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My views on Informed
Choice
Decision making is said
to be a physiological construct. This means that although we can
never “see” the decision making process, we can infer from an
observable behaviour that a decision has been made (Wikipedia,
2007). This essay explores the concepts of informed decision
making and choice in the context of maternity care. I’ll
identify barriers to making informed decisions, and how I use
this knowledge to promote informed decision making in my
teaching of prenatal classes.
Informed Decision Making
and Choice
People make decisions
everyday from small ones such as what to have for breakfast to
more significant ones such as whether to have a baby or not.
Choice is being pitched to us for everything, so it’s easy to be
cynical about the idea.
The term decision making
implies that there is a choice to be made. Anyone can make a
decision; however Robertson (1994) argues that making an
informed decision is more than just choosing. It requires
knowing the options, the advantages and disadvantages of each,
and all of the alternatives. For an informed decision to succeed
in the maternity care context other skills are necessary,
including communicating with care providers, determination,
assertiveness, support and decision making skills.
Kitzinger (2007) points
out that the word choice in childbirth is so commonly used that
we forget that it is not the only important element. Choice
implies that we have an assortment of options to choose from and
that the decision making processes is simply to pick one.
Informed decision making is not one simple single concept, it
encompasses many complex issues such as choice, consent and
refusal of procedures (Newburn 2000).
In reality parents are
often guided toward informed consent, but this may or may not be
the only option. Of course, refusing to consent to a procedure
can also be viewed as choice.
Decision making is
influenced by many factors, such as socio-economic status,
disabilities, culture and the media. All of these influence a
person’s ability to process and understand information. People’s
attitudes and access to resources can also be barriers to
informed decision making (Choice, 2008). There are not always
right or wrong answers and no particular path is the ideal one
for all people. There will be answers that are right or wrong
for a particular person which depend upon that person’s
preferences, values and believes.
Barriers to Making an
Informed Decision
Is informed decision
making a reality or merely an illusion? This is the question
many of us advocating for woman’s maternity rights are asking.
Frustration from our struggles to empower women against the
institutionalization of birth has made some of us weary and
disillusioned about the issue.
Many factors influence
the reality of decision making, both prior to and during labour.
In order for us to tackle these issues, we need to identify them
first.
Information and Time
Not all women choose to
attend prenatal classes or have access to them. Knowledge
attained before a woman goes into labour can be invaluable and
lay the foundation to making informed decisions while in labour
(Nichols and Humenick, 2000). The quality of information
received during prenatal classes can have a huge impact on
informed choice. If a woman is lacking information, or has
received wrong information, how can she make an informed
decision?
In my community, the
majority of pregnant women are seen by obstetricians.
Appointments are often no longer than five minutes (Arms, 1998).
This does not allow for adequate exploration of relevant issues,
such as prenatal testing, place of birth, pain relief, medical
interventions and methods of delivery. Women who are seen by
midwives are able to discuss these topics prenataly, however,
only less than 8% of women have access to midwifery care in
Ontario (Ontario Ministry of Health, 2006)
Time becomes a more
significant factor during labour. It is agreed by many authors
that lack of time is a major barrier to informed decision making
(Rubin, 1985; Welch 2002). The nature of labour and birth often
leads women to use heuristics in their decision making process.
This principal refers to decision making when all possibilities
cannot be explored resulting in people taking shortcuts in
reasoning and rushing to a decision (Magalhaes, 2005)
For example, I had a
doula client determined to have a VBAC. During her second
labour, her cervix did not dilate past 4 cm after several hours
of active contractions. The decision to use pitocin was made,
but the baby quickly became distressed. Due to the mother’s
history, she felt pressured by the obstetrician into providing
consent for an immediate caesarean section. Other options, such
as decreasing the pitocin and waiting, were not explored.
Fear Stress and State of
Mind
Our culture has
programmed women to fear childbirth and mistrust their own
bodies.
