Friday, June 5, 2009

Forced caesarean, informed consent?

I was linked to this post by friend on Twitter. I have no way way of knowing the exact circumstances of this child being removed from its parents. Perhaps there were other issues, I hope it was not, as the story suggests, because of the mother declining to sign a consent form for a caesarean section, should it become necessary, during her stay in the labour ward. Ultimately the woman had a vaginal birth of a healthy child and caesarean was not necessary, however she was taken to court because of her refusal to sign a consent and her child was removed from her care. There may well be other circumstances involved and this is only part of the reason however the simple story of requiring a woman to sign a consent for caesarean "just in case" it is required and then accusing her of breach of her responsibility to the child because she refused to sign is something worthy of serious consideration. This took place in New Jersey in the United States of America, so a different cultural social and medical perspective to ours in New Zealand. None the less I would have thought that processes around obtaining consent, and considerations of when intervention in birth is appropriate, should be similar in any supposedly 'civilised' 'western' 'economically advantaged' society

Seymour (2000) discusses informed consent in childbirth in terms of UK, US and Australian legislation. He suggests that coercing women to accept treatment is not supported in law and that women have a right to full information and to make their own decisions based on that information. Seymour suggests it is paternalistic for a practitioner to discuss risks and benefits of different options and then expect a woman to take a particular course which the practitioner feels to be the correct and obvious choice. Informed decision making means that women are free to make decisions based on information, their knowledge of the situation and their own circumstances and preferences. Once this decision is made women should not be coerced into making a different choice unless circumstances change. The woman is then informed of this change and is able to reconsider her decision.

In New Zealand this right for women to make decisions about their care is upheld by the code patient rights and is monitored by the Health and Disability Co missioner. When acknowledging that the woman has the right to consent we must also therefore acknowledge that the woman also has the right to decline treatment for herself and her child. Informed decision making therefore involves a process of giving information and allowing the individual time to consider this information before asking if they will agree to the procedure, or which of several choices she will take. Signing a form on admission to a health facility to give the health practitioners blanket rights to perform any procedure they feel may be necessary in the circumstances is therefore not informed decision making.

Giving information in such a way that there is no real choice is not informed decision making. For example to state "I need to do this now, is that OK?" is not an informed consent process. Some practitioners seem to use this type of statement for consent to a variety of procedures, from taking a blood test, to obtaining a heel prick blood test from a baby, taking blood pressure, to administering medication. For the decision to be truly informed the practitioner needs to find out what the woman knows about the procedure and fill any knowledge gaps for her in simple, non medical terminology. It is preferable to do this well in advance of the intervention that is being undertaken and to give some written information for the woman to consider. Only then can the woman make a truly informed decision about whether she is happy to have this intervention or not. If the practitioner believes a decision places the woman or baby at risk then he or she has a responsibility to tell the woman. The practitioner has the option of declining to provide care for the woman if he or she believes what the woman wants is outside their scope practice and would place the practitioner at risk. IN this unusual circumstance the woman should be given the opportunity to be referred to another health practitioner who may be able to accommodate her needs. For example if a woman wants a home birth and the practitioner does not provide this service then the woman should be given the names of practitioners who can provide this for her. This option of refusing to care for a woman should not be used as a means of coercing the woman to accept a decision she is opposed to.

In conclusion women have a right to make informed decisions. This means women also have the right to decline treatment which has been recommended to them. Practitioners need to be able to provide information and allow women to make decisions even if those may not be the decisions that the practitioner believes to be the best in the circumstances. Practitioners should document the information that has been shared with a woman, what the outcome of the discussion has been and what decisions have been made.

Seymour, J. (2000). Childbirth and the law. London: Oxford University Press. Available in part online from google books

Image: "What to do" from starry eyed Cece's photos on


Pam said...

Hi Carolyn,

I'm passionate to the point of being a complete pain in the behind about informed consent. This came to light especially when I started LMC work locally. I was told that all women who are booked to birth on the unit had to sign a consent form for "maternity services" I always refused to ask my women to sign it and often got a "smack" on the knuckles by the ward receptionist for not completing my documentation correctly. The DHB have never challenged me I think just putting it down to Pam being 'stroppy' once again.
One advantage of doing the post grad study is that I put the question of its purpose and whether any other unit in the country did the same thing on the blackboard discussion forum. The answer came back to me that in the past some units had done it in the past but since the Cartwright inquiry in 1995 it had been abolished and so it could be perceived as being in breach of rules 6 & 7 of the HDC. One disadvantage of only being here the last 5yrs.
Finding this out has given me the courage to bring it up with the local NZCOM rep and I really wish to challenge this practice further.

Carolyn said...

Well done Pam for challenging this practice. I think sometimes these things have just been done because it is the way it has always been done, rather than thinking about the rationale for what is being done. I would expect that despite the fact that the woman has signed a consent on admission she would still be given information about any interventions that become necessary and has an opportunity to consent before anything is done.

InfoMidwife said...

This is very disturbing, however nothing surprises me coming out of America. This topic is very dear to me, I am passionate about women's right to choose, to make informed decisions. However we all know that America is pro fetus, and women are secondary. It seems ludicrous that a woman can refuse a c/section and have a normal birth best outcome for both mother and baby and then to have the courts take her baby away for failure to comply with the medical model - this is just outrageous but unfortunately typically American. I pray that we do not follow there example.

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