I was involved in an interesting (online) conversation the other day which left me thinking – as all the best conversations do! I have a bit of a “thing” about language use. I’m constantly examining, seemingly benign, writings for hidden messages. And, of course, seek and ye shall find.
So these findings were from a post about an updated maternity care policy for “low risk” women. I jumped straight in, before I even read the article, because I hate seeing that term “low risk” bandied about. It seems like nearly every article I read on the advances of our maternity care system are just for “low risk” women, (homebirth and continuity of care advances in particular are always for low risk women) but who gets to decide who’s low risk? Some person gets to decide I’m “high risk” just by looking at a piece of paper which says I have 2 scars on my uterus. They don’t need to speak to me to make that decision. They don’t ask me how I perceive my risk status. And who is the bearer of this risk? Me? Or is it the risk to the hospital that is considered low or high? An interesting topic on its own, but not where this conversation went.
We moved the conversation to focus on who policies and guidelines are written for: Audience, purpose and intent, which brought up a couple of issues for me.
I’ll start with the biggest issue for me. Is the language used around birth and decision making only relevant in terms of how care providers talk to women? I’m going to go out on a limb and say NO! If care providers aren’t talking about informed decision making and acknowledging where the decision making capacity lies (ie: with the woman!) when they are talking to each other then they aren’t going to be talking about it with their clients. Policy is written in a way that does not support informed decision making by the woman. It’s written “If xyz then you (the clinician) do abc.” So that’s how doctors present it to women. Common policy “directives” include: “If you go 10 days over we *will* induce.” “If you are planning a vbac you *must* have CFM.” “When you present to birth suite you *need* a VE to determine progress.” For example this particular guideline has a big section heading “If indicated, perform vaginal examination on admission”. If indicated? What about “If the woman requests one”? Or “After a full discussion of the risks and benefits and asking the woman to make an informed decision”. Where’s the acknowledgement that it is perfectly NORMAL to decline vaginal examinations because they are generally fairly useless anyhow? And there is a line for “CTG monitoring only where indicated”. Who decides whether it is indicated? Where’s the conversation about (or even just acceptance of) the risks and benefits as they pertain to the individual woman and her informed choice about whether to have CTG monitoring?
This leaves us with two major issues.
1) We end up with a whole heap of women who believe they do not have the right to decline a procedure. They don’t question the doctors “orders” or ask questions about how this policy applies to their individual case. In the vbac support group I moderate I see one particular, very disturbing, comment a lot. “I didn’t know I could say no.” Why didn’t these women know that that could say no? Because their doctor didn’t tell them. Why didn’t the doctor tell them? Because s/he is extremely busy and was just reading a small excerpt of policy (or reciting it back from memory). And that part of the policy doesn’t talk about informed decision making by the woman. It just says “if xyz then do abc.”
2) The second major issue is that you end up with a whole bunch of doctors who aren’t expecting the woman to decline. It seems like it never even entered their mind that a woman might decide that what’s in the (one size fits all) policy may not be the best fit for their specific individual circumstances. And then you (sometimes!) end up with a care provider who is defensive and this can lead to conflict and confusion. Perhaps if care providers were already using language which acknowledges the decision making capacity of the woman then they wouldn’t be so shocked when women act within this capacity!
As to the “audience” of a policy document. While the care providers are certainly the primary audience it is worth remembering that consumers (ie: women) these days have widespread access to maternity care policies. Women are accessing and assessing these policies before they choose care providers and before they discuss their birth plans. I accessed the Qld Health VBAC policy and Induction of Labour policy documents while I was formulating my birth plan and I have to say that it really set a confrontational tone. I felt like I would need to go in fighting for my right to decline certain aspects of these policies and as such I may have put together a plan that was more confrontational than it needed to be. Had the policy acknowledged my options and choices and laid out that I was the decision maker in all things my plan would have reflected that tone.
Now a lot of policies are being “modernised” and are including bits in them about making sure you seek the informed consent of the woman before performing a procedure on her. I have an article coming up which looks at this in more depth, but here’s a sneek peek. Seeking informed consent is not the same thing as asking a woman to make an informed decision.
So – what is my solution to this problem? I’m so sorry I don’t have one (well, not a simple one anyway!). I know – how rude to point out a problem and then not put forward a solution! But this is a really huge and tricky issue. It goes back to the culture in which care providers are training and working and then this feeds the culture that women are stuck birthing in. Change needs to be driven from all angles. From within the system and from outside the system. EVERYONE needs to contribute – midwives and OBs and hospital administrators, policy advisors and politicians, women (and men!) need to take to the streets. Improve birth in a way you feel comfortable – become a consumer rep, sit on steering committees, set up support groups, run education evenings for pregnant women and their partners, run information sessions for care providers, tell your daughters that no-one has a right to tell them how they may birth their babies. The more we talk about these issues the more likely that high level policy changes will take place.
For myself I am helping to promote change in the birthing culture by becoming a birth doula – I will support women to have ALL the information they need to make informed decisions in regards to their pregnancy and birthing care. I will also get my Hypnobirthing Australia certification so I can run independent childbirth education classes, teaching women all about birth and the hypnobirthing techniques. I will (hopefully!) run Hypnobirthing Australia information sessions for care providers at our local hospitals. I will keep writing about these ideas of bodily autonomy, human rights in childbirth, informed decision making and pregnancy and childbirth education. Everyone has something to contribute to improving the maternity care culture. Let’s make sure that people KNOW that the current birthing climate is not okay. It’s important that care providers, as well as women, use language that acknowledges where the power lies in birth – with the woman. So repeat after me: My body, My birth, My choice!!
A good article in many ways, as hospital based care is rarely >clinical evidence based caredoesn't bleed out and dieand if you or your baby dies, the responsibility lies on the care provider<
which can put them in prison for life.
Find a provider you can trust, who provides evidence based. Ask a lot of questions. If you are deemed too high risk for that individual, continue to employ that person for educational purposes (if you can afford both a midwife and an ob).