Monday, August 01, 2011

"Women have the right to ..."

What right or rights do women have? What special rights do childbearing women have? What rights do mothers and babies have?

This question has played in my mind recently. Readers who have read the previous post may have noticed the statement:
"Women have the right to self determination and to be supported and encouraged to get on with ..."
Do they? Really?

What does 'self determination' look like? How does it work when difficult decisions need to be made in maternity situations? How does it work when the woman is frightened by the power of her labour? What support and encouragement is appropriate ...? Isn't that the time when the "best laid plans" come undone?

We know that in modern societies all competent persons (female or male), in the context of health care, have the right of refusal. The woman in maternity care has this right, even when her refusal may result in what most would consider to be adverse consequences for herself and her baby.

'Refusal' is very different from 'self determination'.

Consider this scenario:
Midwife: "Jane, I am advising you to go to hospital and have an induction of labour, for the following reasons [eg post 42 weeks' gestation] ..."
Jane: "I understand that you advise induction of labour. Would you please tell me what is likely to happen if I refuse your advice."
Midwife: "As your midwife I would continue to check you and your baby, and tell you if I detect any changes. I would also advise obstetric review at XX hospital. The tests that are usually carried out at this time are fetal monitoring, ultrasound studies that check blood flow to your baby, and measurement of your baby's amniotic fluid level. These investigations, which can be repeated as time passes, may detect subtle changes in baby's condition, or may reassure us that your baby is well."
Jane: "I have always planned to wait for spontaneous onset of labour, unless there is a valid reason to interrupt my natural process. I don't think 42 weeks gestation alone is sufficient reason. Therefore I will refuse induction today, and wait for labour to begin. I am willing to make an appointment for specialist obstetric review."

This conversation, in which the midwife gives professional advice (for whatever reason), and the client/consumer makes a decision, based on her understanding of principles of appropriate maternity care, and the information given to her, to refuse that advice, is what I call 'informed refusal', or 'informed decision making'.

A very different conversation would be something like:
Midwife to Jane: "You're 42 weeks. What do you want to do now? Induction or wait for labour?" [ie self-determination]

Since the early 1990s, midwives and maternity consumers have quoted the reports of the British government's inquiries into maternity care, that women want the 'THREE C's' choice, control, and continuity of care. Since the early 1990s I have worked with Australian women and midwives, and have often used the THREE C's as a guide in the uncharted terrain of birth reform.  However, this little mantra should not be seen as a statement of women's birthing rights.

I have seen situations in which a woman's choice, or her sense of control [self determination], have led to what I see as disastrous outcomes - loss of life, and potentially preventable harm.  In these situations 'continuity of care' has been 'continuity' [same person] without the 'care' from a professionally skilled person who has the duty and ability to act in the interests of mother and baby at all times.  The care has been confused, fragmented, and ineffective.   A midwife or doctor who says "What would you like to do now?", when the only responsible statement is, for example, "I must advise you that your baby needs to be born now ..." is forgetting their professional duty to that woman.

When a woman has effective continuity of care, with a midwife who she (the woman) respects, and who respects her, there will be no doubt about the differences between a woman's rights, a woman's choices, and the midwife's duty of care. 

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