INFORMED DECISION MAKING

By Lisa Mackell Previously published in Birth Issues, Fall 2011

As a parent, we are faced daily with making decisions that will have an effect on our children and family. Did you know that parental decision-making starts before your child is born? There are many decisions to make, and making the best decision, with all the correct information, is making an informed decision.

Why is it important for me to be actively involved in the decision-making about my maternity care?

Being pregnant may feel like an awesome responsibility, but the more knowledge you have, the easier it will be to make informed decisions about your pregnancy and birth with confidence. The decisions you make and the care that you receive can have lasting effects on the health and well-being of your baby, yourself, and your family. Therefore, it is important that you understand the benefits and risks of any procedures, drugs, tests, or treatments that are recommended to you during pregnancy, labour and birth.

Your health care provider is responsible for explaining why the type of care is being recommended, what it involves, and the risks and benefits of the care for both you and your baby. Your health care provider should also tell you about alternatives to the care being recommended and their risks and benefits. You have the right to accept or refuse procedures, drugs, tests, or treatments, and to have your choices honored.

Making informed decisions about maternity care means getting the best and most up-to-date information possible, and contrasting that information with your values and preferences, and then deciding what’s right for you, your baby, and your family.

Key questions about making informed decisions: Not fear!

On which basis are you making the decision? Are you agreeing to a medical recommendation because,• You believe in your caregiver knowing what is best for you and baby?• You are in your 3rd trimester and don’t think you can change caregivers?• You don’t want to create a fuss?• Your partner is pressuring you?•  You are feeling bullied into a decision?• You are too tired to think or speak up?• You never felt you were given an option?• You are afraid and concerned your caregivers will be mad at you?

• You are afraid of the pain and are losing control?

Take the time to think through your decision, as it should never be made out of fear or pressure. Fear disempowers you, and more often than not, makes you make poor decisions that you will later regret. Know that you are the only one who will live with the consequences of your decisions. Your doctor or midwife will move on to another patient, and although they may be temporarily disappointed or ticked off, it will not last … and the experience will be forgotten or classified as ‘past.’ But you won’t forget your decisions and it will impact you during your postpartum period. If you refuse to make a decision, and one is made for you, you will still live with it and have to deal with it later. So you may want to consider learning about the pros and cons of medical interventions, knowing the facts and taking the approach from least invasive to most invasive. And most important of all—only make the decision when you are calm.

In this calm and private space, think of the following key points each time you are making a decision:• What are my options?• What are the benefits and risks for me and my baby for each of these options?• What are my values and preferences and those of other family members?

• What choices are available and supported in my care setting and through my health care provider?

Choosing your health care provider and place of birth

Choosing your care provider and your place of birth are two of the most important decisions you will be making. Because birth is 90% mental, the ability of a labouring woman to feel calm and supported will affect her birth outcome—but also her birth satisfaction, the bonding with her babe, her postpartum recovery and her attitude toward birth. This is especially true of first time moms.

Becoming a Mother by Crystal Driedger

Imagine a woman who wants to give birth at home, but cannot find a midwife. This woman will need to give birth in a hospital and more likely than not, she will be stressed and more closed. She will probably have a slower labour, which could trigger a cascading effect of interventions. She may give birth naturally and have a healthy baby, but she may feel dissatisfied by her experience and have a hard time postpartum. Imagine another woman who wants a doctor but desires one that specializes in natural childbirth. If she cannot find one, she will make compromises, which will likely also affect her birth outcome.

Midwives—Although there are different types of midwives, they all specialize in caring for healthy women anticipating a normal pregnancy and birth. They focus on health and wellness and encourage women and families to be part of the decision-making process. Midwives only attend low-risk pregnancies and births. They are trained to identify possible problems in pregnancy, and work together with physicians for births. Midwives attend births in birth centers, at home, and in hospitals.