Many of my clients would
not even consider giving birth outside the traditional hospital
setting. The state of mind of a woman at the time of birth may
also influence her ability to make an informed choice. Doubt
about her ability to make the best choice may lead her to hand
over decision making to others who she feels are better equipped
to make the “right” decision.
Mckey (2006) illustrates
in her novel “The Birth House” how fear and social pressure
affected women’s decision of place of birth in the 1940’s in
Canada. She recounted the history of how women’s traditions and
wisdoms of childbirth, in the name of progress, turned into the
oppression of the medical institution taking away their choice
through fear, shame and empty promises.
One of my doula clients
was hoping to have a natural birth until she found out that her
baby was breech. In my community, if a breech is diagnosed, the
woman’s care has to be transferred to an obstetrician. The
midwives referred her to an OB experienced with breech
deliveries. She was offered the choice of a scheduled caesarean
section or a vaginal delivery. The midwives and I were thrilled
that she was given the choice (which is very rare here), but she
wasn’t. She felt the burden of making a decision that carried
risks. I helped her get all information available for both
options, while keeping my own excitement of the possibility of a
breech delivery to myself. My client was very stressed by the
implications of making this decision given that she would feel
responsible for a bad outcome.
Rubin (1985) states that
what makes someone abdicate the freedom to choose is a fear of
generating self-hate in anticipation of a bad outcome. With
decision making comes responsibility and thus it is the choice
of some people to hand over the decision making to others.
William James (1956),
American psychologist and philosopher emphasized this by asking:
“If a free act be a sheer novelty,
that comes not from me, the previous me, but ex nihilo, and
simply tacks itself on me how can I, the previous I, be
responsible?”
This made me realize that
my client did not want to be given a choice. She wanted someone
to tell her what to do. While to another woman this choice may
have been empowering, to my client it was overwhelming.
Ultimately, she chose the
caesarean section because she felt it was the most familiar to
her, and she felt safer going down a path so many people had
traveled. Thus, another component of informed decision making is
the woman’s own level of confidence. Hellman (1993) describes in
his article “Flaky Decisions” the tendency people have to take
the known, or most traveled road, even when the evidence shows
that there is no advantage to taking one over the other.
Another client of mine,
also in the care of midwives, ruptured her membranes prior to
going into labour. She was Strep B positive, and the protocol in
my area is to consult with and obstetrician and immediately
start I.V. antibiotics. She didn’t mind having the antibiotics,
but when the OB suggested inducing labour she was very upset.
This idea went against her instincts. His presence in the room
was very cold and authoritative and left no room for discussion.
She was assertive enough to ask him for some time by herself to
think and make her decision; however her decision to go ahead
with the induction did not surprise me at all. Even though,
theoretically, she could have denied the suggested procedure,
the way the OB presented it to her was authoritative and
manipulative. Making a decision is remarkably susceptible to the
way in which the information is presented. This “framing effect”
is a barrier to making an informed decision (Benedetto et al
2006).
In my experience of
teaching classes and preparing my doula clients prenataly for
being assertive and making informed decisions, I have seen how
healthcare professionals can melt away all that preparation with
a wink. When a care provider abuses their power of authority,
they can manipulate the greatest fear of all pregnant women: the
fear that something really bad could happen to their baby, and,
even worse, that they would be to blame. This psychological
harassment can be used to control women while in an extremely
vulnerable state.
Yann Martel (2001) has a
very real description of fear and how it acts upon us in his
novel “Life of Pi”.
“I must say a
word about fear. It is life’s only true opponent. Only fear can
defeat life. It is cleaver, treacherous adversary, how well I
know. It has no decency, respects no law of convention, shows no
mercy. It goes for your weakest spot, which it finds with
unerring ease. It begins in your mind, always. One moment you
are feeling calm, self-possessed, happy. Then fear, disguised in
the grab of mild-mannered doubt, slips into our mind like a spy.
But disbelief is a poorly armed foot soldier. Doubt does away
with it with little trouble. You become anxious. Reason comes to
battle for you. You are reassured. Reason is fully equipped with
the latest weapons technology. But to your amazement, despite
superior tactics and a number of undeniable victories, reason is
laid low. You feel yourself weakening, wavering. Your anxiety
becomes dread.
