Empowering Birth Blog

Is Ultrasound Really Safe?

Check out this great article on ultrasound: Marsden Wagner: Ultrasound More Harm Than Good?

It is Your Right to Say NO (Informed Consent and REFUSAL)

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!

 

Webinar 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. 

 

  Adequate Information 

o Provider gives diagnosis, prognosis, and alternatives, including choice of no treatment. 

Comprehension 

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 

recommended; 

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 satisfaction 

  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.” 

 

The Mother-Friendly Childbirth Initiative  

  CIMS Evidence Basis for the Ten Steps of Mother-Friendly Care (PDF), The Journal of 

Perinatal Education, Winter 2007 

 

Additional Links 

 

  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 

1. Cahill, J. (1998). Patient participation – A review of the literature. Journal of Clinical Nursing, 7(2), 119–128. 

2. Christiaens, W., & Bracke, P. (2007). Assessment of social psychological determinants of 

satisfaction with childbirth in a cross-national perspective. BMC Pregnancy and Childbirth, 7, 26. 

3. Declercq, E. R., Sakala, C., Corry, M. P., & Applebaum, S. (2006). Listening to mothers II: Report of the second national U.S. survey of women’s childbearing experiences. New York: Childbirth Connection. 

 4. Elwyn, G., Edwards, A., Gwyn, R., & Grol, R. (1999). Towards a feasible model for shared decision making: Focus group study with general practice registrars. British Medical Journal, 319(7212), 753–756. 

5. Goodman, P., Mackey, M. C., & Tavakoli, A. S. (2004). Factors related to childbirth satisfaction. Journal of Advanced Nursing, 46(2), 212–219. 

6. Green, J. M., & Baston, H. A. (2003). Feeling in control during labor: Concepts, correlates, and consequences. Birth: Issues in Perinatal Care, 30(4), 235–247. 

7. Green, J. M., Coupland, V. A., & Kitzinger, J. V. (1990). Expectations, experiences, and 

psychological outcomes of childbirth: A prospective study of 825 women. Birth, 17(1), 15–24. 

8. Hack, T. F., Degner, L. F., Watson, P., & Sinha, L. (2006). Do patients benefit from participating in medical decision making? Longitudinal follow-up of women with breast cancer. Psycho-oncology, 15(1), 9–19. 

9. Hammond, K., Bandak, A., & Williams, M. (1999). Nurse, physician, and consumer role 

responsibility perceived by health care providers. Holistic Nursing Practice, 13(2), 28–37. 

10. Harrison, M. J., Kushner, K. E., Benzies, K., Rempel, G., & Kimak, C. (2003). Women’s 

satisfaction with their involvement in health care decisions during a high-risk pregnancy. Birth: 

Issues in Perinatal Care, 30(2), 109–115. 

11. Hindley, C., & Thomson, A. M. (2005). The rhetoric of informed choice: Perspectives from 

midwives on intrapartum fetal heart rate monitoring. Health Expectations: An International Journal of Public Participation in Health Care and Health Policy, 8(4), 306–314. 

12. Hodnett, E. D. (2002). Pain and women’s satisfaction with the experience of childbirth: A 

systematic review. American Journal of Obstetrics and Gynecology, 186(Suppl. 5), S160–S172. 

13. Jomeen, J. (2004). The importance of assessing psychological status during pregnancy, childbirth and the postnatal period as a multidimensional construct: A literature review. Clinical Effectiveness in Nursing, 8, 143–155. 

14. Jung, H. P., Wensing, M., & Grol, R. (1997). What makes a good general practitioner: Do patients and doctors have different views? British Journal of General Practice, 47, 805–809. 

15. Knapp, L. (1996). Childbirth satisfaction: The effects of internality and perceived control. Journal of Perinatal Education, 5(4), 7–16. 

16. Krupat, E., Hsu, J., Irish, J., Schmittdiel, J. A., & Selby, J. (2004). Matching patients and 

practitioners based on beliefs about care: Results of a randomized controlled trial. The American 

Journal of Managed Care, 10(11, Pt. 1), 814–822. 

17. Lavender, T., Walkinshaw, S. A., & Walton, I. (1999). A prospective study of women’s views of factors contributing to a positive birth experience. Midwifery, 15(1), 40–46. 

18. Levy, V. (1999a). Maintaining equilibrium: A grounded theory study of the processes involved when women make informed choices during pregnancy. Midwifery, 15(2), 109–119. 

19. Levy, V. (1999b). Protective steering: A grounded theory study of the processes by which midwives facilitate informed choices during pregnancy. Journal of Advanced Nursing, 29(1), 104–112. 

20. Loh, A., Leonhart, R., Wills, C. E., Simon, D., & Hoter, M. (2007). The impact of patient 

participation on adherence and clinical outcome in primary care of depression. Patient Education 

and Counseling, 65(1), 69–78. 

21. MacDorman, M. F., Declercq, E., Menacker, F., & Malloy, M. H. (2006). Infant and neonatal 

mortality for primary cesarean and vaginal births to women with no indicated risk, United States, 

1998–2001 birth cohorts. Birth, 33(3), 175–182.  

