, get their feedback right from the beginning and have their feedback go into the updates and iterations of this tool over time. As we were developing this tool and doing the testing of this tool, prioritized having a design for equity, making sure that it was going to meet the needs of the population at our hospital system. And so for Anne, where she had access to PubMed and she could get up to date and get all of this information and distill it, we wanted to have something that any individual, regardless of their level of education, their health literacy, could really access this and still get the most fundamental information from this tool. And so it's written at a sixth grade reading level. We prioritized gender neutral language and actually wrote the tool in second person using you so that the individual reading it could really identify as their own decision and their own choice. We also really wanted to use non-judgmental language. We know that some words like normal and natural may be triggering for some people. So really tried to keep it very neutral overall. So those are a lot of the pieces that went into developing that testing of the tool and these kind of reiterations. And I know that Anne continues to do interviews with individuals right now as we work on some new tools and work on improving the web version of the partner to decide induction tool. Yeah. And I think just the overall big picture is right. I was reflecting on how many of my identities needed to be there, including my personality, by the way, right? Like the fact that I thought I could make a different decision that wasn't presented to me, right, is like partially a personality and culture thing, right? But I really wanted to design a tool where you would have to have none of my identities. You wouldn't need to be a native English speaker. You wouldn't need to be white. You wouldn't need to have private insurance. You would definitely wouldn't have to have a doctoral training to be able to access the evidence and actually understand it. And I also, you know, sometimes it's it's always hard. I'm sure Rebecca, you deal with this all the time. It's hard to decide which evidence to use. That's a whole component of how you build the tool like this or how you, you know, what you decide to use as evidence. And I really went with very mainstream evidence because I wanted providers to use it. And I wanted OBs to use it, not just midwives, like not just early adopters. I wanted it to be a really mainstream usable tool. So I chose to just, you know, Cochrane reviews are often considered gold standard evidence. This particular Cochrane review and probably others, it's not perfect. It has issues. It is not the perfect evidence, but it is pretty good evidence that is pretty widely accepted by providers. And I think of note, right? That's the statistic that was thrown at me of like, why would I want an induction three times higher risk of stillbirth rate? That person was quoting me the Cochrane review. So I really wanted to use that evidence, but share it with absolute numbers. So actual numbers and not just in relative terms, because often, like my own experience, even when a provider is using the most up to date statistics, they're often only sharing and relative risk, which by the way is understandable since many studies and many guidelines reported that way. So you have to actually do math, right? To get to the absolute numbers. But I wanted to sort of do that math for people and make it easier for providers to explain that and easier for people to understand it. Yeah, we talk a lot about that in our research team at EBB, like whenever we're drafting something and all we have is relative risk. I'm like, is there any way we can get the absolute risk? So for those of you don't know, relative risk is the risk of something happening to you in comparison to someone else. So for example, with the arrive trial, there was a 16% reduction in 39 week elective induction, but the absolute risk was actually a decrease of 3.6% because the risk went down from 22.2% to 18.6%. And if you do the math, that's a 16% reduction in relative risk, but you know, it can be a little misleading. So I really like how in your tool, you do give the actual numbers. It's just easier for all of us out there to understand, especially when you're talking about something as important as like the risk of stillbirth, you want to know the actual numbers, right? Not just some kind of number that you have to do a math formula to figure out what it means. So, and Kari was mentioned, you do a lot of focus groups and you do a lot of conversations with families. If there have been any conversations that surprised you or what did you learn from parents, you know, when they were talking with you about their thoughts and feelings on labor induction? Yeah, I mean, I was really quite shocked. I'm in a positive way by what pregnant people I interviewed said about what using this tool with their provider meant to them. In retrospect, my goals were very humble. They were very focused on like, are people actually understanding, right? I was really focused on this like access to information piece of it. Is it? Yeah, so it was very focused in my questions for pregnant people about like, you know, can you tell me what the choices are? Can you tell me what the pros and cons of each choice are? I was really looking for like, were they understanding, right? Like the way I had worded it, the way I had portrayed graphics and things like that, were they actually able to write? Were they accessing that evidence and those numbers at all kinds of reading levels in all kinds of languages? And so I had this question that I was asking and I still ask, you know, sort of tell me about the conversation you had with your provider. And I was expecting people to say things like it was at my 38th week appointment. They gave me the paper. We talked about it, things like that, which people did tell me. But people also said things like, you know, this just gives me so much power. And when someone said that to me, I'm sure my eye is completely bugged out of my face because I just wasn't expecting someone to say something like that. I was so focused on this, like, did you learn the thing I'm trying to convey in this tool that I was underestimating the power that a tool like this can have, especially for someone who has not been engaged like this in other visits on other topics, right? It's a very different and new experience. Another person said, you know, before this, I felt like I was on this conveyor belt of prenatal care, just sort of like every visit, going