title: Development of a support tool for complex decision-making in the provision of rural maternity care.
abstract: BACKGROUND
  Decisions in the organization of safe and effective rural maternity care are complex, difficult, value laden and fraught with uncertainty, and must often be based on imperfect information. Decision analysis offers tools for addressing these complexities in order to help decision-makers determine the best use of resources and to appreciate the downstream effects of their decisions.
  
  
  OBJECTIVE
  To develop a maternity care decision-making tool for the British Columbia Northern Health Authority (NH) for use in low birth volume settings.
  
  
  METHODS
  Based on interviews with community members, providers, recipients and decision-makers, and employing a formal decision analysis approach, we sought to clarify the influences affecting rural maternity care and develop a process to generate a set of value-focused objectives for use in designing and evaluating rural maternity care alternatives.
  
  
  METHODS
  Four low-volume communities with variable resources (with and without on-site births, with or without caesarean section capability) were chosen.
  
  
  METHODS
  Physicians (20), nurses (18), midwives and maternity support service providers (4), local business leaders, economic development officials and elected officials (12), First Nations (women [pregnant and non-pregnant], chiefs and band members) (40), social workers (3), pregnant women (2) and NH decision-makers/administrators (17).
  
  
  RESULTS
  We developed a Decision Support Manual to assist with assessing community needs and values, context for decision-making, capacity of the health authority or healthcare providers, identification of key objectives for decision-making, developing alternatives for care, and a process for making trade-offs and balancing multiple objectives. The manual was deemed an effective tool for the purpose by the client, NH.
  
  
  CONCLUSIONS
  Beyond assisting the decision-making process itself, the methodology provides a transparent communication tool to assist in making difficult decisions. While the manual was specifically intended to deal with rural maternity issues, the NH decision-makers feel the method can be easily adapted to assist decision-making in other contexts in medicine where there are conflicting objectives, values and opinions. Decisions on the location of new facilities or infrastructure, or enhancing or altering services such as surgical or palliative care, would be examples of complex decisions that might benefit from this methodology.
authors.affiliation: Senior Policy and Decision Analyst, Compass Resource Management, Vancouver, BC.
authors.forename: Glen
authors.initials: G
authors.lastname: Hearns
authors.forename: Michael C
authors.initials: MC
authors.lastname: Klein
authors.forename: William
authors.initials: W
authors.lastname: Trousdale
authors.forename: Catherine
authors.initials: C
authors.lastname: Ulrich
authors.forename: David
authors.initials: D
authors.lastname: Butcher
authors.forename: Christiana
authors.initials: C
authors.lastname: Miewald
authors.forename: Ronald
authors.initials: R
authors.lastname: Lindstrom
authors.forename: Sahba
authors.initials: S
authors.lastname: Eftekhary
authors.forename: Jessica
authors.initials: J
authors.lastname: Rosinski
authors.forename: Oralia
authors.initials: O
authors.lastname: Gómez-Ramírez
authors.forename: Andrea
authors.initials: A
authors.lastname: Procyk