Understanding the range of possible birth choices on offer is one thing, negotiating them is another. Patient autonomy and health literacy is something you need to be across if you are working towards a physiological labour and birth. What I’m talking about here is the concept of a birthing woman having the right to be informed about and say ‘yes’ or ‘no’ to medical procedures and interventions suggested to her.
What health literacy and medical decision making should look like in practice is ‘patient autonomy’ on the part of the patient—in our case the birthing woman—who will make her choices in light of the evidence provided and based on her values and research, her baby’s and her own health, her sense of responsibility and her capacity. Now her choice might either be giving ‘informed consent’—that is, saying ‘yes’ to what’s suggested; or it may be ‘informed refusal’—saying ‘no’ to what’s suggested. In either case there will be an expectation that her autonomous choice will be accepted without coercion or refusal of support and goodwill. On the part of the medical caregiver, in theory they should practice in a way that honours patient autonomy and, in our case, provides the birthing woman with ‘women-centred care’ by sharing evidence-based information. They will quantify risk specific to the particular woman and her baby, and practice within the code of ethics of their profession.
That is what it should look like. But what it more often looks like in practice is a passive patient being informed of what is happening. Or, in many cases, not even being informed. The dynamic at play in these situations is what can be described as the ‘trance of acquiescence’. In medical settings many of us have low levels of health literacy and may not realize that we even have a choice. We seem to automatically give up our autonomy and slip into this ‘trance’, accepting whatever is suggested without discernment about whether we want it, whether we need it, or what agendas might be behind whatever is being suggested. This passive trance of acquiescence is actually the psychological equivalent of a fear-based ‘freeze’ state.
Because of this, interactions between medical caregivers and their patients are often transacted within this dynamic—a compliant trance of acquiescence on the part of the fearful patient, and, a corresponding ‘assumption of acquiescence’ on the part of the medical caregivers. In many birthing situations this is what passes as ‘informed consent’.
Added to this ‘trance’ and ‘assumed acquiescence’ dynamic, many of us are ‘conflict avoidant’. We want to keep a ‘good vibe’ over and above speaking up for our needs in a tricky situation. Also, a tendency towards conflict avoidance is heightened in the birthing woman who is flooded with oxytocin—the loving, ‘tend and befriend’ hormone. She just wants to be sweet to everybody. So in the face of any tough negotiations about procedures and interventions she is more likely to fold if the environment gets tricky. Not only that, if the situation becomes conflicted this will impact the whole hormonal balance anyway—shooting up an adrenalin response which effects oxytocin levels. You might win the point but the optimal hormonal flow for normal physiological birth will be compromised.
You need to be awakened from this acculturated ‘trance of acquiescence’ and get savvy about the practices and procedures you will routinely be offered, in order to give ‘informed consent’ or—and given that routine protocols are designed for worst-case scenarios—more likely ‘informed refusal’ to protect yourself from any unwanted interventions. You need to be aware of informed consent, but also of your right to informed refusal.
Philosophical match
These issues of patient autonomy and appropriate care bring us to the importance of ensuring you find a carer who is a good ‘philosophical match’ with you. Ideally, if physiological birth is your intention, you’ll find a match with caregivers who are woman centred in their practice. Woman-centred practitioners also want to work with women who are fully aware of the personal responsibility required of them when giving informed consent or refusal. This compatibility in terms of understanding patient autonomy would contribute to a philosophical match.
You can see that it would become problematic if a birthing woman, aware of her need and right to exercise patient autonomy, is attended by a caregiver who is expecting acquiescence on her part. A power play generally gets going that does nothing for the birth hormones. Just as problematic would be the scenario of a woman caught up in the trance of acquiescence who wants to be told what to do, but is attended by a caregiver looking for her to take responsibility and make her own choices based on the evidence. So much is dependent on ensuring that you have a philosophical match with your caregivers. This is where continuity of care with a known caregiver comes in – trust comes out of an established relationship and a shared philosophy.
Human rights in childbirth
Rebecca Schiller in Why Human Rights in Childbirth Matter (Pinter & Martin) addresses the relevance of human rights to maternity care. ‘The fundamental human rights values of dignity, privacy, equality and autonomy are often relevant to the way a woman is treated during pregnancy and childbirth,’ writes Schiller. ‘Failure to provide adequate maternity care, lack of respect for women’s dignity, invasions of privacy, procedures carried out without consent, failure to provide adequate pain relief without medical contraindication, giving pain relief where it is not requested, unnecessary or unexplained medical interventions, and lack of respect for women’s choices about where and how a birth takes place, may all violate human rights and can lead to women feeling degraded and dehumanized.’
Obstetric violence
When contemplating this ‘yes or no’ issue, we might also put into the mix the definition of obstetric violence, presented by UK obstetrician Dr Amali Lokugamage:
Obstetric violence is the act of disregarding the authority and autonomy that women have over their own sexuality, their bodies, their babies and in their birth experiences.
It is also the act of disregarding the spontaneity, the positions, the rhythm and the times the labour requires in order to progress normally when there is no need for intervention.
It is also the act of disregarding the emotional needs of mother and baby throughout the whole (childbearing) process.
Sadly, this definition of obstetric violence is what so often passes for standard care in birth – so you can see how important it is to be on the case about informed consent and informed refusal.
Evidence-based care
But there’s some good news coming out of recent research.
It supports trusting birth rather than continuing to over-medicalise it, and even though there is always a time lag before research translates into changes in practice and protocols, nonetheless its very encouraging. ‘Safe prevention of the primary caesarean delivery’, a consensus statement from the American College of Obstetricians & Gynecologists and the Society for Maternal-Fetal Medicine recommends taking a more ‘hands off’ approach – waiting longer on babies to initiate labour because induction increases the risk of caesarean; suspected ‘big’ babies not an indication for caesarean; slow but progressing labour in first stage is not an indication for caesarean; extended timing protocols for second stage of labour (up to 3 hours for first baby); changes to the interpretation of fetal heart rate patterns; encourage continuous labour support as it is one of the most effective ways to decrease the caesarean rate. It seems the research is finally shining a light on trusting birth and women’s birthing capacity.
Conclusion
Putting together an awareness of human rights in childbirth; naming obstetric violence; referring to evidence-informed care, brings us to the conclusion that yes, you can say no. And if physiological birth is your intention, in a system not centred on supporting it, then there are many instances in which you must say no, if you are to honour your birthing capacity.
A version of this article was originally published in The Natural Parent Magazine, 2014.