What We're Seeking: Informed Consent & "Choice"

"What We're Seeking" is a bi-weekly series that expands upon Safer Midwifery for Michigan's statement of purpose.  This week's post examines the issue of informed consent as a means for making an informed choice.

Midwives and their clients are proponents of "educating" themselves and making "informed" decisions about the care they receive.  Women often feel "empowered" by making choices for themselves instead of inviting a physician to do so for them.  This brings me to the question, what does it mean to truly make an informed choice?  In order for someone to make an informed choice, giving their consent, they must first have some body of information on which to base their decision.  The word choice indicates that they are choosing between at least two options.

The aforementioned definition would imply that midwives offer clients balanced research, information that supports multiple perspectives, and then the client decides what is best for her without influence of fear or mantra.  In order to achieve the goal of making an informed choice a client also assumes that the research being presented by her midwife is credible, evidence-based, and in tact (meaning it hasn't been manipulated to influence her in a particular direction).    

After establishing a clear understanding of what informed decision making entails, lets look at the opposite end of the spectrum, indoctrination and brainwashing behavior. 

A) Indoctrination: 

1. To instruct in a body of doctrine or principles.

2. To imbue with a partisan or ideological point of view.

(Synonyms: brainwashing, schooling, training, inculcation, ingraining, instilling)

B) Brainwashing:

1. Intensive, forcible indoctrination, usually political or religious, aimed at destroying a person's basic convictions and attitudes and replacing them with an alternative set of fixed beliefs.

2. The application of a concentrated means of persuasion, such as an advertising campaign or repeated suggestion, in order to develop a specific belief or motivation.

(Synonyms: indoctrination, conditioning, persuasion, re-education, manipulation)

Now it's time for you to decide.  Below are a few scenarios for your consideration.  Each is based on real life experiences with out-of-hospital midwives in MI.  Read each one and determine in your own opinion if you think it represents informed choice or indoctrination.

Scenario I:  

The biggest decision a mother makes is where to have her baby.  When considering the options, every mother looking at out-of hospital birth asks the question, "Is it safe to have my baby outside the hospital?"  When touring a freestanding birth center early in pregnancy, here's how the conversation went for one MI mom ~

Client: Is it safe to have our baby here?

MW: Birth is as safe as life gets.  Your body was made to do this and women have been giving birth for centuries.  Birth centers aren't for everyone.  We screen our clients carefully and only take on low risk women with normal pregnancies.  In addition, we have attended hundreds of births.  We know how to spot trouble and get you the help you need in plenty of time.

Client: What if something goes wrong? 

MW:  The hospital is only 12 minutes away should you need to transfer care.  We transfer moms often and for a variety of reasons.    

Client: Have you had adverse outcomes before? 

MW: We did deliver one baby who we knew wasn't fit for life outside the womb.  There are no guarantees and babies do die in hospitals too.  Having your baby at our birth center is safer than the hospital, who has a cesarean rate of 32%.

Client: What does the birth center model offer in comparison to the hospital?  How do the two differ?

MW: The hospital staff does not know how to support natural childbirth because they don't often see it anymore.  They are bound in practice by limitations that insurance companies require of them, like not letting you eat during labor, tying you to a bed with an electronic fetal heart monitor, and giving you IV medications.  In a hospital, you are subject to the doctor's protocols and decision making, and much more likely to receive unnecessary interventions.  At the birth center, babies are born gently, in comfortable rooms, and in birthing tubs.  Your instincts guide you, no one is telling you when to push or how to move.  You can eat and move freely and let labor progress naturally.  

Comments:  What evidence-based information was given to inform the client from Scenario I?  The only fact I can find is the cesarean rate for the local hospital.  Were there any risks discussed for either option? How can this client have made an informed choice when she was only told about all the wonders Natural Child Birth & what the birth center has to offer, but none of the specific risks?  To say that, "There are no guarantees, they only take low risk clients, they transfer to the hospital and that the hospital is only 12 minutes away," is not an explanation of risk, they are marketing statements.  There is no talk whatsoever about those risks that come up in an instant during birth that can't be avoided, the potential for harm when those situations arise outside a hospital, or the benefits that modern obstetrics can offer in certain situations.  There is no discussion about what would constitute high-risk.  There is however a lot of implicit philosophy already starting to be suggested as superior.  With NO discussion of risks involved, how can this client make an "informed" choice about where to have her baby safely?

Scenario II: Approaching 20 weeks, a midwife asks her client if she'd like to have a 20 week ultrasound.

Client:  Is there a reason to have an ultrasound other than finding out the gender? 

MW: It's really up to you.  There's no reason to have to do an ultrasound.  In fact there aren't really enough studies to know if ultrasound technology is 100% safe for babies in utero. 

Client: Well we don't want to know the gender and I guess if there's no reason to do one, why take the risk? 

MW: Here's our waiver form to decline an ultrasound if it isn't something you want to do.  The choice is yours.

Comments: Again, influence of opinion or sharing evidence-based data?  Does this conversation show balanced information that would lead a mother to make and "informed" choice? Does signing a waiver mean she's been "informed"?

Scenario III:  A birth center client is asked if she would like to do the typical Gestational Diabetes Screening, after all the choice is hers to make.  The midwife gives her client a piece of paper to read over that explains what Gestational Diabetes is, who is at risk, and how to avoid/treat it.

Client: Is this testing necessary? 

MW: Considering your nutritional habits, I don't see any reason to be concerned.  You can have the testing done if you want to. (Note: this particular client of average weight and height, has gained 40 pounds already, by 24 weeks gestation)

Client: What would happen if the test came back as concerning? 

MW: You would have to monitor your diet more closely and with appropriate effort your baby will be fine.   
Client: What are the concerns about having a baby with gestational diabetes?  

MW: The babies are generally larger, but you body won't grow a baby too big for you to birth.  Being labeled as having Gestational Diabetes increases your chances of having lots of interventions and a c-section.  Here is our waiver form if you decide to decline testing. The choice is yours.

Comments:  Influenced or Informed?

In any of these scenarios, was evidence based information given from multiple perspectives?  Was information given without biased influence?  You can't make a choice about something with only partial information and NO explanation of risks involved.  You also can't make a clear choice about something when you're being subtly indoctrinated to think a certain way about birth.  Bear in mind too, that this subtle indoctrination is coming from the very people you have come to trust, when you come through the door each week for you hour long appointment, greeted with a long hug from a supposed friend, and offered a glass of pregnancy tea.  

The goal of all those caring for pregnant women should be to teach them about birth so that they can fully engage in the journey, rather than to indoctrinate them in a narrow set of beliefs. The key to making an informed choice is first having all the information necessary to consider and decide upon. It's being informed of all of the risks on both sides of an issue.  To be "educated" is to have information from multiple perspectives, not just one point of view.  Indoctrination and brainwashing are not synonymous with education.  Ladies you are not making "educated choices", the choices are being instilled in you, made for you, with carefully presented statements of untruth and a side dish of fear about how awful the hospital will be.     

Establishing standards for the practice of midwifery in Michigan is exactly what women deserve in order to have the opportunity to make an actual, informed choice.  In our current state of severely lacking regulation in MI, how can anyone make a choice about even selecting a midwife to attend a birth, when there is no way to know her number of infant deaths, injuries, complaints filed against her, desertions, transfers, etc.?  If there is no standard for education and scope of practice choosing a midwife is like trying to pick a needle out of a haystack, a haystack loaded with needles, and hoping you don't get pricked in the process.  Making an educated, informed choice about your care is nearly impossible within the current midwife model in Michigan. Time for change.   

For further reading on this topic, visit:  Deconstructing Informed Consent