The Mother's Autonomy in Decision Making (MADM) scale: Patient-led development and psychometric testing of a new instrument to evaluate experience of maternity care

PLoS One. 2017 Feb 23;12(2):e0171804. doi: 10.1371/journal.pone.0171804. eCollection 2017.


Objective: To develop and validate a new instrument that assesses women's autonomy and role in decision making during maternity care.

Design: Through a community-based participatory research process, service users designed, content validated, and administered a cross-sectional quantitative survey, including 31 items on the experience of decision-making.

Setting and participants: Pregnancy experiences (n = 2514) were reported by 1672 women who saw a single type of primary maternity care provider in British Columbia. They described care by a midwife, family physician or obstetrician during 1, 2 or 3 maternity care cycles. We conducted psychometric testing in three separate samples.

Main outcome measures: We assessed reliability, item-to-total correlations, and the factor structure of the The Mothers' Autonomy in Decision Making (MADM) scale. We report MADM scores by care provider type, length of prenatal appointments, preferences for role in decision-making, and satisfaction with experience of decision-making.

Results: The MADM scale measures a single construct: autonomy in decision-making during maternity care. Cronbach alphas for the scale exceeded 0.90 for all samples and all provider groups. All item-to-total correlations were replicable across three samples and exceeded 0.7. Eigenvalue and scree plots exhibited a clear 90-degree angle, and factor analysis generated a one factor scale. MADM median scores were highest among women who were cared for by midwives, and 10 or more points lower for those who saw physicians. Increased time for prenatal appointments was associated with higher scale scores, and there were significant differences between providers with respect to average time spent in prenatal appointments. Midwifery care was associated with higher MADM scores, even during short prenatal appointments (<15 minutes). Among women who preferred to lead decisions around their care (90.8%), and who were dissatisfied with their experience of decision making, MADM scores were very low (median 14). Women with physician carers were consistently more likely to report dissatisfaction with their involvement in decision making.

Discussion: The Mothers Autonomy in Decision Making (MADM) scale is a reliable instrument for assessment of the experience of decision making during maternity care. This new scale was developed and content validated by community members representing various populations of childbearing women in BC including women from vulnerable populations. MADM measures women's ability to lead decision making, whether they are given enough time to consider their options, and whether their choices are respected. Women who experienced midwifery care reported greater autonomy than women under physician care, when engaging in decision-making around maternity care options. Differences in models of care, professional education, regulatory standards, and compensation for prenatal visits between midwives and physicians likely affect the time available for these discussions and prioritization of a shared decision making process.

Conclusion: The MADM scale reflects person-driven priorities, and reliably assesses interactions with maternity providers related to a person's ability to lead decision-making over the course of maternity care.

MeSH terms

  • British Columbia
  • Decision Making
  • Female
  • Humans
  • Maternal Health Services*
  • Midwifery
  • Mothers
  • Obstetrics
  • Patient Participation*
  • Patient Satisfaction
  • Physicians, Family
  • Prenatal Care*
  • Psychometrics

Grant support

1. Vancouver Foundation (NPO) This work was partially supported by operating grant #UNR12-0701 for the provincial community based participatory Changing Childbirth in BC study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.