Fear next turns to you body,
which is already aware that something terribly wrong in going
on. Already your lungs have flown away like a bird and your guts
have slithered away like a snake. Now your tongue drops dead
like an opossum, while your jaw begins to gallop on the spot.
Your ears go deaf. Your muscles begin to shiver as if they had
malaria and your knees shake as though they were dancing. Your
hear strains too hard, while your sphincter relaxes too much.
And so with the rest of your body. Every part of you, in the
manner most suited to it, fall apart. Only your eyes work well.
They always pay proper attention to fear.
Pain
Coping with the pain of
childbirth is not often explored by many pregnant women, despite
evidence of the benefits to mother and baby. Eliminating the
pain is usually the sought after road. The ability to separate
oneself from the preconception that all pain is “bad” and must
be “fixed” is particularly challenging.
While pain can be coped
with, experiencing it can block the ability to think with
clarity. The ability to make an informed decision is sub-optimal
when thinking skills are impaired (Tabboush 2008).
An example of how pain
can influence people’s decision making is women who stop
breastfeeding because of sore nipples. One of my clients chose
to not persist with breastfeeding due to sore nipples caused by
her baby’s tongue-tie bad latch. Despite good information,
access to a physician willing to clip the fraenulum, and good
support, this mother chose to discontinue breastfeeding in
favour of bottle-feeding formula. Her inability to cope with the
pain and think ahead interfered with her decision making
ability, as demonstrated by the regret she felt after the fact.
Another example is the
increased pain a labouring woman experiences during transition
creating a frame of mild described by Bradley (McCutcheon-Rosegg,
1984 p15-16) as indecisiveness, self-doubt and dependency. This
inability to make decisions while in pain makes women dependent
and in need of support and advocacy.
Support and Advocacy
Informed choice in
maternity care is subject to the amount of support and advocacy
the woman receives from her care providers as well as her
partner. Making informed decisions with regard to childbirth is
complicated by the need to include the wishes of the baby’s
father. All decisions made will have direct or indirect
consequences on the baby and the family unit. A partner who does
not feel involved in the decision making process may not feel
equipped to provide their full support or be able to act as an
effective advocate (Hawkins & Knox 2003).
Due to the
intensification of emotions experienced by labouring women,
which increases as labour progresses, support and advocacy
becomes more and more imperative (McCutcheon-Rosegg,1984).
Original intentions need to be reinforced and encouraged as
labour progresses, or let go of, if circumstances have arisen
that demand their reconsideration. When support and advocacy are
not present, all of the previously discussed barriers become
more difficult to overcome in order to make informed decisions.
While working as a doula,
I have seen, on more than one occasion, partners withdraw from
advocating and providing support as soon as the reality of
labour becomes apparent. I have witnessed the “out of character”
behaviour that is normal to labouring women cause panic in their
partners, and prompt them to hand over decision making to “those
in charge”.
Promoting Informed Choice
in my teaching
Through my work as a
doula, I have observed how these barriers affect decision making
during childbirth. I have used this firsthand knowledge in the
development of my childbirth education classes. My goal is to
provide unbiased, evidenced-based and current information,
unlike classes offered by hospitals which are regulated by
obstetrician-imposed protocols. These protocols determine how
and what information is given thus influencing choice and
informed decision making.
Through the writing of
this essay, I have included a new activity (see Appendix I for a
full description) to reinforce the importance of assertiveness
and communicating with care providers. While I have always
included practice of decision making skills in my teaching I
have realized that without assertiveness, and good communication
decisions made may not be respected.
Conclusion
In my community, the
reality of informed decision making in maternity care is
limited, some areas more challenging than others. Many couples
are not given the opportunity to explore all of their options;
in other instances, individuals lack the assertiveness necessary
to express their wishes to their care providers or lack the
confidence required to uphold their convictions. To overcome
these limitations, including the many barriers to making
informed decisions, these factors are addressed in my teaching.
