Authors: Grace Lim et al
Cesarean delivery is the most common surgery in the world and accounts for 32% of births in the United States. Although neuraxial techniques are preferred, many patients report intraoperative discomfort or emotional trauma. These experiences can contribute to known associations between birth experiences and risk for post-traumatic stress disorder (PTSD), anxiety, and depression postpartum. Current clinical workflows often lack structured tools to support patient-centered decision-making, which can lead to inadequate or poorly timed counseling, miscommunication, mismatched expectations, and heightened perceptions of pain or discomfort when anesthesia plans do not align with patient understanding or preferences.
The lack of consistent, patient-centered anesthesiology education and counseling underscores the need to develop effective communication tools as a core element of high-quality obstetric anesthesia care. This prioritization is not only to uphold high-quality clinical care, but also because positive childbirth experiences are beneficial to the health system for several non-clinically centered reasons. First, hospital reimbursement is increasingly tied to patient experience, which influences how the anesthesia care team is perceived within the institution. Also, hospitals desire to provide obstetric care services, because they serve as a gateway to future healthcare interactions, including pediatric care and subsequent surgical and women’s health services. Finally, women make 80% of household health care spending decisions, playing a central role in recommending hospitals and influencing healthcare utilization within their communities. For these reasons, anesthesia care professionals across all practice settings have a vested interest in ensuring that obstetric anesthesia care for cesarean delivery is patient-centered, evidence-based, and aligned with broader institutional goals for quality and patient satisfaction.
The Elevating Anesthesia Choices for Cesarean Delivery (ELEVATE) Project aimed to identify barriers, facilitators, and evidence gaps in delivering patient-centered anesthesia care. Stakeholders included patients, clinicians, professional societies, health systems, payers, and policymakers. The project’s primary objective was to define and prioritize patient-centered outcomes related to anesthesia care, to inform a framework for future comparative effectiveness research. The Project aimed to define a research and quality improvement agenda that prioritizes patient preferences, safety, and clinical outcomes. Stakeholders collaborated to identify key barriers, facilitators, and strategies to improve anesthesia care choices for cesarean delivery.
The purpose of this article is to summarize ELEVATE’s key findings, including evidence gaps and suggested structural changes needed to optimize patient-centered decision-making in cesarean anesthesia care. A comprehensive report of the ELEVATE Project and all project collaborators is available in the Supplemental Material, https://links.lww.com/AA/F717.
ELEVATE PROJECT METHODOLOGIES
Stakeholder Engagement and Convening Process
Stakeholders for The ELEVATE Project were identified through purposive sampling based on their roles in patient care, policy, advocacy, and research related to cesarean delivery. Professional society representatives were nominated by their organizations; patients and advocates were recruited through community networks and maternal health coalitions.
ELEVATE Stakeholders represented a range of perspectives and expertise to ensure that proposed solutions addressed the needs of both patients and providers. Patients and advocates, including doulas, childbirth educators, and community organizations, provided input grounded in lived experience. They highlighted barriers in communication, limited access to high-quality anesthesia care information, and concerns around autonomy during cesarean delivery, as well as the long-term consequences of surgical and anesthesia care-related complications on maternal physical health, mental health, and well-being. Their contributions ensured that identified research priorities and policy recommendations reflected the issues most important to patients. These individuals are included as coauthors or contributors.
Healthcare providers included representatives from the disciplines of anesthesiology (including individuals practicing in private and community practices and academic settings), obstetrics, midwifery, and nursing. These participants offered clinical perspectives on existing practices, workflow constraints, and variations in anesthesia care across different hospital settings. Representatives from professional societies, including the American Society of Anesthesiologists (ASA), the Society for Obstetric Anesthesia and Perinatology (SOAP), the American College of Obstetricians and Gynecologists (ACOG), Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), and the American College of Nurse Midwives (ACNM), provided context on existing guidelines and professional standards relevant to cesarean anesthesia care. This interdisciplinary input supported alignment with best practices.
