Informed Choice and the Politics of Maternity Care

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Midwifery Model of Care and True Informed Choice

At its most basic level, informed choice is the process by which care providers involve clients in decisions about their care. Well of course, you may say, but as we shall see the waters become murky the deeper you delve into the  real-life experiences of clients navigating the modern pregnancy and birthing care system. In the interests of clarity, a more nuanced and specific definition of informed choice is the process of choosing from options based on accurate information and knowledge. These options are developed through an equal partnership between care provider and parents that empowers them to make decisions resulting in successful health outcomes for themselves and their babies. True informed choice occurs when clients and care providers engage in open, honest communication about the range of care options that exist. It is essential in this scenario for care providers to give an unbiased explanation of risks and benefits, as well as accept unconditionally the choices that clients make. Informed choice does not happen unless clients can decide on a course of action without feeling scared or anxious about retribution for doing so.

There are several components or principles of informed choice that must be included in any discussion of options in order for the concepts of choice and empowerment to be meaningful and relevant. These include:

  • The known or potential diagnosis requiring testing or treatment ………. WHAT?
  • The nature and process of proposed testing or treatment ………. HOW?
  • Potential benefits of any tests, drugs, or procedures ………. WHY?
  • Potential complications and side effects of any tests, drugs, or procedures ………. WHAT IF?
  • Likelihood of treatment success for this client and her baby
  • Reasonable alternatives available ………. WHAT ELSE?
  • Benefits and risks associated with alternatives
  • Freedom to say no and/or choose something else without fear of retribution
  • Written documentation of options counseling and decision of client to accept/decline testing or treatment

The components outlined above are consistent with the Midwifery Model of Care which acknowledges a trusting client-midwife relationship, shared decision-making, full disclosure of information, and the importance of self-determination and empowerment of parents. The ability to build a trusting relationship is at the very heart of engaging with clients in decision making and facilitating situations in which clients feel safe and empowered. This approach does not seek out or deny risks or danger, but attempts to be open to recognizing it if and when it arises. Open, honest discussions with clients about potential problems or complications rest on the premise that while we cannot erase uncertainty, we can develop responses to meet its challenges that resonate with our core beliefs and lifestyle and create safety.

Standardized Obstetric Care and Informed Compliance
Provider/client power imbalance negatively affects informed choice. A power imbalance exists in the medical/obstetrical model of care because emphasis is placed on the expertise and control of care providers. Autonomy and decision-making power rest in the hands of providers who are able to influence the decisions that clients make. In this model, full disclosure and information sharing between providers and clients does not generally happen. A medically oriented list of choices is presented, and a biased explanation of risks and benefits follows. Most clients in these types of relationships will make choices that they know their providers agree with, in order to avoid antagonizing or angering them. Informed choice is not occurring when there is a power imbalance; a more apt term is “informed compliance.” This term refers to communications about health care options that are biased to influence clients’ decisions. Components or aspects of informed compliance that differentiate it from informed choice include:

  • Communication patterns about medical risk that are biased to influence the client’s decisions, and which usually lead to a provider-desired decision
  • Provider information about risk is framed toward offering a superior choice over another to avoid perceived risks – the client is not equally informed about risks
  • Information is given, but choice is not always honored and respected
  • Troublesome because pregnant clients value professional opinion and are receptive to clinical direction

Lack of informed choice due to a provider/client power imbalance affects maternity care in several ways. First, trust in providers erodes when clients do not feel safe or confident to express their own beliefs and choices. Fear of retribution is a significant factor involved in clients allowing care providers to hijack control of their pregnancy and birth experiences. Research demonstrates that doctors expect to be in control in maternity care settings. Furthermore, they like “compliant” clients who share their backgrounds and values and dislike clients who they perceive as “non-compliant,” questioning, or difficult. This affects the treatment of clients in their care: those who are seen as difficult tend to be ignored or even treated cruelly. This has a profound effect on parents during pregnancy and labor, who are paradoxically strong, yet vulnerable, during these times. When parents are not allowed to trust their own intuition and opinions, they are not able to trust their own bodies, pregnancy, or birth itself.

Second, when decision-making power rests with providers, a mechanistic, institutionalized package of pregnancy and birth options outweighs the individual physical, social, and spiritual needs of parents. They become trapped into passively accepting procedures, drugs, and interventions that providers think are priorities, rather than listening to their own voice of wisdom within and making choices that are best for themselves, their babies, and their families.

Third, power imbalances ensure that in most situations, the person who does the “informing” influences the decisions that individual clients will make. It is important to remember that parents don’t experience maternity care or participate, however minimally, in that care in a vacuum. Intersections of ideology, resources, class, education level, race, lifestyle, gender identity, and sexual orientation influence how clients make choices from a medically-oriented menu of options over which they have little control to define or change. Not only are choices limited by obstetric regimens and protocols, but also making choices about these is largely meaningless when parents have little understanding about, or control over, the value systems on which such regimens are based.

Moving Toward Better Communication
Since childbearing does have risks associated with it, a meaningful dialogue should be initiated and maintained between care providers and clients to discuss theoretical and potential risks. All risks should be communicated in both positive and negative terms and placed in context so that parents understand the probability of an outcome occurring. Elements of informed choice should be addressed whenever a decision needs to be made. The process of informed choice is not an isolated occurrence, and should be on-going throughout pregnancy, birth, and postpartum.

Individualized care that is continuous, personalized, and based on shared and equal power is important for the therapeutic relationship between care providers and client. Recognition of the inherent power and wisdom of parents helps them to trust themselves to make appropriate and healthy decisions, and helps foster a relationship based on open dialogue, equality, and trust. Several key actions that care providers can do to truly implement informed choice are:

  • Facilitate discussions, rather then steer clients towards a line of thinking that they agree with
  • Use open-ended questions to help clients explore their own feelings
  • Acknowledge that making decisions is sometimes hard, and there is not always a “right” answer
  • Validate clients’ feelings
  • Establish a relationship based on connection, trust, and mutual respect
  • Provide the most up-to-date evidence-based research findings to help parents make decisions