For my clients, the most influential barrier is not making
informed decisions, but acting upon them. Robertson (2002)
believes that no amount of education will ultimately affect the
birth outcome, that this is primarily influenced by the
attitudes, values and practices of the caregiver in charge. I
agree that caregivers have a huge influence on the birth outcome
but I also believe that we can prepare women to know what to
expect and therefore be in a better position to be assertive and
stand up for themselves, but unless they are able to confront
“the establishment”, making informed decisions during their
maternity care remains a dream rather than a reality.
Daniela Vasconcellos
(2008)
REFERENCES
Arms, S. (1998) Giving
Birth: challenges & choices Birthing the Future Productions
Barriers to choice (no
date) Choice: promoting shared decision making [ONLINE]
Available from http://www.choicementalhealth.com/barrierschoice.htm [Accessed on 8 December
2007]
DeMartino B. Kumaran D.
Seymour B. et al (2006) Frames, Biases, and Rational
Decision-Making in the Human Brain Science, 313(5787) 684 -687
Gawain S. (2000)
Developing Intuition Novato, California, Nataraj Publishing
Goer H. (1999) The
Thinking Woman’s Guide to a Better Birth New York, The Berkley
Publishing Group
Hawkins M. & Knox S.
(2003) The Midwifery Option: a Canadian guide to the birth
experience Toronto, HarperCollins Publishers
Hellman P. (1993) Flaky
Decisions Management Review, 64
James, W. (1956) The will
to believe and other Essays New York Dover
Kitzinger S. (no date)
Beyond choice Birth Choice UK
[ONLINE]
Available from
www.birthchoiceuk.com/SheilaKitzinger.htm
[Accessed on 9 December
2007]
Magalhaes L. (2005)
Decision Making and Stress Toronto, University of Toronto
Matel Y. (2001) Life of
Pi Toronto, Vintage Canada
Mccutcheon-Rosegg S.
(1984) Natural Childbirth: The Bradley Way New York, Penguin
Group p15-16
McKay A. (2006) The Birth
House Toronto, Alfred A. Knopf Canada
Ness A., Rubin l.,
Frederick-Berner J. ( 2006) The Birth that’s Right for You
Toronto, McGraw-Hill
Newburn M. (2000)
Informed Choice – are you getting there? RCM Midwives Journal,
3(9) 278-281
Nichols F. & Humenick S.
(2000) Childbirth Education: Practice, Research and Theory
London, Sounders
Ontario Ministry of
Health (2006) Midwifery Outcome Reports Ontario
[ONLINE]
Available from http://omp.metrics3d.com/
[Accessed on 15 March
2008]
Robertson A. (1994)
Empowering Women: teaching active birth Camperdown, Australia,
ACE Graphics
Rubin T. (1985)
Overcoming Indecisiveness New York, Harper & Row Publishers
Tabboush Z.S. (2008)
Fitness of Patients in Pain to Make Optimal Decisions Anesthesia
& Analgesia, 106:669-670
Welch D. (2002)
Decisions, Decisions: the art of effective decision making
Amherst, New York, Prometheus Books
Wikipedia, the free
encyclopaedia (no date) Decision Making
[ONLINE]
Available from: http://en.wikipedia.org/wili/Decision_making
[Accessed on 8 December
2008]
BIBILIOGRAPHY
Bender D. et al (1995)
Ethics San Diego, Greenhaven Press
Gladwell M. (2005) Blink
New York, Little Brown and Company
Kaplan L. (1999) Coping
with peer pressure New York, The Rosen Publishing Group
Missner M. (2004) On
Ethics. Toronto, Wadsworth
Spoel P. (2007) A
feminist Rhetorical Prespective on Informed Choice in Midwifery
Journal of the Canadian Society for the Study of Rhetoric Vol.2[ONLINE]
Available from:
http://uregina.ca/~rheaults/rhetor/2007/index.html
[Accessed on 8 December
2008] |