through the motions and getting this and talking about it with my provider and making this decision with their support was awesome. And I just wasn't expecting to hear things like power and awesome, especially with the question I was asking, which was like, tell me about your conversation with your provider. And then another story I like to tell because it really helps me talk to providers and healthcare settings. Settings about the need for this tool is right on one end of the scenario is me, like a person who didn't want an induction. On the other side, there might be someone who really wants an induction. And this one person that I interviewed, I really stayed with me, her story and why she was interested in induction. So this was a very recent immigrant to the US. And we were doing the interview in Spanish. And in the country she was coming from, early induction didn't exist, was not a thing. So it wasn't a thing she knew about. And she was in a really tough situation where she had a toddler at home, no partner. And she sort of had one person in the United States locally that she felt comfortable with her toddler going with while she was in the hospital having her next baby. And this person was only available on the weekend. Now, is induction the right solution for this? I won't comment on that. But what she said to me in the interview was, I never would have known I could even ask about this. I didn't know this option existed and that it might be the way that I end up in the hospital like giving birth over the weekend and my toddler won't go into temporary state custody and instead will be with my friend. And I share that story because one of the things I sometimes hear from hospitals and healthcare systems is like, well, we don't do elective induction right now. We don't have the staffing, whatever. We don't offer that right now. So we don't need your tool. It's a really clear example of a person who would never have known to ask. Whereas someone like me, if I had wanted, really wanted a 39 week induction, I would have known that that was a thing that I could advocate for. Maybe they couldn't accommodate it, but I could certainly bring it up early and often and really try to advocate for myself. And this other person couldn't. And to me, that's not fair. And that is one of the reasons why I think everyone should be using this tool. No matter what your hospital policies are, no matter what your personal opinion is, that that I'm not sure if she decided to get an induction or not. And if that was being able to be accommodated, but she was so grateful to know that that was something she could talk about. And she wouldn't have known that if it weren't for the tool because she was in midwifery care and that wouldn't have been brought up. Interesting. Yeah, it just goes to show you information is power for, you know, all of us. And that makes me think though, Kari, and was talking about the provider side of the conversation. Can you talk a little bit how providers are using this decision aid and how it's impacting the conversations about induction? Yeah. I think what's really nice about this tool is that it's short. It's succinct. It's easy to use in a clinical encounter. You can kind of drive your eye towards key areas that you might want to point out with the patient and bring this topic up with them. And it's something that you can use over several encounters to. You could start earlier and just say, Hey, you're 37 weeks. Congratulations. Your term. This is so exciting. Sometimes people ask me what will happen if I go to my due date? Here's like a QR code. You can go and read this and we'll talk about this, you know, and something that as your pregnancy continues, we can discuss it a little bit more. I like that aspect of the tool. When I think about myself personally and then some of the other providers that we worked with as we were launching this project, I think what it revealed was the whether they're explicit or implicit biases that we do have as providers. I mean, I absolutely recognize my positionality as a midwife and my preference for physiologic birth and allowing things to begin spontaneously. And the patients that I care for that might not be where they're coming from. And just as Anne was talking about the different patients who and their experiences with this, if I haven't had the opportunity to talk to people about this, I'm probably just going to go with my own recommendation or my hospital institutional policies, like we'll do an induction at 41 weeks. And that's kind of the end of the conversation. So it really has opened that up in my own mind and in my own counseling around this. And one of the physicians that we worked with as we were doing this work too, she had kind of a similar aha moment that I did around this. And she started noticing, wow, I really am prone to recommend a 39 week induction and I'm not offering these other options. I'm not really talking to people about even going post dates. And I think one of the things that she had recognized too is how that bias had crept in to the different patients that she was caring for. So if patients were asking questions about it or if they were of a certain race or a language ability that she might be more likely to even encourage that 39 week induction versus having a broader conversation. So I think that is a really powerful part of this tool as well. And one of the things that we've talked about when we discuss this with other hospitals and other teams is having a tool like this and having these different options of this early 39 week induction, a 41 week or kind of awaiting spontaneous labor. It doesn't negate a recommendation. Like I can still make my recommendation to a patient say, you know what, you're really healthy, you're low risk, you are an ideal individual. So let's wait and see what happens with labor. But what are your preferences and here are your choices and your options. And so that I think is key to understand with the tool as well, that it just it lays out the choices. It provides that opportunity for a patient to consider their values and preferences and then have that shared decision around the way to move forward. So it sounds like you haven't had too much trouble. Like I'm assuming getting midwives to adopt using the decision tool. What about obstetricians? I mean, I would say everyone is uncomfortable with whatever is furthest from their current practice. So including midwives, I think midwives are easier to sell again, because as Carrie said, shared decision making is like a hallmark of their whole profession. And so once you it's easier to sort of