Policymakers, including the Pennsylvania Secretary of Human Services, representatives from the Centers for Medicare & Medicaid Services (CMS, United States), the Pennsylvania Perinatal Quality Collaborative, other quality improvement experts, payers, and health system leaders participated in the ELEVATE convening to provide insight into policy barriers, quality improvement opportunities, reimbursement considerations, and the operational realities of implementing patient-centered anesthesia care practices across diverse care settings. Although many participants were from Pennsylvania due to stakeholder roots in the Pennsylvania Perinatal Quality Collaborative, stakeholders were drawn from national organizations and health systems to ensure broad relevance.
Researchers and policy experts with expertise in maternal health, anesthesia care, and comparative effectiveness research contributed to the development of a research agenda focused on addressing evidence gaps related to anesthesia care choices, patient outcomes, and provider communications. Health system leaders and healthcare payer representatives, including individuals from Medicaid and private insurers, participated in all activities to provide additional context regarding financial and structural barriers to implementing prenatal anesthesia care consultations and other patient-centered strategies.
The stakeholder engagement process was designed to facilitate discussion, identify areas of alignment, and clarify where perspectives differed. Project staff conducted semi-structured interviews with patients, clinicians, and policy participants. The process began with individual semi-structured interviews and open-ended surveys, which were transcribed and subjected to qualitative content analysis to identify key themes and commonly cited constructs related to patient-centered anesthesia care choice, perceived research gaps, and priority outcomes. These constructs informed the development of a structured follow-up survey, which was distributed to all participants to quantify priorities and assess areas of consensus. Survey responses were used to refine the agenda and identify high-priority discussion topics for the convening. During the convening, participants took part in facilitated large-group discussions to review preliminary findings and identify key challenges and opportunities. Small breakout groups allowed participants to focus on specific issues, including the role of prenatal anesthesia care consultations, approaches to shared decision-making, and strategies to improve communication between patients and anesthesia care teams. The summit concluded with consensus-building exercises to define shared priorities for research, clinical practice, and policy. The ELEVATE Project ran from June 2024 through June 2025, and the in-person summit was held over two days in January 2025 at the University of Pittsburgh in Pittsburgh, Pennsylvania, USA.
KEY FINDINGS
Patient-Centered Outcomes
The a priori objective of the ELEVATE Project was to define and prioritize patient-centered outcomes for cesarean anesthesia care. Stakeholders consistently identified sense of control, effective pain management, emotional well-being, and clear, respectful communication as top priorities (Figure 1). Although providers often emphasized clinical outcomes such as pain scores or complication rates, patients stressed that autonomy, being heard, and having their preferences respected were equally important to their overall birth experience. This divergence highlights the need to evaluate anesthesia care not only on technical success, but also on how well it supports patients’ values and emotional needs. Sense of control, in particular, emerged as a central outcome across discussions, reflecting the importance of patient involvement even in urgent or unexpected deliveries.
Figure 1.
Stakeholder ratings of barriers to patient-centered cesarean anesthesia care. This figure shows ELEVATE stakeholder assessments of barriers most critical to address for improving patient outcomes (n = 42). The y-axis and x-axis represent average points allocated (out of 100) by survey respondents indicating magnitude of impact (y-axis) and significance (x-axis). Higher values on the x-axis indicate barriers perceived as more significant, while higher values on the y-axis indicate barriers perceived as more impactful.
Table 1.
Barriers to Optimizing Anesthesia Care and Patient-Centered Choice for Cesarean Delivery
| Barrier | Description |
|---|---|
| Limited prenatal counseling opportunities,, | Patients often do not meet anesthesiology teams before the day of delivery, reducing time to elicit preferences and provide tailored information. |
| Clinical urgency and time pressure | Emergent or unplanned cesarean deliveries limit the ability to engage in shared decision-making, due to immediate clinical needs. |
| Competing demands on labor and delivery units | Anesthesia teams often balance high caseloads, rapid turnover, and on-call emergencies, reducing available time for extended patient interaction. |
| Staffing variability and provider familiarity, | Inconsistent provider assignment and differences in familiarity with specific neuraxial techniques may limit anesthesia options. |
| Resource constraints, | Lack of access to certain medications, monitoring tools, or anesthesia modalities in some settings restricts clinical options. |
| Documentation and communication gaps,, | Patient preferences, prior experiences, or contraindications may not be captured or communicated across care episodes or between institutions. |
| Conflicting clinical priorities in obstetric care | Obstetric and anesthesia teams may have differing perspectives on optimal timing or approach for anesthesia care, especially under pressure. |
| Patient anxiety or limited health literacy, | Fear, uncertainty, or limited understanding of anesthetic techniques may hinder patient engagement or informed decision-making. |
| Inadequate institutional support for innovation, | Lack of structured pathways for prenatal anesthesia care team engagement or patient education tools may reflect systemic inertia. |
Emotional well-being, including the prevention of trauma associated with loss of control or poor communication, was also identified as a key outcome. Stakeholders agreed that meaningful progress in improving anesthesia care for cesarean delivery requires routine measurement of these patient-centered outcomes alongside traditional clinical indicators. The importance of providing psychological support for obstetric patients has been highlighted by some professional societies. Incorporating patient-reported experiences into quality improvement initiatives and research efforts will ensure that anesthesia care is evaluated not only for technical success, but also for how well it aligns with the preferences, values, and emotional needs of the patients receiving care.
