Informed Choice and Informed Consent

I’m writing three papers this week. One twenty pager on delivering compassionate care during miscarriage. One twelve pager on Aboriginal midwifery in Canada. One fiver pager on how to analyze research papers for quality. It’s a good thing I like writing because this is nuts.

Writing papers means that I’m also reading papers. A lot of them. Probably more than 60 pieces of peer-reviewed literature in the last two weeks. Interestingly, I found one 2013 article by Jessica Shaw that speaks to the medicalization of childbirth in North America. I thought I would share a quote from that article that got me thinking about what we consider “normal” in Canada for birth.

From Shaw (2013):

“As Parry (2006) wrote, “The medicalized birth is [now] so ingrained in our society that people can think of no other way to frame their experiences” (p. 464). When medical interventions become routine, the concept of what a normal birth looks like changes (Lothian, 2006; Munro et al., 2009; Parry, 2008). Whereas for millions of years normal or “natural” birth for women generally consisted of an unmedicated, vaginal delivery, over the past few decades in North America birth has become more medicalized and less reliant on women’s innate birthing abilities (Brodsky, 2008; Harper, 2005). As women began to share medicalized birth stories and talk about medical interventions as common procedures that are required for the normal progression of labor, the concept of what a normal birth ought to be like has changed.” (Shaw 2013)

So I guess medicalized births (C-sections, interventions such as fetal heart monitoring and epidurals, induction of labour, etc.) are the new norm. Shaw argues throughout the rest of her paper that women today actually have less confidence to deliver naturally, because of a perception that they need medical intervention to birth safely and properly. She adds that this might be happening because of a power imbalance between care provider and client, in the birthing environment.

What I love about midwifery is that it challenges both of these assumptions. Not only do midwives promote a less interventionist model (unless of course, you need that epidural, in which case, let’s DO THIS) but midwives also operate via informed choice rather than informed consent. Distinguishing between these two terms is important. They are not interchangeable and they actually result in very different care. Here’s how I interpret them:

Informed Consent the clinician decides. They tell you what procedure they want to do, what the risks are for that procedure, and then you say yes or no. Usually, no other option is given. This is the medical model of care.

Example 1: a woman is having high pain in labour. The clinician says, “At this point we can offer you an epidural. Here are the risks [blah blah blah I haven’t learned this yet blah blah blah]. I’ll give you some time to read the consent form and come back in about 30 minutes for your decision.”

Example 2: a clinician says to her client, “Labour isn’t progressing as quickly as we would like so in about 4 hours I’m going to rupture your membranes, alright?”

Informed Choice the client decides. The clinician offers you a few options based on what is going on and what their clinical experience (and the evidence) says might work. This is the midwifery model of care.

Example 1: a woman is having high labour pain. The clinician says, “These are the four pain-control options we typically offer to women at this stage in labour. Here are the risks and benefits of each one. How would you like to proceed?”

Example 2: a clinician says to his client, “You aren’t progressing as much as I’d like to see for this stage in labour.  Sometimes, if I manually help to open the membranes around the baby this can move things along more quickly. Some women have said that it can be uncomfortable while others report no problem. There is a minor risk of infection and [blah blah blah more things I haven’t learned yet blah blah blah]. The other option is to wait and monitor progress. What do you feel comfortable with?

Subtle difference, but ultimately two totally opposite approaches to care. Sometimes, in informed consent, it can seem like the only choice is to say yes. Without options otherwise, how could you not agree?

If you do have a clinician that uses the informed consent approach, Shaw suggests having a birth plan ready to have your voice heard. Don’t be afraid to be vocal and ask for other alternatives if you want to know your options. Remind the health care team of your birth plan. This could be as simple as, “Do I really need this exam?” or “Are there other options?”

Now just for fun, here are some neat 2004 Stats Canada figures that, in my opinion, show how the informed choice model used by midwives is leading to better birthing experiences for women. Of course, you get to decide if you agree with me or not …

In 2004 Statistics Canada reported that:

  • 71% of women whose primary caregiver at birth was a midwife rated their labour and birth experiences as “very positive”
  • 53% of women whose primary caregiver at birth was an obstetrician/gynaecologists, family doctor, nurse, or nurse practitioner rated their labour and birth experiences as “very positive”

Reference:
Shaw, Jessica C. A. 2013. “The Medicalization of Birth and Midwifery as Resistance.” Health Care for Women International 34 (6): 522-536.

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One response

  1. Pingback: Length of Pregnancy Research | Disclosed Moments

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