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Factsheet – Choice and consent during birth

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Factsheet – Choice and consent during birth

Emma Hill
Birth Suite Midwife, Sydney, Australia
@emma_hill_avec_femme (Instagram) @EmmaH_avecfemme (Twitter)

Summary

This factsheet provides information regarding consent during pregnancy, birth and in the postnatal period.  Consent is a fundamental human right and one that should not be diminished during pregnancy or birth.

Consent includes the right to receive information regarding the benefits and risks of any recommended intervention so you are able to make an informed decision that best suits you and your baby. Interventions may include prenatal testing, induction of labour, fetal monitoring, vaginal examinations, epidurals, episiotomies, assisted births (forceps or vacuum) and lower section cesarean sections.

Interventions for your baby may include immediate cord clamping, vaccinations, newborn screening and other tests.

This fact sheet will provide you with information regarding the importance of consent and your human rights during childbirth.  We share the current evidence regarding consent and the potential impacts to women when they feel their human rights have not been met.  Furthermore, we provide practical tips to support you in voicing your wishes whilst you become a new mother.

 


What we know

 

Pregnancy and childbirth are a pivotal time in a woman’s life with access to safe and supported birth a fundamental human right.  A positive birth experience is strongly linked to women experiencing a sense of control through choice and involvement in decision making with consent.All women have the right to make their own autonomous decisions regarding their own bodies through legal protections such as the right to refuse treatment and informed consent.It is important to note that women may experience trauma when they feel a lack of involvement and control in decision making.3-4 The principles of consent apply equally to birthing woman as to other competent adults and women hold the right to decline any intervention.5 Intervention without informed consent can result in significant emotional costs to the women and families involved. It is known that valid consent can reduce unnecessary intervention through education, clarification and understanding of the right to refuse treatment.6

 

Research has identified that safety and psychosocial wellbeing are vitally important during childbirth with women seeking care that is responsive to their needs, beliefs and values.7  A review of the literature identifies that procedures undertaken without consent, unnecessary intervention and breaches of bodily autonomy are considered harmful.8-12  Global evidence tells us that women in childbirth can be exposed to non-consented intervention and non-supportive care.13  Furthermore women have been asked to consent to procedures or interventions that have not been adequately explained. For your consent to be valid it must be given voluntarily and without coercion or influence and without misrepresentation regarding the need for the intervention.14-15 We also know that it can be extremely difficult for women to assert their autonomy when they are vulnerable and in a medically dominated arena.16

 

Finally, we know that a continuity of care model where you are supported by the same midwife or obstetrician throughout your pregnancy, birth and the postnatal period is vital. Women’s experiences are enhanced by this model and the chance of intervention without consent reduced.17

 


What we don’t know

 

Currently there are different laws internationally governing consent and no global agreement regarding the best manner in which to measure a women’s experiences in regard to violations of consent.  As a result we don’t have a full understanding of the incidence of interventions being performed without consent nor the impact on women’s choice and wellbeing.18 Further, in some instances, women may not be aware that a violation of bodily autonomy and consent has occurred due to the use of analgesia. The literature does reference numerous reports of exposure to unwelcome interventions such as episiotomies, without consent or knowledge whilst a woman’s sense of touch is altered under analgesia.19

 


Mothers and families: How to use the evidence

 

  • Seek a continuity of care health professional where you have a known midwife or obstetrician who works with you throughout your pregnancy, birth and the postnatal period. This promotes the development of trust and supports you to discuss your preference for your care.
  • During your antenatal visits ask your healthcare provider about consent and informed decision making. Discuss with them the importance of your consent and your right to be informed prior to any information. Advise your health care provider that you will be an active participant in decision making and that you hold the final approval regarding any decisions relating to your health and that of your baby.
  • Access prenatal education in order to be well educated and informed with regard to informed consent and autonomy in childbirth.20Use this time to ask questions and seek information regarding interventions that may occur in childbirth.
  • Seek a healthcare provider who makes you feel safe and who responds to your questions and concerns. Remember you can seek another provider if your needs are not being met.
  • Consider developing a flexible birth plan where you clearly state your wishes and desires for your care. Birth plans have been found to be a successful strategy for improved birth experiences.21

 


Midwives and birth workers: How to use the evidence

 

  • Birth workers such as midwives and obstetricians have a professional, ethical and legal requirement to provide safe and respectful care.22As health care workers we are involved in the intimate personal care of women and this by its very nature makes express consent an essential component of practice.
  • Provide the women in your care with information regarding choices that is accurate, clear and evidence based.23
  • Encourage women and their birth partners to attend prenatal education classes in order to be well prepared prior to the birth of their babies.
  • Unwanted interventions that breach the woman’s bodily integrity are considered harmful.24It is important to note that the touching of a women without first seeking an informed and valid consent may (in some countries) be unlawful. 25-26
  • There is increasing international concern regarding the iatrogenic (harm caused by medical treatment) impact of obstetric intervention where there is an absence of clinical need.27 Several studies have noted that women receiving unwanted and often un-consented interventions including vaginal exam viewed them as violating and degrading.28-29It is critical note that though health professionals may determine their interactions and interventions to be routine, women may view then as violating and traumatic.30

 