Barriers to Patient-Centered Anesthesia Choice
Stakeholders identified a range of barriers that limit the ability to offer patient-centered anesthesia care choices for cesarean delivery. These barriers exist at the system level, the delivery unit level, the provider level, and the patient level, each contributing to the disconnect between available anesthesia care options and the patient’s ability to make informed decisions about their care (Table 1). Importantly, stakeholders emphasized the need for anesthesiology education and planning for all pregnant individuals, not just those with scheduled cesarean deliveries. Even for those planning vaginal birth, unplanned cesarean delivery remains common, warranting proactive counseling.
Lack of Prenatal Information
One key barrier is the absence of a standardized process and funding for prenatal anesthesia care consultation. National policies and institutional protocols in France endorse standardized prenatal anesthesia care consultations, particularly in the context of general obstetric anesthesia care and pain management planning., Most patients in the United States do not have the opportunity to meet with an anesthesia provider before the day of delivery, and many receive only a brief consultation immediately before the induction of anesthesia. As a result, anesthesia care education occurs either late in the process or not at all, leaving patients with little time to ask questions, express preferences, or fully consider the risks and benefits of different anesthesia care approaches. Indeed, most patient education about anesthesia care occurs during prenatal education classes, where the focus is on labor, vaginal birth, and breastfeeding. When patients are offered anesthesia care education only at the time of delivery, the focus is often limited to the immediate clinical situation. For patients admitted for labor with anticipated vaginal delivery, it is unusual to offer an expansive discussion of anesthetic options for cesarean delivery.
Inconsistent Provider Communication
Variability in provider communication further limits patients’ ability to make informed anesthesia care decisions. Stakeholders described a wide variation in how anesthesia care options are presented, how risks and benefits are explained, and how much time is allocated for these conversations. Some providers offer detailed, balanced explanations of the different techniques available, along with contingency planning for various modes of delivery, while others present a single preferred option with little discussion of alternatives. This inconsistency means that a patient’s experience and level of informed decision-making may depend as much on the individual anesthesia provider’s communication content and style as on the patient’s preferences or clinical situation.
Limited Rural Access
Limited access to anesthesia providers in rural and smaller hospitals presents another barrier to patient-centered anesthesia care. In most settings, anesthesia care is provided by generalist anesthesiologists or nurse anesthetists whose primary experience and responsibilities lie outside the labor and delivery unit. Anesthesia providers and stakeholders recognized that while offering choice aligns with patient-centered care, it must be balanced with safety, feasibility, and existing clinical standards. In rural and smaller facilities, patients may have fewer anesthesia care options presented to them, and certain neuraxial approaches, such as the combined spinal-epidural technique, may be unavailable in some facilities due to staffing or training limitations., In some cases, generalist providers may default to the technique they are most comfortable with – supporting safety considerations – regardless of patient preferences.
