Last month I "attended" a webinar entitled Informed Consent and Refusal in Maternity Care given by the Coalition for Improving Maternity Services. I always felt that there was something wrong about a care provider walking into a hospital room declaring, "it is time for your IV," and there is. Informed consent is not a declaration, it is a process of information dissemination (see below). Informed consent means giving the mom space to make an informed refusal (how many of us have attended births where mom's attempts to refuse an intervention have swiftly been pushed aside). The best part is that we all benefit when informed consent and refusal is respected, mothers, babies, AND providers. Please read the below handout prepared by the webinar presenters and pass this information along to your friends. Pregnant moms need to know that they are the decision makers. Healthcare providers can be sued for failure to obtain sufficiently informed consent (examples below).
Care providers should provide diagnosis, prognosis, and alternatives, including choice of no treatment.
Without true informed consent and refusal, empowered birthing is not possible. A big thank you to the Coalition for Improving Maternity Services for creating the below handout!
Informed Consent & Refusal in Maternity Care
Session Presenters: Tabaré Depaep, Esq.,Holly Goldberg, BA, PhD-c, Cordelia Hanna-Cheruiyot, MPH, CHES, CCE, CBA
The research supporting this educational activity is published in The Journal of Perinatal Education, Volume 18, Number 1, 2009, pp. 32-40.
What is informed consent and refusal?
Informed consent is a process of information dissemination. It involves providing the patient with sufficient, evidence-based information so she can make a decision that reflects self-determination, autonomy, and control.
It is a process of information exchange.
It is based upon involving patients in the decision making process.
Every pregnant woman has the right to make informed decisions about the care for herself and her fetus. Examples of judicial interventions that support patient rights:
Schloendorff v. Society of New York Hospitals, 1914.
Health care provider held liable for failure to get patient’s consent to surgery.
Salgo versus Leland Stanford Jr. University Board of Trustees, 1957.
Health care provider held liable for withholding information necessary for making an informed decision.
The essential components of informed consent and refusal
Numerous national and international professional associations promote patients’ rights to informed consent and refusal, including the American College of Physicians, American Medical Association, and March of Dimes, among others. The American College of Obstetricians and Gynecologists’ (ACOG) publication Ethics in Obstetrics (2004) included the ACOG Committee on Ethics’ statement on Informed Consent (PDF). This document details the following essential components of informed consent and refusal.
o Provider gives diagnosis, prognosis, and alternatives, including choice of no treatment.
o Provider is aware of and understands the patient’s situation/possibilities;
o Provider uses language that is understood by the patient;
o Patient’s consent is given freely, intentionally, and voluntarily.
Freedom of Choice
o Patient is free of coercion/free from outside pressures;
o Patient chooses among options and has the right to choose other than what is
o Patient gives provider the right to perform action.
The benefits of informed patient decision making:
Benefits for Providers:
Better patient/provider relationships
Enhanced trust in providers
Higher patient evaluation of providers
Increased patient recommendations of provider to others
Benefits for Patients:
Improved quality of life and physical and social functioning
Enhanced emotional well-being, increased sense of empowerment and self-esteem
Increased adherence to treatment plan and improved clinical outcomes
Shorter recovery periods
Benefits for Childbearing Women:
Lower levels of fear
Less depressive and post-traumatic stress symptoms after birth
More positive feelings toward newborn
About the Coalition for Improving Maternity Services (CIMS)
CIMS is a coalition of individuals and national organizations with concern for the care and well-being of mothers, babies, and families. Our mission is to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs. This evidence-based mother-, baby-, and family-friendly model focuses on prevention and wellness as the alternatives to high-cost screening, diagnosis, and treatment programs. CIMS is a not-for-profit organization recognized as tax-exempt under Internal Revenue Code section 501(c)(3). CIMS abides by the WHO-UNICEF “International Code of Marketing of Breast-milk Substitutes.”
CIMS Evidence Basis for the Ten Steps of Mother-Friendly Care (PDF), The Journal of
Perinatal Education, Winter 2007
The Six Care Practices that Support Normal Birth, Lamaze International
Listening to Mothers Surveys and Reports, Childbirth Connection
References Related to Informed Consent and Refusal
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© 2009 Coalition for Improving Maternity Services (CIMS). Permission granted to freely reproduce with attribution.
Seems like the evidence is stacking up against inductions. "Hospital's Oxytocin Protocol Change Sharply Reduces Emergency C-Section Deliveries." And I quote "As oxytocin utilization declined from 93.3% to 78.9%, emergency cesarean deliveries decreased from 10.9% to 5.7%." (emphasis mine).1 Hopefully hospitals will soon be changing their induction protocols but in the meantime, if your doctor plans an induction, you might want to share this article with him.
