HOW DO WOMEN VALUE TRADE-OFFS IN MATERNAL-FETAL MORBIDITY AND MORTALITY?

Purpose: To calculate utilities to assess women's willingness to trade-off maternal morbidity for fetal benefit among a community-based sample of pregnant and non-pregnant women of reproductive age.

Method: We recruited English-speaking women aged 18-45 in clinical settings and at community-based events. Eight health states were selected for the study: 4 maternal (healthy, stroke, hysterectomy, death) and 4 neonatal (healthy, severe cerebral palsy (CP), severe mental retardation (MR), death).  Each participant's utilities were assessed on 9 pairs of ‘mom/baby' delivery outcomes comprised of maternal and neonatal health and death plus 1 randomly selected maternal and neonatal outcome (stroke or hysterectomy, CP or MR).  Participants ranked the 9 pairs of outcomes in order of preference; then Standard Gamble methods were used to measure utilities. 

Results: Utilities were assessed in a total of 485 participants (a recruitment rate of 85%). Twenty-one percent were pregnant; 63% were parents; and 54% were African American.  Twenty-seven percent ranked at least one health state pairing as worse than ‘mom death/baby death.' These were excluded from the analysis. Utilities (depicted in Table) only differed significantly between pregnant and non-pregnant women for ‘mom healthy/baby death' (0.62 vs 0.54, p=.04).

 

Mom	Baby	Mean
Healthy	Healthy	1.00
Hyst	Healthy	0.86
Healthy	CP	0.83
Healthy	MR	0.79
Hyst	CP	0.78
Stroke	Healthy	0.75
Hyst	MR	0.74
Death	Healthy	0.72
Stroke	CP	0.67
Stroke	MR	0.67
Death	CP	0.55
Healthy	Death	0.54
Death	MR	0.53
Stroke	Death	0.45
Hyst	Death	0.45
Death	Death	0.00

Conclusion: When women were asked to valuate pairs of maternal/fetal outcomes that required a trade-off of morbidity and mortality, they tended to assign greatest value to conditions that limited maternal morbidity and lowest value to conditions that resulted in neonatal mortality.  These findings have clinical implications in that they highlight the importance of assessing individual patient's preferences and goals of care for high-risk obstetrical conditions wherein pregnancy prolongation threatens maternal morbidity or mortality (e.g. severe preeclampsia or preterm premature rupture of membranes).  Furthermore, as efforts to determine the optimal timing and mode of delivery in high-risk settings may best be achieved using decision analyses and comparative effectiveness models, our findings can aid future research efforts.  Utilities assessed among reproductive-aged women should be utilized to inform the practice and policy surrounding obstetrical decision-making.