Misinformation
Inaccurate information, particularly through social media and non-clinical sources, also complicates efforts to offer patient-centered anesthesia care choices. Many patients rely on information obtained from online communities, blogs, and social networks rather than from their clinical care team. While some of this information is accurate, much of it is incomplete or misleading, which contributes to confusion or unrealistic expectations about anesthesia care risks, benefits, and expected experiences. In pregnancy and early labor, patients are typically focused on their intended vaginal delivery, and therefore both patients and providers may be hesitant to engage in discussions about potential cesarean delivery anesthesia care options. Patients who arrive at the hospital with inaccurate information may have difficulty processing new or conflicting information provided by the anesthesia care team, particularly in a time-sensitive environment. In the case of unplanned cesarean delivery, the priority for shared decision-making centers on the mode of delivery, which frequently depletes patients’ bandwidth for a comprehensive discussion of anesthetic options. Stakeholders highlighted that opportunities for counseling and consent differ markedly between elective and urgent cesarean deliveries, with elective procedures allowing more time for information-sharing, preference elicitation, and expectation management.
Figure 2.
Stakeholder prioritization of patient-centered outcomes for cesarean anesthesia care. This figure depicts how stakeholders (n = 42) ranked six outcomes for evaluating anesthesia care during cesarean delivery in response to the question, “Which patient outcomes are most important to consider in researching cesarean delivery anesthesia care?” The y-axis lists the outcomes that respondents ranked (sense of control and autonomy, pain management and satisfaction, emotional and psychological well-being, neonatal outcomes, long-term health and quality of life, and patient satisfaction). The x-axis represents the count of responses assigning each outcome a rank from 1 (highest priority) through 7 (lowest priority). Each horizontal bar is subdivided into colored segments corresponding to rank order as indicated in the figure key.
Table 2.
Summary of Key Recommendations from the ELEVATE Project
| Recommendation domain | Key actions or priorities |
|---|---|
| Patient-centered outcomes | Measure and incorporate patient-reported experiences such as sense of control, emotional well-being, and communication quality into care evaluation. |
| Barriers to address | Improve consistency in counseling, reduce misinformation, address urgency/time constraints, and align provider communication styles. |
| Facilitators | Explore telehealth-based prenatal counseling, improve written and multimedia decision aids, adopt empathetic communication frameworks. |
| Policy & research gaps | Study the impact of prenatal consultations and adjuvants on outcomes; incentivize counseling reimbursement; create quality metrics tied to patient experience. |
Collectively, these barriers reduce the likelihood that patients will receive consistent, accurate, and timely information about their anesthesia care options. They also contribute to variability in how decisions are made, with some patients having limited involvement in the process and others receiving more robust counseling. Addressing these barriers will require both structural changes to improve the availability and quality of prenatal anesthesiology education and improved provider communication skills to ensure that patient preferences and clinical realities are both appropriately considered (Figure 2).
Facilitators for Supporting Patient-Centered Choice
Structural Solutions
Expanding access to prenatal anesthesia care consultations was a recurring theme throughout the discussions. Ensuring that patients have an opportunity to discuss anesthesia care options before labor allows for a more informed decision-making process. When patients receive anesthesiology education only at the time of delivery, they may be under stress or have limited time to process information, leading to decisions that are based more on urgency than on true preference. Establishing routine prenatal anesthesia care consultations would allow for structured conversations that address patient concerns, clarify misconceptions, and ensure that patients understand their options in advance. Resource constraints pose a challenge to universal implementation, but stakeholders proposed scalable solutions such as group telehealth consultations or integration into routine prenatal visits. These represent future directions for testing feasibility and effectiveness.
Communication Tools
Standardizing provider communication was also identified as a key facilitator in improving patient-centered care. Stakeholders described a wide variation in how anesthesia care options are presented and how risks and benefits are discussed. Adopting an empathetic framework for communication would help ensure consistency in how information is conveyed. Strategies such as the “Name, Understand, Respect, Support, Explore” or NURSE framework, which emphasizes naming, understanding, respecting, supporting, and exploring patient concerns, can be incorporated into anesthesia care counseling to improve trust and relationship-building in provider-patient interactions. Standardized communication approaches would not only help patients feel heard and engaged in the decision-making process, but it will also improve the clarity of information shared, including medical pieces of information such as cesarean delivery scenarios, likelihood, and anesthetic options available for each.