Thank you Jennifer Block for telling it like it is, Extreme Birth, Indeed. The word is getting out! It seems like only a year or two ago that it was almost a heresy to suggest the OB recommending induction (or a cesarean) for a big baby might just be wrong. The word is getting out, thanks to folks like Jennifer Block (and a million others, just had to point out this latest article by Block).
"Studies show that the 8 percent to 9 percent of U.S. women who use midwives and the 6 to 7 percent who choose family physicians generally experienced just-as-good results as those who go to obstetricians. Those who used midwives also ended up with fewer technological interventions. For example, women who received midwifery care were less likely to experience induced labor, have their water broken for them, episiotomies, pain medications, intravenous fluids, and electronic fetal monitoring, and were more likely to give birth vaginally with no vacuum extraction or forceps, than similar women receiving medical care. Note that an obstetric specialist is best for the small proportion of women with serious health concerns."1
Check out this fantastic Maternity Care quiz from Consumer Reports (and share it with your friends and family!). And while you are on their site, read this very accessible article on the importance of evidence-based care "Back to Basics for Safer Childbirth."
1. Consumer Reports Maternity Care quiz, http://www.consumerreports.org/health/medical-conditions-treatments/pregnancy-childbirth/maternity-care/maternity-care-quiz/maternity-care-quiz.htm,
Some of the most interesting information from my recent retreat in West VA came from a midwife who is also a doctor. Since she is a doctor, she must support vitamin K for newborns, right? Of course not! Though a big believer in informed consent (I admired the emphasis she places on encouraging her clients to educate themselves and make their own decisions while keeping personal bias out of the equation), she personally believes that babies must have historically been born with "low" levels of vitamin k for a reason (imagine that!). She explained that babies are born with fetal hemoglobin and must make the transition to adult hemoglobin. The fetal hemoglobin must break down and be processed by the liver and vitamin K might interfere with this process. She suggested I order Sara Wickham's book (which I intend to do) but here is an article on Vitamin K, written by Sara Wickham, that I thought I would share. I think Ronnie Falcoa's website has done a good job of summarizing the issues and research (or lack of research) on administering Vitamin K to newborns.
I just wrote the below post on the moms listserv to which I belong. It was prompted by a discussion on induction...
I wanted to respond to a recent message in which a mom mentioned that her doctor said induction did not increase the risk of cesarean. Unfortunately doctors often say things that are not evidence-based. I suggest reading the book Pushed, the Painful Truth about Childbirth and Modern Maternity Care by Jennifer Block, www.pushedbirth.com, for countless stories of caregivers practicing non-evidenced based care. On that note, let me quote the below paragraph from Pushed on induction.
The book makes a great case for doing your own research rather then blindly following your doctor's suggestions during pregnancy. I HIGHLY (can't say it enough) recommend that you read Jennifer Block's book whether you are pregnant or not. It is very easy to digest and full of loads of well-cited information about birth in the U.S. If you are happy with your induction, that is fine, but the hard-core fact is that many many women are being encouraged to be induced for "controversial reasons" that are not supported by research and the results can be harmful to mom and baby. And I am absolutely not saying that induction or a bit of pitocin to speed things along is never warranted. But induction for a "suspected big baby," for example, is not supported by either ACOG OR the literature (see Pushed page 8).
It is studies like this one that remind us to be careful when looking at the research. So high consumption of caffeine might lower our risk of ovarian cancer. Wonderful! Lets all go out and up our caffeine intake! If for one LOVE lattes (my weakness). But be careful before you run out that door, however, caffeine is also linked to miscarriage. I think the same is to be said for GBS testing, and many other topics. One study might encourage you to call your doc and schedule the test or request a particular intervention but another study will call for judicious use of testing/interventions and warn of unintended/harmful side effects. Do the research but don't forget to check in with your intuition.
Science continues to catch up with what midwives have always known. Many conditions in pregnancy, including pre-eclampsia, are strongly affected by diet. Two articles in the past week explore the possible link between increased risk for pre-eclampsia and diet. One article, "Maternal vitamin D deficiency increases pre-eclampsia risk" noted that "vitamin D deficiency at less than 22 weeks gestation was a strong, independent risk factor for pre-eclampsia."1 In the second article "Diet, gestational hypertension and pre-eclampsia" researchers found that higher intakes of fish appeared to lower the risk of pre-eclampsia.2 To date science claims no known cause of pre-eclampsia while midwives (and some physicians) have seen clear links between pre-eclampsia and diet.
