What Is the BRAINS Decision Making Tool?

BRAINS is a decision making tool that stands for benefits, risks, alternatives, intuition, nothing, second opinion.

Why Is Informed Decision Making in Pregnancy So Important?

There are so many decisions to be made during pregnancy and birth, it can all feel a bit overwhelming. Some people may find it so overwhelming that they default to ‘going with the flow’ of what their healthcare professional advises them to do. We believe that it is incredibly important for women and birthing people to make the decisions that are right for them – not just because they’ve been told ‘it’s policy’ or ‘it’s in the guidelines’. For some people, following policy and guidelines will feel like the right thing to do and for others it won’t – using BRAIN helps make decisions that are right for you.

You have the legal right to to accept or decline any test or intervention that is offered to you, yet we are still amazed by the amount of people we meet who question if they’re ‘allowed’ to do x, y or z. We wrote about this in our blog post, ‘Am I allowed?’, because you are absolutely allowed to accept or decline any test or intervention that is offered or recommended to you during pregnancy. Power dynamics between healthcare professionals and women can be very unbalanced, so it’s not uncommon that we hear of people being pressured or coerced into accepting the status quo. Birthrights have a wealth of information and fact sheets on their website about your rights during pregnancy and birth – and we will continue to signpost to them again and again. 

The beautiful thing about the BRAIN decision making tool is that it can be applied to pretty much any decision you need to make during pregnancy, birth or in the postnatal period. It can be used for the ‘big’ decisions, the ‘small’ decisions – and everything in between. It can be really helpful to methodically go through to help you reach a decision from a thoughtful place rather than a fearful place. Except in the super rare cases of true ‘life or death’ emergencies, there will usually be time to go through BRAIN before making a decision.

How to Use the BRAIN Tool: A Step-by-Step Guide

To use BRAIN, ask yourself the following questions when faced with a decision:

Benefits – what are the benefits of the test / intervention / procedure?

Risks – what are the risks of the test / intervention / procedure?

Alternatives – are there any alternatives to the test / intervention / procedure?

Intuition – what is your intuition, or your gut saying? 

Nothing – what happens if you do nothing for 1 hour, 1 day, 1 week etc? 

Second opinion - would it help to ask for a second opinion from another person? (e.g. doctor / midwife)

Using BRAIN for a Big Decision: Should I Have an Induction of Labour?

Example decision to be made: having an induction of labour for post dates

Benefits – the NICE guidelines recommend induction of labour for ‘post dates’ between 41- 42 weeks to reduce the rate of stillbirth. It is helpful to know what the rates of stillbirth are for ‘low risk’ women & birthing people, to help you decide if this is a benefit for you.

This research from 2019 by Muglu et al. gives us these figures on the risk of stillbirth at the following gestations for ‘low risk’ women or birthing people who have had uncomplicated pregnancies : 

• 38 weeks 0.12 per 1000, or 1 in 8333
• 39 weeks 0.14 per 1000, or 1 in 7142
• 40 weeks 0.33 per 1000, or 1 in 3030
• 41 weeks 0.80 per 1000, or 1 in 1250
• 42 weeks 0.88 per 1000, or 1 in 1136

Risks – induction of labour for non-medical reasons (postdates is not a medical reason) carries risks for both women and babies – including more likely to need an instrumental assisted birth, a caesarean section, an epidural, experience labour as more painful, babies are more likely to experience asphyxia (reduced oxygen supply) and birth trauma. 

Alternatives – the alternative would be to await spontaneous labour, or to have a caesarean section (although that should prompt another BRAIN analysis!).

Intuition – how do you feel about having an induction of labour? Do you have concerns about your baby’s wellbeing or do you feel confident that they are well? Does it worry you going beyond 41 or 42 weeks of pregnancy? Does it feel, in your gut, like the right choice to make? Or does having the induction, or awaiting events, make you feel anxious? We cannot recommend Sara Wickham’s book, In Your Own Time, for balanced, sensible information about the timing of induction of labour.

Nothing – what happens if you do nothing, but check in again at a later point in pregnancy? Would you reassess at 42 weeks? Would you accept some extra monitoring of the baby’s heartbeat? This would usually be in the form of attending a maternity unit a couple of times a week for a CTG monitoring, although it is important to know that this is not an evidence-based practice, nor has it been shown to improve outcomes.

Going through a decision methodically like this allows you to weigh up the pros and cons – and in this scenario to decide if the increased risk of stillbirth outweighs the risks associated with induction of labour. Only you can decide what level of risk is acceptable to you.

Using BRAIN for a 'Smaller' Decision: Should I Have a Glucose Tolerance Test?

Example decision to be made: having a glucose tolerance test because you have a risk factor for developing gestational diabetes eg a BMI >30

This decision may feel big to some, in our experience most people accept the glucose tolerance test when at their first midwifery booking appointment if they’re told they have a risk factor. We do not feel that it is generally presented as a choice – something for women and birthing people to go away and have a think about. We also do not believe that in-depth discussions are happening about what it means to have the test and what the potential benefits AND risks are.

Benefits – knowing if you have developed gestational diabetes or not may help you make changes to your diet and exercise habits that may be beneficial for your overall health and the health of your baby. If you have recently been diagnosed with gestational diabetes, check out this blog from nutritionist Lily Nichols about managing your diagnosis without fear.

Risks – if you have the test and are found to have gestational diabetes this impacts the care you are offered for the rest of your pregnancy. For example, you will be offered more regular growth scans and will be offered an induction of labour at 40+6 weeks at the latest as per the NICE guidelines (regardless of if your gestational diabetes has been ‘well controlled’ or not). Rachel Reed offers a useful explainer of gestational diabetes and a critique of the screening process and label here.

Alternatives – the alternative to having a glucose tolerance test could be to do home blood glucose monitoring to see how and if what you’re eating affects your blood sugars and then adjust your diet accordingly. It could be keeping an eye on any glucose in your urine at your midwife appointments when they offer to dip your urine and having your bump measured to assess the size of the baby (although this by no means can say how much your baby will weigh at birth, it may indicate if the baby is growing smaller or bigger than expected). It could also be doing nothing and simply declining the test. 

Intuition – what does your gut say about having a glucose tolerance test? Do you feel it would be beneficial and provide you with more knowledge? Will you feel stressed not having one if it’s been recommended? Will you feel stressed if the results are positive for gestational diabetes? Or could this knowledge be empowering? 

Nothing – you may choose to decline the test completely. It is usually offered between 24 – 28+6 weeks of pregnancy, which is worth knowing if you do change your mind. It is also worth remembering that doing nothing at this point does not have to mean doing nothing for your entire pregnancy – you are allowed to change your mind! 

What Else Can You Use the BRAINS Tool For?

Hopefully these examples of using the BRAINS tool have been helpful and remember that this tool can be used for any decision you need to make during pregnancy, birth and the postnatal period. Making decisions that are right for you during your pregnancy can be empowering and contribute to a positive pregnancy, birth and postnatal experience. Your decisions may align entirely with what has been recommended by your healthcare provider or they may differ – either way, using BRAINS helps you figure out what is right for YOU.

See some more examples below, some things you’ll know the answer to straight away and others you’ll need more time to think about:

During pregnancy:

• Bump measurements
• Testing for Group B strep. (GBS)
• Taking aspirin for low PAPP-A

During labour & birth:

• Having IV antibiotics in labour for GBS
• Having your waters broken
• Having an epidural

Postnatal

• Having blood thinning injections
• Vitamin K for your baby
• How you birth your placenta