Leveraging Telehealth Access
Telehealth was identified as a potential solution to improve access to prenatal anesthesia care consultations for all patients, and particularly in rural and underserved areas. Virtual prenatal consultations could allow patients to receive counseling on anesthesia care options from an anesthesia provider even if one is not physically present at their hospital., Although this approach can help address regional disparities in access to anesthesiology education, it is important to acknowledge that certain techniques, medications, or resources discussed may not be available in all delivery settings, particularly in rural or smaller hospitals.
Enhancing Patient Decision Aids
Improving patient decision aids was also seen as a critical step in supporting informed choice. Many patients arrive in the Labor and Delivery unit with misinformation obtained from non-clinical sources, particularly from social media. Standardized, evidence-based patient educational materials tailored to different cultural and linguistic backgrounds would help address gaps in knowledge and reduce the influence of misinformation. Decision aids that are accessible, clearly written, and visually informative could help patients better understand the differences between labor analgesia techniques, options for cesarean anesthesia care, potential risks and benefits, and what to expect during and after the procedure. Ensuring that these materials are widely available in both digital and print formats would improve patient access to reliable information.
Multimodal Strategies
Together, these facilitators highlight that improving patient-centered anesthesia care will require coordinated rather than isolated solutions. Expanding access to prenatal consultations, standardizing provider communication, leveraging telehealth, and enhancing decision aids each address different gaps, but in combination they create a more comprehensive approach to improving patient understanding, engagement, and decision-making. Framing these strategies as a multimodal package underscores their complementary and synergistic potential and offers a clear path forward for scalable and most effective implementation.
Policy and Research Gaps
Prenatal Consultation Research
Stakeholders identified several research and policy gaps that limit the ability to deliver patient-centered anesthesia care for cesarean delivery. A key priority is the need for comparative effectiveness research focused on the impact of prenatal anesthesia care consultations on clinical outcomes and patient experience. These consultations, especially when conducted well before delivery, provide an opportunity for patients to better understand their options, express preferences, and ask questions outside the time pressures of labor. However, limited evidence exists on their effect on outcomes such as sense of control, trust in the care team, and satisfaction with the birth experience. Research is needed to evaluate different consultation models — varying in timing, content, and provider type — to determine which best support patient-centered outcomes across diverse delivery settings.
Adjunctive Medication Use
There is also a need for research examining the role of adjunctive medications in improving intraoperative comfort during cesarean delivery. Although neuraxial anesthesia remains the preferred choice and is used in 95% of cesarean deliveries, patients continue to report intraoperative discomfort and emotional distress even when these techniques are used appropriately. Adjunctive medications, including anxiolytics and low-dose intravenous analgesics, may improve patient experience, but their use is highly variable and often guided more by individual provider practice than by evidence-based protocols. Using anxiolysis and light sedation may be reframed as compassionate care, rather than as a failure of neuraxial technique. Comparative effectiveness research could help clarify which adjunctive approaches are safe, effective, and acceptable to patients, particularly in the context of patient preferences for maintaining awareness and involvement during delivery.
Communication Strategy Research
Another priority for research is the development and evaluation of patient-centered communication strategies within the clinical setting. While multiple frameworks exist to guide provider communication, few have been formally evaluated in the context of cesarean delivery anesthesia care. Examples include plain-language scripting, teach-back methods, and decision aids co-designed with patients., Research is needed to identify which communication strategies improve patient understanding, enhance trust, and promote shared decision-making in both prenatal and intrapartum settings. In addition to assessing their impact on patient experience, research should also evaluate the feasibility of incorporating these strategies into existing workflows, particularly in busy labor and delivery units.
Reimbursement Policy Reform
In addition to research priorities, stakeholders identified several policy strategies to support patient-centered anesthesia care. Reimbursement for prenatal anesthesia care consultations, as discussed above, emerged as a critical enabler, particularly for health systems and practices serving Medicaid populations. Many payers do not currently reimburse for prenatal consultations outside of high-risk settings, limiting the financial feasibility of offering these services routinely. Policy changes that support reimbursement for prenatal consultations would remove a structural barrier and create an incentive for hospitals and providers to adopt this practice. Sustainable implementation will require payment reform and policy support.
