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Questions to Consider when Interviewing a Doctor or Midwife
In the United States, doctors and midwives are bound by federal laws and regulations, as well as professional guidelines, to provide pregnant women with accurate, up-to-date, and understandable information, so that women can make informed decisions regarding their maternity care (care during pregnancy, labor, childbirth, and the early postpartum period). Despite this requirement, many pregnant women feel that they do not receive enough information about treatment options and alternatives to make important decisions about their care (Goldberg 2009).
What exactly is "informed consent"? The definition of informed consent from the Surgery Encyclopedia states: "Informed consent is a legal document in all 50 states. It is an agreement for a proposed medical treatment or non-treatment, or for a proposed invasive procedure. It requires physicians to disclose the benefits, risks, and alternatives to the proposed treatment, non-treatment, or procedure. It is the method by which fully informed, rational persons may be involved in choices about their health care." Quoting from the American Medical Association’s own admonition to its members: “In turn, your patient should have an opportunity to ask questions to elicit a better understanding of the treatment or procedure, so that he or she can make an informed decision to proceed or to refuse a particular course of medical intervention” (AMA, 2009).
The American College of Obstetricians and Gynecologists states that providers of maternity care must have an understanding of the woman's situation and use language that she is able to understand. The provider must give adequate and accurate information regarding the woman's condition and available treatment options, including no treatment at all. The provider must make sure that the woman gives consent freely, intentionally and voluntarily without coercion or pressure from the provider, facility or others and that she gives permission for any treatment before it is performed. She must have the freedom to choose between alternatives, even if that choice goes against the provider's recommendation (ACOG Committee on Ethics 2004, p.11).
The following questions are provided as a resource from Solace for Mothers, Inc. to assist pregnant women and their partners in finding a doctor or midwife who will respect their legal right to informed consent during maternity care.
Do you explain the risks benefits and alternatives to all treatments, procedures and medications before they are administered?Maternity care providers (obstetricians, midwives, family physicians) are legally required to explain all the risks, benefits and alternatives to any treatment before it is begun in a way in which you understand what is proposed. Informed consent operates on the belief that it is your right to direct what happens to your body. A health care professional must consult with you before any decision is made and any treatment carried out.
How do you respond when a woman refuses to consent to a proposed treatment?It is your right to refuse a proposed treatment and the provider must respect your decision. You may find, however, that some providers would prefer that you accept any treatment that they propose, rather than trusting that you will have the ability to make a good choice based upon the information presented to you. When you ask this question of the provider, you should be able to get an idea of how respectful he/she is of personal choice. If you notice the provider using words or presenting scenarios that are meant to stir up fear, you can expect him/her to act similarly when you are actually being treated.
Do you provide alternatives to a proposed treatment when a client/patient finds your first suggestion unacceptable?A provider's response to this question will give you an idea of how flexible the provider is in his/her practice. Some providers are more rigid in their practice protocols, and may be unaware of alternatives to their standard care model. Some providers may be very hesitant to provide care outside of their usual routines. Because of your right to choose treatment that is acceptable to you, it is important that your provider to be willing to fully and accurately discuss the situation to your satisfaction.
Under what circumstances would you discontinue care for a patient/client?In rare cases, some providers will dismiss a client/patient under circumstances in which the provider feels that he/she is not able to work within an individual’s preferences and desires. In order to avoid such a surprise, you can ask the provider this question to gauge his/her level of comfort collaborating on your care. The answer to this question will help you to determine at the outset whether this relationship proposed with this provider will be a fit for you and your value system.
When you suggest a treatment with which I am uncomfortable, will you provide more information about the pros and cons of this treatment, discuss it with me, and/or give me the opportunity to discuss the treatment privately with the support people I have present?A provider is legally required to give you as much information you feel you need to make an informed choice. This mandate is a part of the “patient’s bill of rights.“ The process of informed consent requires the provider to be patient and understanding of your needs. You may find that it is very helpful to discuss a given situation with your partner and/or doula before you state your decision. You are also free to consult with other providers for second (and third) opinions. During labor and delivery, you may feel that time is more limited. In those situations remember that you must consent before any procedure or treatment is done to you. Consent is only truly informed when it is given without pressure or coercion and you fully understand the procedure to which you are agreeing. By definition, informed consent must also include the right to “informed refusal.”
