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Informed Choice And The Politics Of Pregnancy And Birth Care

By Lex Londino, MSN

At the most basic level, informed choice is the process by which care providers involve clients in decisions about their care. The waters become murky, however, when you delve deeper into the real-life experiences of clients navigating the modern pregnancy and birthing care system. In the interests of clarity, here’s a more nuanced definition of informed choice: the process of choosing from options based on accurate information and knowledge. These options are developed through an equal partnership between the care provider and the parents, which empowers them to make decisions resulting in successful health outcomes for themselves and their babies. True informed choice occurs when clients and care providers engage in open, honest communication about the range of options that exist. It is essential for care providers to give an unbiased explanation of risks and benefits, as well as accept unconditionally the choices that clients make. Informed choice does not happen unless clients can decide on a course of action without feeling scared or anxious about retribution for doing so.

Several components of informed choice must be included in any discussion of options for the empowerment to be meaningful. Start by answering these questions:

  • WHAT? The known or potential diagnosis requiring testing or treatment

  • HOW? The nature and process of proposed testing or treatment

  • WHY? Potential benefits of any tests, drugs, or procedures

  • WHAT IF? Potential complications and side effects of any tests, drugs, or procedures

  • WHAT ELSE? Explore reasonable alternatives

Other important components are:

  • Likelihood of treatment success for this client and her baby

  • Benefits and risks associated with alternatives

  • Freedom to say no or choose something else without fear of retribution

  • Documentation of options counseling and the client’s decision to accept or decline testing or treatment

Midwifery Model of Care and Informed Choice

The components outlined are consistent with the Midwifery Model of Care, which acknowledges a trusting client-midwife relationship, shared decision-making, full disclosure of information, and the importance of self determination and the empowerment of parents. The ability to build a trusting relationship is at the very heart of engaging with clients in decision-making and facilitating situations in which clients feel safe and empowered. This approach does not seek out or deny risks, but attempts to be open to recognizing danger if and when it arises. Open, honest discussions with clients about potential problems or complications rest on the premise that while we cannot eliminate uncertainty, we can develop responses to meet its challenges that resonate with our core beliefs and lifestyle and create safety.

Standardized Obstetric Care and “Informed Compliance”

Provider/client power imbalance negatively affects informed choice. A power imbalance exists in the medical/ obstetrical model of care because emphasis is placed on the expertise and control of care providers. Autonomy and decision-making power rest in the hands of providers, who can influence the decisions that clients make. In this model, full disclosure and information sharing between providers and clients does not generally happen. Providers present a medically oriented list of choices, and follow it with a biased explanation of risks and benefits. Most clients in these types of relationships will make choices that they know their providers agree with, in order to avoid antagonizing or angering them. Informed choice does not occur when there is a power imbalance; a more apt description is “informed compliance.” This term refers to communications about healthcare options that are biased to influence clients’ decisions. Components or aspects of informed compliance that differentiate it from informed choice include:

  • Communication patterns about medical risk that are biased to influence the client’s decisions, and which usually lead to a provider-desired decision

  • Provider information about risk is framed toward offering a superior choice over another to avoid perceived risks—the client is not equally informed about risks

  • Information is given, but choice is not always honored and respected

This is troublesome, because pregnant clients value professional opinion and are receptive to clinical direction. Lack of informed choice due to a provider/client power imbalance affects maternity care in several ways. First, trust in providers erodes when clients do not feel safe or confident in expressing their own beliefs and choices. Fear of retribution is a significant factor in clients allowing care providers to hijack control of their pregnancy and birth experiences. Research demonstrates that doctors expect to be in control in maternity care settings. Furthermore, they like “compliant” clients who share their backgrounds and values, and dislike clients who they perceive as noncompliant, questioning, or difficult. This affects the treatment of clients in their care: Clients seen as difficult tend to be ignored, or even treated cruelly. This has a profound effect on parents during pregnancy and labor, who are paradoxically strong yet vulnerable during these times. When parents are not allowed to trust their own intuition and opinions, they are not able to trust their own bodies, pregnancy, or birth itself.

Second, when decision-making power rests with providers, a mechanistic, institutionalized package of pregnancy and birth options outweighs the individual physical, social, and spiritual needs of parents. They become trapped into passively accepting procedures, drugs, and interventions that providers think are priorities, rather than listening to their own inner voices of wisdom and making choices that are best for themselves, their babies, and their families.

Third, power imbalances ensure that in most situations, the person who does the “informing” influences the decisions that individual clients will make. It is important to remember that parents don’t experience maternity care or participate, however minimally, in that care in a vacuum. Intersections of ideology, resources, class, education level, race, lifestyle, gender identity, and sexual orientation influence how clients make choices from a medically oriented menu of options, over which they have little control to define or change. Not only are choices limited by obstetric regimens and protocols, but also making choices about them is largely meaningless when parents have little understanding about, or control over, the value systems on which such regimens are based.

Moving Toward Better Communication

Since childbearing does have risks associated with it, care providers should initiate a meaningful dialogue with clients to discuss theoretical and potential risks. They should communicate all risks in both positive and negative terms, and place them in context so that parents understand the probability of an outcome occurring. They should address elements of informed choice whenever a decision needs to be made. The process of informed choice is not an isolated occurrence, and should be ongoing throughout pregnancy, birth, and postpartum.

Individualized care that is continuous, personalized, and based on shared and equal power is important for the therapeutic relationship between care providers and their clients. Recognition of the inherent power and wisdom of parents helps parents trust themselves to make appropriate and healthy decisions, and helps foster a relationship based on open dialogue, equality, and trust. Several key actions that care providers can do to truly implement informed choice are:

  • Facilitate discussions, rather than steer clients toward a line of thinking that they agree with

  • Use open-ended questions to help clients explore their own feelings

  • Acknowledge that making decisions is sometimes hard, and there is not always a “right” answer

  • Validate clients’ feelings

  • Establish a relationship based on connection, trust, and mutual respect

  • Provide the most up-to-date evidence-based research findings to help parents make decisions

With this in mind, providers can offer the best, most comprehensive care, individualized to give parents the birthing experience they desire.

What is Midwifery?

Woman is primary actor(“births” baby as “client”) Provider is primary actor(“delivers” baby from “patient”)
Labor and birth are supported as normal life events Labor and birth are managed as pathological conditions
Interventions are used only when necessary Interventions are routine
Birth takes place within preference and needs of woman Birth takes place within preferences and policies of provider/institution
Health focus is one motional, mental, physical well-being Health focus is on survival
Woman meant to”assume risk” for decisions Provider often”assumes risk” for decisions