When neutrality misleads: shared decision-making and professional responsibility in perinatal medicine

Shared decision-making pervades perinatal practice, invoked in counseling about prenatal screening, trial of labor after cesarean delivery, vaccination in pregnancy, and place and mode of birth, as though its meaning were settled. It is not. The literature contains several distinct and partly incompatible models of the clinical encounter, and the definitions issued by authoritative bodies, from the American College of Obstetricians and Gynecologists (ACOG) to the Centers for Disease Control and Prevention (CDC), disagree among themselves. From this ambiguity two errors follow: shared decision-making is equated with clinician neutrality, the presentation of options without a recommendation, and it is treated as a substitute for informed consent rather than one element within it. We argue, first, that the term should never appear in obstetric guidelines or consent processes without a stipulated definition naming the model intended and whether a recommendation is permitted; and second, that the appropriate counseling posture depends on the clinical situation. Neutrality is owed when a perinatal decision is preference-sensitive, as in abortion counseling, trial of labor after cesarean, or aneuploidy screening. Neutrality is inappropriate when the evidence clearly favors one course, as in vaccination in pregnancy or low-dose aspirin prophylaxis for preeclampsia, because presenting non-equipoise as equipoise misinforms the woman and can leave two patients unprotected. We examine the 2025 reclassification of US COVID-19 vaccination recommendations in pregnancy as a cautionary case.