get them to quickly be like, oh, yeah, I guess it isn't fair that some of my patients don't know that they could even ask for an option. I do want them to know about all of their options, even if I don't recommend that. On the OB and health systems side, I more get like hesitation around waiting, right? Sort of anything. And forty one, forty two weeks seems extreme. Yes, it's like, well, it's often about hospital policy or I'll hear. But forty one weeks is a medical indication. So I'll hear that or I'll hear, you know, we don't need your tool because we don't offer like at my hospital, we're not able to do thirty nine week inductions. And to me, you peel back the onion on that comment. It means that people are uncomfortable naming options, that they're sort of uncomfortable bringing up something that isn't easily available, which is understandable. But also you still get into that. Some people already know that and some people don't. But the other piece is that when someone tells me we don't do elective induction, so we don't need to use your tool, it completely leaves out this like forty one to forty two week and beyond choice that again, all of you know, it should be a choice. It is a you know, it is a choice. This is also, I always say like the American College of Obstetricians and Gynecologists says that like in their guidelines, they actually say that patients should be offered induction between forty one and forty two weeks. And they recommend induction at forty two weeks. That is not the same as having a policy where everyone is induced at forty one weeks. Right. And so there are these real gaps between even what. These national organizations say and then what actually happens in the real world. And that's not even right. The people who are just sort of saying, I recommend thirty nine weeks. That's the safest choice for you and your baby, right? Even on the things that are very much in all of the national guidelines, we are not routinely doing that or experiencing that. So what I'm hearing you say is the challenge in getting some obese adopted is first of all, they might not be comfortable with the options of waiting till forty one or forty two weeks or even going past forty weeks I've heard in some cases. And then the other issue has to do with they see a forty one or forty two week induction is medically necessary, whereas this decision aid tool is technically about like choosing an elective induction. So there's some kind of misunderstanding about the terminology there. Yes. Yep. Go ahead. Yes. And which is why I've come to use the word routine induction. OK, because to me, it may be for some it's a little jargon. He but it sort of gets away from this like this idea that because I think forty one weeks is routine induction in most practices in this country. If you know, and some it's earlier and some it's a little later, but there usually is a pretty strong policy and practice in place at a given health care system. So I think talking about whatever that is, whether at your institution, that's forty weeks or forty one weeks or forty two weeks or forty one and five days or whatever it is, that's still a choice that people should be informed about and be able to make the decision of whether that, you know, they recommended. But is that the right thing for that person? OK, interesting. I hadn't really thought about using that language routine instead of elective at forty one or forty two weeks. That's really helpful. There are two things that you said earlier that really stuck out at me. I want to make sure we have time to talk a little bit about how listeners can access the decision aid. But you all were mentioning like, and when you were sharing your story and this kind of like starting it was at 38 weeks of telling you, you know, we want to schedule your induction. What I'm hearing from a lot of doulas with their clients is that these conversations about elective induction, which, like you said, are more about routine. It's what that doctor does or what that practice likes to do. It's creating a lot of anxiety. The pressure to decide is something that they didn't even think they would have to decide because they just assumed their body would go into labor. And now all of a sudden they're being told that, you know, we need to schedule this and they're receiving pressure, coercion, scary, threatening language. That that could in itself cause potential health complications with that increase in the sympathetic nervous system, you know, and the anxiety surrounding having to make that decision or feeling that pressure. Has any thought at all about that in your like developing of this tool? Yes. So thank you for this question because one of the really interesting things that came out of our patient interviews when we were first implementing the initial versions was that patients wanted this tool introduced earlier than providers wanted to introduce it. So from the provider's perspective, it was like, well, I, you know, this person might go into labor and then I've spent my precious, you know, time in these, like these really short visits on this topic that isn't even might be relevant to them. So providers, especially those who weren't really recommending 39 week inductions didn't want to bring up the topic until 39 or 40 weeks, right? To sort of save time in visits. And patients were very clear of like, this doesn't need to be some stressful, quick decision that I need to make. I want to hear about this at 37 and 38 weeks so that I have plenty of time to read this, talk to my partner, talk to my mom, you know, whoever are your people and have those opportunities to like ask your next question at your next visit. So that was really interesting because that really helped providers buy in to like actually we do need to move it earlier to hear that so clearly from patients because it is stress. And I experienced a lot of anxiety between my conversation where I said, no, you're three times higher of stillbirth is not compelling enough for me to do an induction and actually going into labor. I spent many moments really worrying like, am I making the right decision? What if God forbid something terrible happens? Will I ever forgive myself? Because it is very scary, especially when often the only risk or benefit of any of these options without a tool like this is stillbirth. No one talks about anything else. It's just like, you better do this because your baby might die, which the reason I included it in the tool is there is evidence that people should be aware of of a small increase in risk. People, in my opinion, get to make that decision for themselves