Decisions, decisions

Throughout your pregnancy and during labour, birth and parenting, you will be faced with a seemingly never-ending array of decisions to make. There’s no right choice for every woman, as what you choose will be influenced by your personal beliefs, values and culture.

The one thing that does hold true for all women, however, is that your choices about your body and your baby deserve to be respected. As you consider the best options for you, it is essential to remember that you have the right to accept or decline any test, treatment or procedure proposed by your medical care provider or hospital.

For whose benefit?

Although hospital care providers have your physical safety as their primary goal, they are also employees of a large institution. And, as a large institution, your hospital has a long list of policies and protocols designed to ensure efficient management. When a medical care provider indicates that a certain procedure is required, this requirement may have more to do with adhering to hospital policy than with an assessment of your specific situation.

In general, most hospital regulations do not take into consideration the factors that ensure the most positive birth outcome for mother and baby – factors such as privacy, patience, low lighting and a woman’s freedom to be upright, active, well nourished and well hydrated throughout labour. Surprisingly, the majority of hospital protocols and policies toward birth are not based on the most recent scientific evidence. Rather, these regulations are often driven by other issues, such as cost control, staffing constraints and protection against liability and litigation.

Healthy mother, healthy baby…?

When recommending a procedure to a woman in labour, care providers will often focus solely on perceived physical benefit, to the disregard of the woman’s and baby’s emotional and psychological wellbeing. It’s clear that this focus is too narrow and that what’s needed is an expansion of the definition of ‘healthy mother, healthy baby’. Physical, emotional and psychological wellbeing are not mutually exclusive; rather, they are interdependent and should be the goal of anyone working in maternity care.

Debby Gould of Birthtalk.org, an Australian organisation that provides birth trauma support, sums up this view when she says, “The goal of emerging from birth with body and baby intact is a bit of a no-brainer, really. Of course we all want that. But what many health providers fail to recognise is that it is completely possible to support a woman to birth a child so she feels mentally healthy afterwards, without compromising safety in any way.”

How do you know what to choose?

You have the right and responsibility to be an active participant in decision-making, but how do you know what choices to make? In order to make the decisions you feel are best, you need to educate yourself with the latest evidence-based information.

• There are many trusted websites, journal articles and books that provide comprehensive yet accessible research on the most important topics in pregnancy, labour, birth and parenting.
• Independent (not hospital-based) childbirth education classes provide another source of unbiased information based on the latest evidence.
• Your doula not only shares knowledge with you but also helps you prepare your Birth Preferences Statement. She is with you in your birth space and can remind you and your partner to ask the questions you need to make decisions based on fact, not on arbitrary hospital regulations.

What questions can you ask your medical care providers?

You are fully within your rights to ask the questions you need of your medical care providers. Your care providers are there to work for you and an open dialogue will help ensure you receive the  support you need. Be sure to share your Birth Preferences Statement with your care provider during your antenatal visits so she/he is aware of what is important to you.

If you are not satisfied with the answers to your questions or the response to your Birth Preferences, don’t let the discussion end there. Ask your care provider for the evidence supporting her/his information and consider seeking a second opinion. If you’re still not satisfied or if you don’t feel your request for information is being met respectfully, you have the right to change care providers and chosen birthplace, even in the very late stages of pregnancy.

When you are in labour, ensure that you are given the time and information you need to make decisions on any procedures proposed to you. Your doula can help you with this. There are several useful memory tools to help you remember the most crucial questions to ask.

• The most basic is BRA – that is, asking ‘What are the Benefits, Risks and Alternatives to what is being recommended?’
• A more comprehensive tool is BRAIN – asking the same questions as above and adding on:   
• I – ‘What is my Intuition telling me?’ (and this is important, as labouring women have a very strong intuitive sense as to their baby’s wellbeing)
• N – which can stand for either ‘Does this need to be done Now, or can it wait awhile?’ or ‘What would happen if I chose to do Nothing (to refuse the recommendation)?’

One of the most important roles you have as a parent is standing up for what you believe is best for your baby. Don’t let institutional policies and protocols stand between you and what you think is right.

Your right to Informed Consent and Informed Refusal

You have unassailable rights regarding the care offered to you and your baby. Again, just because a procedure is part of a hospital’s protocol doesn’t mean you must accept it if you don’t believe it’s in your or your baby’s best interest.

You have the right to informed consent and informed refusal of any medical test, treatment or procedure.

• This means that a “competent person must freely and voluntarily give consent to a specific treatment/procedure”. Consent cannot be coerced nor can it be a ‘blanket’, covering a full range of treatments/procedures.
• If care providers do not gain consent prior to a treatment/procedure, it could lead to an action for ‘trespass to the person’ (that is, assault and/or battery).
• Medical care providers have a duty of care to provide adequate information so that consent or refusal can truly be informed.

The right of informed consent and refusal is protected under Australian law. Similar laws exist in many other countries, so be sure to investigate the law relevant to your location.

• In Victoria, informed consent and refusal is covered under Section 10(c) of the Victorian Charter of Human Rights and Responsibilities.
• Additionally, the Australian Medical Association (AMA) released in April 2013 a position statement advising doctors that they should respect the decisions of fully informed pregnant women. This is part of a 10-point statement covering Maternal Decision-making.

For further information and more detailed analysis of your rights, please see the Links under Your Rights in Childbirth.

WHO else defends your rights in childbirth?

The World Health Organisation (WHO) acknowledges that every woman has the right to choose the type of care she and her baby receive and to have access to information about her health, her options and the intervention rates of local maternity services.

WHO also recommends:

• Women should be able to move around during labour and choose a position for birth.
• Electronic monitoring of the baby’s heart in labour should not be routine.
• Drugs should not be routinely used.
• Babies should not be separated from their mothers and breastfeeding should be promoted.
• Labour should not be induced for anyone’s convenience; the rate should not be higher than 10 percent.
• Artificial rupture of membranes should not be routine.
• Episiotomies should be avoided.
• The caesarean rate in any region should be no higher than 10 to 15 percent.