Decisions, Decisions, Decisions
Every day we make decisions about our lives, mostly just little ones like what to wear or what to eat. There are days and weeks when we need to make big decisions like where to live, whether to change jobs or maybe where to go on holidays. For these bigger decisions, we usually find out as much information as possible about all our options, we weigh up the pros and cons of those options and we come to a final decision.
Should it be any different when we are pregnant? Shouldn't we consider carefully where this baby will be born, what type of care would suit us best or what way I will feed this baby?
Sometimes in our maternity care, we are faced with choices or decisions and we can go through our usual decision-making process. Sometimes it might seem like there isn’t a choice due to what is routine or policy in our maternity unit. It might feel like our caregiver’s decision is final but – and this is a big but – in fact, all decisions about our care are ours to make. We can decide to do exactly what our caregivers suggest, some of what they suggest or none of what they suggest. This is our right and it’s also our responsibility. But if that responsibility seems daunting – because we’re conditioned to think of our caregivers as THE experts in pregnancy and birth and who are we to question them – think about this: who cares most about this baby? Whose family does this concern most? Whose start to confident parenthood is going to be affected by how this birth goes?
A woman’s right to informed decision making and the principles of informed consent and informed refusal are declared in both the Maternity Strategy 2016-2026 and the national maternity services standards – for more detail, see the end of this document.
The bump2babe guide has highlighted significant differences in intervention rates and in policies in the Irish maternity services. We hope this helps parents to understand that what is routine in one maternity unit is not routine in another. This means that all aspects of care have ranges of appropriate and safe options and that parents can discuss these options fully with their caregivers before reaching a decision.
Remember, knowing what to expect doesn't mean we have to accept certain aspects of care for ourselves or our baby just because it's routine. We can – and should – make informed decisions about our care and the care our babies receive.
But how can we know what's best for us or our babies if we are not informed? Read on to find out how to get the information you need.
INFORMED DECISION MAKING
If you find yourself unsure about a course of action being recommended during your antenatal or postnatal care or during labour, listed below are a number of questions to ask which may help you make a decision.
We asked the maternity care providers how they ensured that parents’ decisions during labour and birth are informed decisions? All units answered this question but with varying degree of detail. In general, the responses implied there would be provision of information through antenatal classes, leaflets and through discussion with your midwife or doctor and that practices are based on national or international guidelines. No unit mentioned informed refusal, but there can be no informed consent without the possibility of informed refusal. The right of the mother/parents to give informed refusal, e.g. to withhold consent for a procedure, was not addressed. Cuidiú/Antenatal Ireland remains concerned that the emphasis in units is solely directed towards securing consent for interventions.
The more questions you ask the more information you will receive to help you make informed decisions – this applies to both routine and non-routine procedures. Evidence-based information on the benefits, risks, alternatives (including watch-and-wait approach) and implications (knock-on effects) will help you make the best decision for you and your baby.
In summary: Your care and the care of your baby should be based on informed decisions by you (and your partner if applicable). This means you don't have to comply with hospital policies and practices simply because they're routine. Nor do you have to agree to any form of treatment/care/feeding method for your baby with which you are unhappy. This link explores more on making informed decisions.
Here are some comments that we got from parents and caregivers about informed decision making.
'The key to a positive birth experience is two-way communication.' Mary, midwife
'Even though my birth didn’t go as planned I didn’t feel a failure because I was involved in the decision making. I never felt out of control.' Claire, mother
'Because of informed decision making, the parents and midwife become a team where advocacy happens naturally.' Lynda, midwife tutor
'Each of the decisions was made after full discussion with me and I totally understood why the steps taken were necessary. Even with the benefit of hindsight I wouldn’t change any of them because they enabled my beautiful daughter to be born safely.' Síle, mother
'I felt really empowered to support my partner by being able to engage with the midwives and doctors on an equal footing – I was worried that I might come across as defensive or aggressive but being able to ask reasonable questions calmed me down.' Paul, father
Section 4.11 of Creating A Better Future Together: National Maternity Strategy 2016 – 2026 covers consent and information. The first two paragraphs of this section outline the principle of consent in maternity care:
“Throughout pregnancy and, particularly, during labour, women will be required to make decisions in relation to their medical care. It is a basic rule of the common law of tort (e.g. civil wrong which causes injury to another, such as negligence), and a fundamental ethical requirement, that consent must be obtained in advance of the provision of any medical examination, treatment, service or investigation. This is also well established in ethical standards.
Requiring informed consent is an expression of respect for a person’s autonomy (i.e. the ability to make decisions free from external influence) and the patient’s right to bodily integrity. The doctrine of informed consent also recognises the right of individuals to weigh risks and benefits for themselves. For consent to be deemed valid, it must be voluntary and informed, and the person giving consent must have sufficient capacity to make the decisions at hand. As is the case in all other clinical contexts, pregnant women should be afforded the opportunity to make informed decisions about their maternity care.”
It goes on to describe processes to enable women to make informed decisions which are similar to the BRAIN method above. Informed refusal is addressed in the final paragraph of this section of the strategy.
"There may be cases where, following such discussion and disclosure, a woman wishes to continue with her choice of informed refusal to proceed, or persist with a treatment/procedure, and that decision is based on her desire to achieve the best possible outcome for herself and her baby. Where an assessment is made that the informed refusal would not threaten the life of or have a deleterious effect on the baby, then the woman’s choice of informed refusal should stand."
The National Standards for Safer Better Maternity Services include the following:
Standard 1.4: Women are empowered to make informed decisions about their care.
Standard 1.5: Informed consent to care is obtained in accordance with legislation and national policy.
Based on an article written by Louisa Crowley and Niamh Healy for the 2011 edition of bump2babe The Consumer Guide to the Maternity Services in Ireland, and updated in June 2018 by Niamh Healy