Wednesday, April 2, 2008

Informed choice in childbirth: What about midwifery responsibility?

This is a great video of a presentation by Barry Schwartz. He is a phsycologist and discusses the paradox of choice.

In midwifery we pride ourselves on offering women "informed choice". What does this mean? Women need to understand what is happening during pregnancy labour and birth. Midwives have a responsibility to support and guide women through the process of becoming mothers. As a midwife I have an responsibility to outline the type of care the woman might expect from me, for example if I provide care at homebirth and in a primary or secondary facility. If I can support her choice for water birth or if this is outside my area of expertise. I need to have these conversations with women early in the care I provide so that there are no unexpected surprises as the birth approaches. If I cannot provide an aspect of care that she wants then I need to refer her to somone else who can.

When it comes to the point where a woman does not want to make a choice and wants her midwife to make this choice for her what should we do? Are the women we care for overwhelmed with choice and is this OK? As midwives and guardians of normal birth do we need to inform women about about all battery of medical interventions that have become part of the 'normal' birth experience? Do we need to prepare all women for ultrasonography, Group B Streptococcus,gestational diabettes, epidural, caesarean section, forceps and ventouse. Should we be more selective in what infromation and choices we give to what women? Are all these choices playing a role in the ever increasing medicalisation and intervention in childbirth in our society?


Hannah said...

Very interesting questions Carolyn.

As you know I am not a midwife, YET ;) But just the other night (at Antenatal Class) we were talking about vitamin K options (none, oral or IM) and a young woman asked me what I thought she should do!

I suggested she research it more over the coming weeks, talk to other parents etc etc but I would never say "do THIS.."

My colleague asked the group if it would be easier if someone just told them what they should do and the majority response was YES!

I think it is OK for midwives to make reccomendations.

And I think women may be overwhelmed with choice, but parenting is a LOT of decision making so they really need to get used to it.

I'm very interested to read midwives' responses to your question re: being more selective with info / choices with some women..

Psalms66 said...

I'm a student midwife - just found your blog when it came on my google list - this post really resonates with me. I just recently found out I am pregnant again (number 5). I have had 3 VBAC's in hospitals, no homebirths (my former husband would not allow it). This will be my first homebirth. as a midwife I can't totally go unassisted, but find the choices surrounding birth astonishing! I can't have a vaginal hospital birth because of bans in my area, but ther are OH SO many choices otherwise it is overwhelming. I never had this before - I had old-school OB's who told me the "best" way to do things, and I obeyed. Though I relish the freedom that has come with these choices I can now make, I am admitedly overwhelmed. Whew.

cool site by the way! I'll be back!

Carolyn said...

Thanks for comments Hanna and Psalm66. I am looking forward to getting more feedback on this from women and midwives.

I would hate for midwifery to take on the perspective that "the midwfe knows best" and the midwife should make decisions about care for the woman. This was the way I have experienced obstetric care in the past and is also probably still the way it is for some.

However I do think midwives should be able to offer an opinion about care options while acknowledging their own biase. For example I am very much in favour of home birth and of water birth, through experiences I have had with women and through researching outcomes and issues for birth in these environments. I would happily recommend these to women while acknowledging that I do have a biase and the decision about where to birth is the womans.

The same may be true for third stage management and the evidence about this is often open to interpretation. Whether to opt for active or passive managment of the third stage? The perspective on this might depend on what the woman and/or midwfe are used to, or their philosophical perspective or their interpretation of the evidence around this. If the midwife is making a recommendation it needs to be clear that it is based on these perspectives and that the final choice is the woman's.

Sarah Stewart said...

I see giving women a choice as being a cop out sometimes. We don't want to make the hard decisions so push them onto the women . I believe that midwives have to stand firm in their philosophy sometimes and say 'this is the care I deliver and why' and stick to it.

Carolyn said...

I agree Sarah. Making sure women have a good understanding of what your philosophy is right at the start of care is important isn't it. They can then choose to stay with you or seek another care provider if they don't like the type of care you offer.

But what about all of the things that medicalise normal healthy pregnant women, all the screening tests that have become part of "normal" care. Do you offer these as choices? Do you tell women all about them? Do you just do them and only tell women if there is a problem? How do you handle this? Counselling and debriefing about all of the screening that we have to do nowadays can take up so much time and energy from everyone, and what does it all achieve?

Lisa Barrett said...

No screening test is part of normal care in pregnancy and birth. It is the midwives role to give ALL information and support the woman in the decision she makes regardless to our own opinion of it. This doesn't mean we can't give opinion when acknowledging bias however delivering care isn't our role. Being with women is. Do we withdraw our care if a woman choses an option that we wouldn't?

Anonymous said...

Hi, I am a sixth year student applying for University to become a midwife. I have been researching to find different oppinions about "Should woman have choice in childbirth?"

Surely, all the information should be given to the expectant mother in a effective way so that both she and dad-to-be know all the possibilities available to them, and the risks that these options carry with them? If the parents choose a method that the midwife has duobts about, then voicing these opinions should be done in such a way that the parents understand them and can change their mind if the so wish. Otherwise, the midwifes should use their knowledge, abilities and facitilies to the maximum to ensure that the parents are able to bring their child into the world in the way that they want to

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