22. March of Dimes. (2006, March). Cesarean sections may be contributing to the rise in late preterm births. Retrieved December 6, 2008, from http://www.marchofdimes.com/aboutus/15796_19306.asp 

23. March of Dimes (2008, July). Induction by request. Retrieved December 6, 2008, from 

http://www.marchofdimes.com/pnhec/240_20203.asp 

24. Marteau, T. M., Dormandy, E., & Michie, S. (2001). A measure of informed choice. Health 

Expectations: An International Journal of Public Participation in Health Care and Health Policy, 

4(2), 99–108. 

25. Martin, J. A., Hamilton, B. E., Sutton, P. D., Ventura, S. J., Menacker, F., Kirmeyer, S., et al. 

(2007). Births: Final data for 2005. National Vital Statistics Reports, 56(6). Hyattsville, MD: 

National Center for Health Statistics. Retrieved December 6, 2008, from 

http://www.cdc.gov/nchs/data/statnt/statnt25.pdf 

26. McGregor, S. (2006). Roles, power and subjective choice. Patient Education and Counseling, 60(1), 5–9. 

27. Meng, K. H. (2008). [Informed consent in public health activities: Based on the universal 

declaration on bioethics and human rights, UNESCO]. Journal of Preventive Medicine and Public Health, 41(5), 339–344. Korean. English abstract retrieved December 6, 2008, from 

http://www.ncbi.nlm.nih.gov/pubmed/18827502 

28. Michie, S., Dormandy, E., & Marteau, T. M. (2003). Informed choice: Understanding knowledge in the context of screening uptake. Patient Education and Counseling, 50(3), 247–253. 

29. O’Cathain, A., Thomas, K., Walters, S. J., Nicholl, J., & Kirkham, M. (2002). Women’s perceptions of informed choice in maternity care. Midwifery, 18(2), 136–144. 

30. Oberman, M. (2000). Mothers and doctors’ orders: Unmasking the doctor’s fiduciary role in 

maternal-fetal conflicts. Northwestern University Law Review, 94(2), 451–501. 

31. Pelkonen, M., Perala, M. L., & Vehvilainen-Julkunen, K. (1998). Participation of expectant mothers in decision making in maternity care: Results of a population-based survey. Journal of Advanced Nursing, 28(1), 21–29. 

32. Rosen, P., Anell, A., & Hjortsberg, C. (2001). Patient views on choice and participation in primary health care. Health Policy, 55(2), 121–128. 

33. Rothenbacher, D., Lutz, M. P., & Porzsolt, F. (1997). Treatment decisions in palliative cancer care: Patients’ preferences for involvement and doctors’ knowledge about it. European Journal of Cancer, 33(8), 1184–1189. 

34. Sakala, C., & Corry, M. P. (2008). Evidence-based maternity care: What it is and what it can 

achieve. New York: Millbank Memorial Fund. 

35. Singh, D., Newburn, M., Smith, N., & Wiggins, M. (2002). The information needs of first-time pregnant mothers. British Journal of Midwifery, 10(1), 54–58. 

36. Spurgeon, P., Hicks, C., & Barwell, F. (2001). Antenatal, delivery and postnatal comparisons of maternal satisfaction with two pilot Changing Childbirth schemes compared with a traditional model of care. Midwifery, 17(2), 123–132. 

37. van der Hulst, L. A., van Teijlingen, E. R., Bonsel, G. J., Eskes, M., Birnie, E., & Bleker, O. P. (2007). Dutch women’s decision-making in pregnancy and labour as seen through the eyes of their midwives. Midwifery, 23(3), 279–286.  

© 2009 Coalition for Improving Maternity Services (CIMS).  Permission granted to freely reproduce with attribution. 

Hmm, Induction Isn't So Good After All...

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.

1 Betsy Bates, "Hospital's Oxytocin Protocol Change Sharply Reduces Emergency C-Section Deliveries", Elsevier Global Medical News, June 23, 2009. http://egmn.idsk.com/stories_global/35_ds_7863805.jsp

"Standard Maternity Care is NOT Evidence-Based"

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).

An obstetrician will deliver better maternity care, overall, than a midwife or family doctor

FALSE!
"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,
accessed 2/13/09

Vitamin K?

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. 

Unfortunately our doctors don't always tell us the truth...

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.

"Gary Hankins, MD, professor and vice chair of obstetrics and gynecology at the University of Texas Medical Branch at Galveston and chair of the obstetric practice committee of the American College of Obstetricians and Gynecologists (ACOG), says nobody should be doing inductions without a good reason. 'That's not good medicine.'... Hankins says he personally never induces for convenience. 'An induction absent a solid indication absolutely increases all risk to mom and baby,' he says.  Laura Riley, MD, medical director of labor and delivery at Massachusetts General Hospital and Hankins's predecessor as chair of the ACOG practice committee, which releases guidelines on such practices, agrees. 'Ideally you wait for natural labor,' she told me. 'Just by the mere fact of induction, you've now intervened in a pregnancy that otherwise would have continued, and you've already increased the risk of a c-section.'" (pg. 8, Pushed, the Painful Truth about Childbirth and Modern Maternity Care, by Jennifer Block).

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).

Be informed but follow your intuition

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. 

Pre-eclampsia is linked to poor diet

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.

Things that make you go hmm....

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.