Family Physicians—Family physicians focus on the health care needs of the entire family. Not all family physicians include maternity care in their practice. Some only offer prenatal care but do not attend births. Those that do attend births only attend low-risk births and will work with an obstetrician if a complication arises. Some rural family physicians are trained in surgery and perform cesarean sections. Family physicians primarily attend births in hospitals.

Obstetricians—Obstetricians (OB’s) may be either medical doctors (MD’s) or doctors of osteopathy (DO’s). MDs have gone through 4 years of medical school. DOs have completed 4 years of study at a school of osteopathic medicine, which emphasizes the study of the body’s muscle and bone structure, in addition to the regular medical school curriculum. Both MDs and DOs must complete an approved 4-year residency program in Obstetrics and Gynecology (OB/GYN) to become obstetricians. OBs care for low-risk and high-risk pregnancies and births. They are trained to identify and treat medical problems in pregnancy, and tend to create a controlled environment to minimize “unlikely events”. They are also trained in surgery and are able to perform cesarean sections. Sometimes obstetricians manage high-risk pregnancies in conjunction with a perinatologist.

Perinatologists—Perinatologists are obstetricians with additional special training in managing high-risk pregnancies and birth. They consult with and accept referrals from other maternity care providers. Perinatologists practice mostly in major medical centers in large cities.

Training—Doctors and midwives are trained differently. They have the same medical knowledge yet practice differently. Midwives are trained to put the woman at the center of their care and to make decisions in partnership with their patients. As pathologists, most doctors are taught to identify potential issues in childbirth. They use the three Ps of childbirth—Passageway, Passenger, Power— that is to say, birth outcomes depend on the pelvis, the baby, and contractions.1 Do you notice that the woman is not mentioned? This approach to childbirth disregards completely a woman’s autonomy and trumps her rights as a human being. Although some medical and nursing manuals are starting to recognize that a woman’s psyche has an impact on birth outcomes the number of caregivers who apply these principles are few and far between.

This may explain why Dr. Michael Klein’s research on the attitudes of Canadian maternity care practitioners towards labour and birth shows that GPs and obstetricians do not believe that a woman’s belief system is important for the outcome of a birth.2 We may thus infer that doctors, perhaps because of their training and the medical culture they work in, do not believe that what a woman thinks, feels, or wants is ultimately important.

If a woman wants to build a trusting relationship with her caregiver, she will need to consider her caregiver carefully. She also needs to allow herself to change midwives or doctors if she feels they are not supportive of her birth plan or if she is suspecting that she is being given lip-service (even during her third trimester). A woman should look beyond the obvious and seek out alternatives. Although she may not have the caregiver she wants in her community, she can arrange to give birth in a hotel suite or to live at her best friend’s to access the care she deserves. There are more options than we think sometimes!

Interventions

We all hope that birth will go smoothly. Most women dream of a nice quick birth. However, some women will have complications, or a slow labour, and require medical interventions. Although interventions save lives and may be necessary, sometimes interventions are used because it is the common thing to do rather than because it is absolutely necessary. This is where a birth plan, a good relationship with your doctor or midwife, and informed consent comes in. These ingredients are important for you to be able to make the best decision for you and your family.

There is also an effect known as the “cascade of interventions.” This is when one intervention leads to a series of interventions. For example, when you accept an epidural you are also going to accept the use of continuous fetal monitoring, catheters, and synthetic oxytocin. It has also been demonstrated that epidurals increases a woman’s chance of having an instrument delivery3. It is important to be aware of the cascade of interventions and to know how to minimize their effects.

Educate Yourself

Knowledge is power. Being knowledgeable always aids in decision-making. Without it a woman cannot be responsible for her care, which is why many caregivers don’t bother asking a woman for her opinion!