Rural Care Standards
Standardizing best practices for anesthesia care in rural and community hospitals was also identified as an important policy priority. In many smaller facilities, anesthesia care for cesarean delivery is provided by generalist anesthesiologists or certified registered nurse anesthetists who are not necessarily dedicated to the labor and delivery unit. These providers may not have the same continuing education opportunities or clinical resources as providers in larger centers with dedicated obstetric anesthesia care teams led by fellowship-trained obstetric anesthesiologists. More evidence is needed to understand how to optimally adapt and implement evidenced-based obstetric anesthesia care protocols (eg, scheduled epidural analgesia rounding and block optimization techniques) to environments where the delivery volume is too low to support a dedicated obstetric anesthesia care team. Standardizing best practices for the management of labor epidurals is important because the quality and functionality of the epidural catheter often determine the anesthetic approach and patient experience during an unplanned cesarean delivery. In addition, further research is needed to test whether telehealth services could provide contextually relevant patient counseling that is useful to both patients and clinicians alike. These efforts would help ensure that patients in rural and community hospitals receive consistent, high-quality anesthesia care.
Patient Experience and Equity Metrics
Finally, stakeholders recommended the development of quality metrics that capture the patient experience of cesarean delivery anesthesia care. Current quality measures focus primarily on clinical outcomes such as anesthesia care-related complications, but they do not account for patient-reported outcomes related to communication, sense of control, or emotional well-being. In this context, “quality measures” refers to formal hospital and health-system Quality metrics (eg, reporting and accountability measures. Developing and incorporating patient-centered metrics into hospital quality reporting programs would elevate the importance of these outcomes, encourage hospitals to invest in strategies that improve the patient experience, and provide meaningful data for quality improvement efforts. These policies and research strategies, taken together, would support the broader goal of ensuring that anesthesia care for cesarean delivery reflects both clinical best practices and the preferences and priorities of the patients receiving care.
CONCLUSIONS
The ELEVATE Project provides a comprehensive roadmap for advancing patient-centered anesthesia care during cesarean delivery. Stakeholders emphasized that a patient’s sense of control, trust in their healthcare team, and effective communication are just as critical as clinical pain management in determining the quality of care. To improve alignment between patient values and anesthesia care, key recommendations include expanding structured prenatal counseling, standardizing communication strategies, supporting decision aids, and addressing research and policy gaps. Together, these priorities highlight the importance of integrating both clinical and experiential outcomes into decision-making to enhance patient experience and clinical results. A summary of core findings and actions is provided in Table 2.
DISCLOSURES
Conflicts of Interest: GL receives salary and research support from NIH UH3CA261067, NIH R01MH134538, Patient-Centered Outcomes Research Institute (PCORI) EASCS-34606, and receives research support, consulting honoraria, and chairs or is member of advisory board from industry: Octapharma, Heron Pharmaceuticals, Edwards Lifesciences, Haemonetics; she also receives stipends for medical expert testimony not related to this publication and royalties from Cambridge University Press for a textbook; she is a member of the SOAP board of directors and a consultant reviewer for ACOG and ASA liaison to the ACOG Alliance for Innovation on Maternal Health’s (AIM) Clinical and Community Advisory Group. JM is section editor for Obstetric Anesthesia at Anesthesia & Analgesia, and she did not handle this manuscript. KC is Vice President for Nursing Practice at AWHONN. EMcG sits on the Board of Directors for ACNM. HN is past President of SOAP and sits on Board of Directors Anesthesia Patient Safety Foundation (APSF). FP is a representative of ACOG. MZ is Chair of the Committee on Obstetric Anesthesia at the ASA. Funding: ELEVATE was supported by the Department of Anesthesiology and Perioperative Medicine at the University of Pittsburgh. ELEVATE Project was funded through a Patient-Centered Outcomes Research Institute (PCORI) Eugene Washington PCORI Engagement Award, EASCS-34606. This manuscript was handled by: Ashraf S. Habib, MBBCh, MSc, MHSc, FRCA.
ACKNOWLEDGEMENTS
We are grateful and indebted to Jasmin Brown, Marja Fox, Christine Heiner, and Andrey Romanov for their invaluable contributions to the success of the ELEVATE Project. Their diligent work and insights were instrumental in shaping the project’s direction and ensuring its outcomes reflect the highest standards.
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