Sunday, April 21, 2013

Informed decision making

As I take a few moments to reflect on the past couple of weeks, I am trying to pull together the issues in the world of maternity, and highlight anything that needs critical comment from yours truly. 
no explanation required!




The AMA's new Position Statement on Maternal Decision-Making is worth focusing on for a few moments.  My initial comments are at the MidwivesVictoria blog.

The topic of  'decision-making' in situations of known risk - particularly breech and twin births - is being discussed constantly by mothers, via social media.  One group, linked to BBANZ, that I belong to, often has messages from women who are torn between options that appear to be poles apart - the elective caesarean, or the unpredictable, un-knowable journey of spontaneous natural birth.  Another option comes up from time to time, especially for women who have financial reserves + private health insurance and can access a private maternity hospital and a sympathetic obstetrician (that's a big IF), that the doctor sets out the 'rules'.

"OK, here's the plan.  You come to hospital as soon as your labour starts and ..."

These few obstetricians, well known for pushing boundaries, set down what they believe is the safest course of action in the given situation.  They (understandably) want good outcomes, as do the women in their care.   They are able to achieve good outcomes if they recognise the time when it is best to depart from the spontaneous natural process, and take decisive action without delay.  This may mean delivering a baby with forceps or ventouse, or moving to the operating theatre for caesarean surgery.  The women understand the rules, as they have been discussed, and are expected to submit to them.

In many cases, this is an acceptable, and successful exchange.  Yet it is medical dominance, with a touch of class, Melbourne style. 

When the doctor enunciates the plan, and receives a compliant nod from the woman, there is a big exchange of trust.  There is not likely to be any subsequent *informed* decision-making by the woman, because she has entered a 'plan' with her doctor.

This phenomenon disturbs me as much as any other form of medical dominance, whether it is carried out in a private arrangement, or in the less refined tactics that we often experience in public hospitals.  The woman's ability to bear and nurture her child is a basic ability that requires huge respect.  I would like to suggest that the AMA position on maternal decision-making is not worth the paper it is written on, unless the protection of the woman's own natural processes in childbearing, including spontaneous onset of labour, giving birth, and breastfeeding, are held in high priority, and not by-passed without a valid reason.

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