References

  1. WHO recommendations: Intrapartum care for a positive childbirth experience. World Health Organization, Licence: CC BY-NC-SA 3.0 IGO.
  2. Kotaska A. Informed consent and refusal in obstetrics: A practical ethicalBirth: Issues in perinatal care 2017 44(3) . https://doi-org.ezproxy.uws.edu.au/10.1111/birt.12281
  3. Elmir R, Schmied V, Wilkes L, Jackson D. Women’s perceptions and experiences of a traumatic birth: a meta-ethnography. Journal of Advanced Nursing. 2010;66(10). https://doi-org.ezproxy.uws.edu.au/10.1111/j.1365-2648.2010.05x
  4. Moyzakitis W. Exploring women’s descriptions of distress and/or trauma in childbirth from a feminist perspective. Evidence Based Midwifery. 2009.
  5. DeBaets A. From birth plan to birth partnership: Enhancing communication in childbirth. American Journal of Obstetrics and Gynecology. 2017; 216 (1) https://dx.doi.org/10.1016/j.ajog.2016.09.087
  6. Sadler M, Santos M, Ruiz-Berdun D et al. Moving beyond disrespect and abuse: Addressing the structural dimensions of obstetric violence. Reproductive Health Matters. 2016 24(47) https://doi.10.1016/j.rhm.2004.002
  7. Downe S, Finlayson K, Oladapo O, Bonet M, Gulmezoglu A. What matters to women during childbirth: A systematic qualitative review. PloS one. 2018; 13(4), https://doi.org/10.1371/journal.pone.0194906
  8. Borges M. A violent birth:Reframing coerced procedures during childbirth as obstetric violence. Duke Law Journal. 2018. 67 (4)
  9. Flanigan J. Obstetric autonomy and informed consent. Ethic Theory Moral Prac, 2016; 19(1) https://doi:10.1007/s10677-015-9610-8
  10. Freedman P, Kruk M. Disrespect and abuse of women in childbirth challenging the global quality and accountability agendas. The Lancet. 2014; 384 (9948). https://doi.10.1016/S140-6736
  11. Sadler M, Santos M, Ruiz-Berdun D et al. Moving beyond disrespect and abuse: Addressing the structural dimensions of obstetric violence. Reproductive Health Matters. 2016 24(47) https://doi.10.1016/j.rhm.2016.04.002
  12. Bohren M, Vogel J, Hunter E et al. The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS Med. 2015. https://DOI:10.1371/journal.pmed.1001847
  13. Bohren M, Vogel J, Hunter E et al. The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS Med. 2015. https://DOI:10.1371/journal.pmed.1001847
  14. Reed R, Sharman R, Inglis, C. Women’s descriptions of childbirth trauma relating to care provider actions and interactions. BMC Pregnancy and Childbirth. 2017 17(1).  https://DOI:10.1186/s12884-016-1197-0
  15. Staunton P, Chiarella M. Law for nurses and midwives (8th ed). https://www-clinicalkey-com-au.ezproxy.uws.edu.au/nursing/#!/browse/book/3-s2.0-C20150018792
  16. Staunton P, Chiarella M. Law for nurses and midwives (8th ed). https://www-clinicalkey-com-au.ezproxy.uws.edu.au/nursing/#!/browse/book/3-s2.0-C20150018792
  17. Sandall J, Soltani H, Gates S, Shennan A, Devane. Midwife-led continuity models of care compared with other models of care for women during pregnancy, birth and early parenting. Cochrane Systematic Review. 2016 https://doi-org.ezproxy.uws.edu.au/10.1002/14651858.CD004667.pub5
  18. WHO recommendations: Intrapartum care for a positive childbirth experience. World Health Organization, Licence: CC BY-NC-SA 3.0 IGO.
  19. Kukura E. Obstetric Violence. Georgetown Law. 106(3) https://heinonline-org.ezproxy.uws.edu.au
  20. Silva F, Viana A, Amorim F et al. The knowledge of puerperal women on obstetric violence. Journal of Nursing UFPE online. https://doi.org.10.525/1981-8963.2019.242100
  21. Taheri M, Takian A, Taghizadeh Z, Jafari N, Sarafraz N. Creating a positive perception of childbirth experience: systematic review and meta-analysis of prenatal and intrapartum interventions. Reproductive health. 2018 15(1). https://doi.org/10.1186/s12978-018-0511-
  22. Reed R, Sharman R, Inglis, C. Women’s descriptions of childbirth trauma relating to care provider actions and interactions. BMC Pregnancy and Childbirth. 2017 17(1).  https://DOI:10.1186/s12884-016-1197-0
  23. Golden P, Coercion or consent? British Journal of Midwifery, 2018; 26(7) https://doi-org.ezproxy.uws.edu.au/10.12968/bjom.2018.26.7.482
  24. DeBaets A. From birth plan to birth partnership: Enhancing communication in childbirth.  American Journal of Obstetrics and Gynecology. 2017; 216 (1) https://dx.doi.org/10.1016/j.ajog.2016.09.087
  25. Flanigan J. Obstetric autonomy and informed consent. Ethic Theory Moral Prac,  2016; 19(1) https://doi:10.1007/s10677-015-9610-8
  26. Clarke E. Law and Ethics for Midwifery. Routledge Taylor & Frances Group: London
  27. Staunton P, Chiarella M. Law for nurses and midwives (8th ed). https://www-clinicalkey-com-au.ezproxy.uws.edu.au/nursing/#!/browse/book/3-s2.0-C20150018792
  28. Sadler M, Santos M, Ruiz-Berdun D et al. Moving beyond disrespect and abuse: Addressing the structural dimensions of obstetric violence. Reproductive Health Matters. 2016 24(47) https://doi.10.1016/j.rhm.2016.04.002
  29. Bohren M, Vogel J, Hunter E et al. The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review. PLoS Med. 2015. https://DOI:10.1371/journal.pmed.1001847
  30. Sadler M, Santos M, Ruiz-Berdun D et al. Moving beyond disrespect and abuse: Addressing the structural dimensions of obstetric violence. Reproductive Health Matters. 2016 24(47) https://doi.10.1016/j.rhm.2016.04.002

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