Instead, empower yourself. Do what you would ask of your own child: Educate yourself! Know your pros and your cons, know what to expect, learn about your anatomy, research your options, and do not delay facing the fact that you will give birth in a few months. You can read books (use the ASAC library or your public library), magazines, studies, Facebook, sign up to moms groups, speak with other women who have given birth (but not those that will scare you) and attend prenatal classes. Attending a prenatal class series during your second trimester will make a difference. Find a prenatal educator who will teach evidence-based prenatal classes. For a partial list of prenatal educators you can refer to the back of this magazine and you can also read the article written by Krystal Hoople in this issue.

Websites can be useful tools too. Choose reputable websites that are not biased one way or another. Typically, websites that end in .gov or .org are going to be more reputable. A website I like to refer to clients is the Society of Obstetricians and Gynecologists of Canada www.sogc.org. Another is the very reputable website called Childbirth Connection www.childbirthconnection.org. Childbirth Connection is a not-for-profit organization founded in 1918 to improve the quality of maternity care through research, education, advocacy and policy. Childbirth Connection promotes safe, effective and satisfying evidence-based maternity care and is a voice for the needs and interests of childbearing families.

It is interesting to note that many obstetricians are surprised at how well women do in home births. There is a suggestion that home birthing women differ from hospital birthing women in that they are more prepared and spend more time educating themselves than hospital birthing women. Dr. Michael Klein may have given us a partial answer to this difference: During the ASAC-sponsored event “Research Matters” on May 7th he said that women who have midwives are more informed and educated than any other women. He believes that this is due to the longer prenatal visits and to the inclusive attitude of midwives, but also to the fact that most women who know and seek midwifery care are part of a network that is already educating them—helping them, in turn, to be more trusting and less fearful of the child-birthing process.

Use your brain

When interventions are being suggested, decisions need to be made. Despite thorough prenatal preparations and education, parents can often feel overwhelmed when they need to make a decision. They often report, “one intervention lead to another … nothing went to plan.” How do you avoid that?

It is often difficult to make a decision when you have a person in front of you waiting for an answer, especially if they have a white coat! You feel obliged to please. During the annual conference of the Canadian Association of Midwives conference last October (2010) in Edmonton, Dr. Andrew Kotaska, who is an obstetrician in Yellowknife, explained that caregivers need to be careful about the way they offer choices. Are they offering, suggesting or ordering their patients? Let’s use the sample of a caregiver recommending an epidural. This caregiver, Dr. Kotaska shared, could recommend it in several ways:1. This is what we are going to do: You are going to have an epidural.2. Do you want to have your epidural now or in 30 minutes?3. I think an epidural is advisable to help you progress and relax. Here are the reasons why and here are the pros and cons. Let me know what you would like to do when I come back.

These statements are all slightly different. The first one disempowers a woman and tells her she is incapable of making a decision, the second is condescending and gives lip-service to woman centered care, and the third gives a medical recommendation but also leaves the women the power to make decisions about her care. Because the first and second scenarios are most commonly used you can imagine the potential for stress and disempowerment.

Because of the “white coat syndrome”, there is no harm in asking your care provider for a few minutes of privacy so that you can weigh the decision without feeling pressure or obligation. During this time you can breathe, cry perhaps, and review the pros and cons of the intervention suggested. While reviewing the pros and cons, use the acronym called B.R.A.I.N. and you will find you will be much more clear and calm when you make a decision:B. Benefits – what are the benefits of this intervention?R. Risks – what are the risks of this intervention?A. Alternatives – what are the alternatives to this intervention?I. Instinct – what do your instincts tell you? What feels right?N. Nothing – what happens if we do nothing or take a wait-and-see approach?

This is also one way for parents to begin to acknowledge their responsibility for decision-making during pregnancy and childbirth (and subsequent parenting). Ultimately they are responsible for making choices for their child and they are responsible for examining the different options—childbirth is the threshold each person passes when they become parents.

Informed Consent vs. Informed Choice

Childbirth educators trained by Childbirth International are taught in their course package that, “Informed consent is a principle of law. It refers to a situation where a caregiver has proposed a certain course of action, explained the risks and benefits, including the risks and benefits of not taking this action, and explained how the test or procedure will be carried out. Note that in disclosing risks, the caregiver need not explain every single possible risk, only the ones that might be reasonably foreseeable.