More thoughts on pre-eclampsia and diet follow from Dr. Michel Odent. Please click on the link to read Dr. Odent's full comment on prenatal nutrition in Midwifery Today's E-News.
Where preeclampsia and eclampsia are concerned, we are able to establish links with several controlled trials of the effects of fish oil supplementation during pregnancy (although eating fish should not be confused with taking capsules). Our research also reflects statistics associated with the comparatively low rate of preeclampsia in countries where the diet is rich in sea fish. My theoretical vision of human preeclampsia also takes into consideration studies of fatty acid profiles of red blood cells, which mirrors the dietary fat intake over a two to three week period. According to a study conducted in Seattle, women with the lowest levels of omega 3 are 7.6 times more likely to be preeclamptic than those with the highest levels. I propose a hierarchy between the numerous biological imbalances associated with preeclampsia. The central imbalance, in my view, is the enormous discrepancy between the blood levels of DHA (the molecule essential for brain development) and the other polyunsaturates. In preeclampsia, the level of DHA remains stable. It does not drop dramatically like the level of other polyunsaturates. The price is an imbalance inside the family of omega 3 fatty acids and finally in the whole system of prostaglandins (I would need pages to enter into all the details). Such data suggest that brain development is a priority among humans: whatever the circumstances, the levels of one of the most important molecules for brain development remain stable. In order to simplify very complex phenomena, I propose to distinguish two critical phases in the genesis of preeclampsia. The first phase is in relation to the response of the maternal immune system at the time of placental implantation (this is confirmed by the fact that a previous miscarriage, a previous blood transfusion, or a long sexual cohabitation before conception reduces the risks of preclampsia). The second phase--the one that is influenced by nutrition--occurs later in pregnancy, when the fetal brain development is the most rapid and the demand in specific nutrients, and in particular long chain fatty acids, is maximum. Then the onset of a vicious cycle is possible, that is to say the disease preeclampsia. Preeclampsia appears as the price some human beings must pay for having a large brain while the nutritional supplies are not appropriate. 3
If I were a researcher, I would follow midwives around and document their work.
(Please note, you do have to sign up for www.ORGYN.com's article's but it is free and WELL worth it.)
1 Diet, gestational hypertension and pre-eclampsia, Issue 18: 3 September 2007, Source: Annals of Epidemiology 2007;17:663-8, from ORGYN Online Magazine, http://www.orgyn.com/en/webzine/2007/Issue_18/Diet__gestational_hy.asp, accessed Sept. 14, 2007.
2 Maternal vitamin D deficiency increases pre-eclampsia risk. Source:Journal of Clinical Endocrinology and Metabolism 2007;92:3517-3522, from ORGYN Online Magazine, http://www.orgyn.com/en/news/2007/Week_37/Day_1/Maternal_vitamin_D_d.asp?C=71129393396790162037, accessed Sept. 14, 2007.
3 Midwifery Today E-News, January 9, 1999 Volume 1, Issue 2, http://midwiferytoday.com/enews/enews0102.asp, accessed Sept. 14, 2007.
I have had the honor of participating in 11 births so far (not counting my own). Odds are that I should have been present at a cesarean birth by now but I have not yet had that experience (silent prayer that my "luck" continues). The chances of having a cesarean weren't always so high. Here is an interesting bit of information from an even more interesting book:
Alfred Rockenschaub, MD, professor of midwifery and physician in charge of the midwifery service of the Ignac Semmelweis Frauenklinik in Vienna, oversaw the delivery of 44,500
babies from 1965-1985. During that time, the cesarean section rate hovered just over 1% and the infant mortality was below the overall rate in Vienna at the time. The cesarean rate rose sharply after Professor Rockenschaub retired, and in 1999 stood at 19%.1
Wow! One doctor left and the cesarean rate rose from 1%-19%. And we know that on The Farm in Summertown Tennessee, out of 2,028 pregnancies from 1970-2000, only 1.4% ended in cesarean.2 If I was a doctor and I knew about those kind of statistics and my cesarean rate was 30%, I would do some serious soul-searching.
1 David K. Cundiff, MD., Money Driven Medicine, Tests and Treatments that Don't Work (David K. Cundiff, MD., 2006), http://www.doctormanagedcare.com/ (accessed August 9, 2007)
2 Ina May Gaskin, Spiritual Midwifery (Summertown,Tennessee: Book Publishing Company,2002),468.