if that is a compelling level of risk to make a decision or not. Interesting. Yeah. I think too, when you talk about having the conversation earlier, when it's presented in this kind of like, this is information you get to choose, like this will be, you know, just something we discuss, but we're not going to force you into anything is a lot different than being told at 38 weeks. Well, we have to schedule your induction next week and then kind of being given threatening language. If you don't very different conversations, I can imagine it would be much less stressful if it's just presented as an option that we'd like to talk about, but you don't have to do, you know, make any decision right now. So that's a good point. And then Kari, one last question I have for you. One of the things we're also hearing from around the United States, well, first of all, doulas are telling us that the majority of their clients are now being induced. It is not, you know, a minority thing anymore. It seems to be more and more with the arrive trial, elective induction, especially in obstetrician practices, but even in midwifery practices, sometimes there's pressure to induce by 40 weeks. Often it's not presented as an elective induction. It's presented as a medically necessary induction, even though it might not be. They might just say, well, we're really concerned about the size of your baby or we're really concerned about your risk of stillbirth, even though there isn't, you know, any, it's almost like presented to the parents as really medically necessary for your safety. And then they find out later that maybe it was coded as an elective induction. You know, it's like being framed as not elective. So what thoughts do you have for our listeners about like how to handle those kinds of situations? Yeah, it sounds so hard. It's a really different climate than it was years ago. And I mean, I know that our induction rates nationally are close to 40%. And so this is certainly something that's happening. And I guess for listeners, I would just really tell them to go and get this tool and try to use it with their provider as well. So although we've designed this for patients and providers, I don't want patients to feel like it has to come from their provider. They can bring this in and use this as a tool to help facilitate some of these conversations. I think it's important to talk to providers around what the guidelines are within their institution that are encouraging the recommendations that they're talking about. And this is where things get complex, right? Because some institutions are going to follow or track more closely to recommendations from ACOG versus others who might be recommending things like induction for a large baby. But I want pregnant people out there to really feel empowered to ask these questions and kind of get underneath it to say, well, why is this recommended? Can you tell me more? I need to understand this. Is there actual risk? What are the risks? You know, here's a tool. Do you think these are my risks? Is there something else that I'm not aware of? And so I like that and asking for the actual professional guidelines, you know, for you to review, because sometimes they might be saying something that's actually not recommended, or if you look at the guidelines for their organization, it might say this is an option, but it's not, you know, it shouldn't be required of patients. Right. So definitely, like you said, just kind of digging into it to find out really what are the medical reasons? Are they legitimate? Yeah, or is this truly just a routine induction, elective induction? Mm hmm. Right. For sure. Karian and thank you so much for coming on the podcast to share your stories and your work that you've been doing. Can you just tell us a little bit about, you know, the best way to access the tool, any features that people can access and any future plans you have for a partner to decide? Absolutely. So the induction of labor decision aid is free and open access. And currently in seven languages working on an eighth, you can go to www.inductiondecisionaid.org or www.partner-to-decide.org and sort of get there through our website. The inductiondecisionaid.org will take you right to the web based version. You can find the paper static version, the sort of PDF version in the bottom right hand corner and all of those languages. And you'll find that information about the different choices. You can go to my values to do that quiz to think about what you care most about on at the bottom of that or in the insert of the paper version. There are some suggested questions you might want to ask your provider that really vary by provider and healthcare setting. And so our good things to ask that we couldn't answer sort of unilaterally for everyone. And I would say also we are working on additional decision aids right now. So we're working on one for vaginal birth after caesarean and another one on birth preferences. Doing similar methods and ways of operating as before really focused on making sure that everyone can have access to that kind of information. And because we are a nonprofit and do offer all of our tools for free, I do encourage you if you can or are able to please do consider donating if you love our tools and are using our tools or want to support the new ones. And we really appreciate any support anyone can provide. That's awesome. And I love people can order laminated copies, which seems like it would be perfect for clinical office or even like a dual bag where you could pull out the laminated copies for, you know, so people can have all the statistics at their fingertips on the different benefits and risks of their options. So thank you, Kari and Anne again for taking on this project and sharing your wisdom with the world. Thanks so much for having us, Rebecca. Thanks for having us. Today's podcast was brought to you by the Evidence-Based Birth Professional Membership. The free articles and podcasts we provide to the public are supported by our Professional Membership Program at Evidence-Based Birth. Our members are professionals in the childbirth field who are committed to being change agents in their community. Professional members at EBB get access to continuing education courses with up to 23 contact hours, live monthly training sessions, an exclusive library of printer-friendly PDFs to share with your clients, and a supportive community for asking questions and sharing challenges, struggles, and success stories. We offer monthly and annual plans, as well as scholarships for students and for people of color. To learn more, visit ebberth.com.