Informed consent is somewhat limited in scope in that it suggests that the caregiver has already selected a course of action and the patient is deciding whether to accept it after receiving the required information, although alternatives may be mentioned. Informed consent relies on the concept that the caregiver may not pressure a patient into a course of action, or withhold relevant information, or bias the presentation of information to favour a certain action—the consent must be voluntary and freely given, and the patient has the option of declining to consent or placing conditions on her consent.

Informed choice, on the other hand, is a process. It is a process of communication, back and forth, between caregiver and patient about the situation a patient faces, what options there are to address the problem, and what the pros and cons of each option are. The patient is then able to weigh the possible options and after due consideration, choose among them without undue pressure to choose any particular option. The caregiver is not simply seeking the patient’s ‘okay’ to proceed, he or she is engaging in a dialogue to help the expectant parent take responsibility for her own choices. Once the patient has made a choice, she may then give informed consent to the procedure chosen.”3

The purpose of informed consent is to respect your right to self-determination. It empowers you with the authority to decide what options are in your best interest and the best interest of your baby. Your rights to autonomy, to the best available information, and to protect your children and yourself from harm due to a caregiver’s dismissive attitude, aggressiveness, poor sportsmanship or bullying are very basic human rights.

Consenting to Treatment

When you give birth in a hospital or birth center you are asked to sign a “consent to treatment” form. Your signature gives permission to the staff to care for you and your baby. Usually this form includes common procedures such as: vaginal exams, fetal monitoring, use of IVs, pain medication, breaking the bag of water, use of forceps or vacuum extractor.

You do not have to agree to everything on the form. You can delete from or add statements to the form. A separate consent is often required for an epidural or for a cesarean section. You can also change your mind at any time by making your wishes known to your caregivers. If you choose not to agree with a treatment or procedure you may be asked to sign a waiver of liability acknowledging that you are taking responsibility for your decisions.

So, where do we go from here?

Good maternity care starts with an understanding that pregnancy and birth are ordinary and healthy events in a woman’s life— with a belief that most of the time the mothers and babies will continue to develop together, as they have for all mankind. We have the evidence and we have learned how to ensure that pregnancy and birth (and beyond) are safe for those involved. We also know that when basic needs are being met, and personal care throughout, most women will go on to have a healthy pregnancy and birth. Whether women give birth in their homes or in the hospital, when birth is allowed to unfold without pressure or interference and the birthing woman feels safe, supported and cared for by her care providers—then mothers and babies thrive.

Informed decision-making should not be about a specific care provider, location or a particular intervention, but about the model of care a woman receives. To all of you women, seek out woman and family centered care. Any doctor or midwife can offer this to you, but it is up to you to ask for it and to ensure they are honest!

Lisa Mackell raises two wonderful boys, and the support of her husband allows her to be with labouring women (and their families) as their birth doula, and to help educate them in her prenatal classes. She feels so blessed to be in this profession. She loves photography and scrapbooking. She lives in Edmonton, was born and raised there too!

Notes:

1. The three Ps of Childbirth, Passageway-Passenger-Power, is taught in medical and nursing schools to explain the mechanics of childbirth. According to this way of thinking, birth outcomes do not depend on the woman at all.

2. Michael Klein, and Kaczorowski J, Hall W, Fraser W, Liston R, Eftekhary S, et al. “The Attitudes of Canadian Maternity Care Practitioners Towards Labour and Birth: Many Differences But Important Similarities.” Journal of Obstetrics & Gynaecology Canada 31, no. 9 (2009): 827-840.3. For more information, go to “Cascade of Interventions in Childbirth” on the Childbirth Connection’s website: www.chilbirthconnection.org

3. Material quoted from Childbirth International student course package. For more information about their courses and training programs, go to www.childbirthinternational.com