Do you allow a woman to give informed consent to procedures that you may think of as routine or standard (for example, an intravenous line, internal and external fetal heart rate monitoring, vaginal examinations, rupturing of the amniotic membranes, the use of drugs to augment labor and/or to expel the placenta, etc.)?Often providers and facilities will require you to sign a blanket informed consent statement saying that you consent to treatments given during labor and birth. A provider may have strong preferences, or the facility the provider works under may have certain requirements to do what he/she is used to doing as routine procedures. If the provider has a firm commitment to informed consent, he/she should encourage you to grant permission to any of the above procedures and others like them before they are undertaken. If not, the provider is not fulfilling his/her legal responsibility to obtain truly informed consent. If your provider does not respond that these are practices to which informed consent apply, he/she does not practice appropriate informed consent.
Do you allow women to give informed consent for situations in which there may be a facility/provider preference, but which are not based upon a medical need (for example, a woman’s position while in labor or pushing, freedom of movement during labor, eating or drinking during labor, etc.)?Facility policies can often be difficult to work around, yet, rules for informed consent still apply. Providers may require you to sign an exemption statement that releases them from any liability if you refuse to comply with certain policies. They may try many verbal tactics to get you to comply. On rare occasions, providers or institutions may even refuse to treat you unless you sign such an exemption. Asking your provider about the facility's policies is critical as your provider’s agreements with you may be overridden by those of a particular care facility. It is crucial that you know this in advance of receiving care.
Do you ensure that a woman gives informed consent every time her infant leaves her arms/room and is placed in the care of a nurse, including the time immediately following birth?Babies are often routinely separated from their mothers and providers may not think to obtain informed consent, as this style of care has become so routine in modern maternity settings. Many mothers and newborns find this practice to be very stressful, and in some cases even traumatic. Since most routine (non emergent) care of newborns can be done while the baby is on his/her mother, or even delayed for some time, you may prefer to have providers and staff ask permission before any separation occurs.
Do you allow parents to give informed consent each time any procedure is done on their infant, even routine procedures (for example weighing, measuring, shots, blood draws, bathing, warming, eye treatments, etc.)?Often providers do not think to ask permission for routine procedures, however, you and your partner may not want your baby being abruptly removed from your care. Also, there may procedures that you do not want, or that you would rather be delayed until after your newborn has bonded with you more fully and until after your baby breastfeeds. You may encounter resistance from providers and staff providing postpartum and newborn care, since many providers and facilities have very rigid routines in this area. Communicating your expectations and needs beforehand can be helpful.
Do you encourage parents to prepare a birth plan and discuss the birth plan with you before labor begins?Birth plans are popular among parents, but not always among providers. If your provider appears reluctant to talk about a birth plan, you might take that as a sign that the provider is not fully committed to informed consent and would prefer that you comply with their recommendations without much discussion. Some providers are very accepting of birth plans as that informs them of your wishes and they are happy knowing that you are involved in your care.
In high-risk situations or emergencies, do you maintain your commitment to “informed consent?”In an emergency, decisions must be made quickly because the life of the mother and/or baby are in danger. Providers may feel stressed to do the right thing quickly enough and, may, therefore, not fully explain the benefits, risks and alternatives to treatments before getting your consent. These can be particularly stressful moments for parents, as well, if proper consent is not obtained for procedures. Confusion, misunderstanding or over-estimating the danger presented by the situation can be especially traumatizing. The provider's response to this question can help you gauge your provider‘s approach to treating you in emergent situations.
Sources:
American College of Obstetricians and Gynecologists Committee on Ethics (2004). Informed consent. In Ethics in obstetrics and gynecology (2nd ed., pp. 9-17). Washington, DC. American College of Obstetricians and Gynecologists. Retrieved March 12, 2009 from: http://www.acog.org/from_home/publications/ethics/ethics009.pdf
American Medical Association, Patient Physician Relationship Topics (2009). Retrieved April 5, 2009, from: http://www.ama-assn.org/ama/pub/physician-resources/legal-topics/patient-physician-relationship-topics/informed-consent.shtml
Goldberg, Holly (2009). Informed decision making in maternity care. The Journal of Perinatal Education. Vol. 18, No. 1, pp. 32-40.
Naris, Brigham (2008). The Gale Encyclopedia of Surgery and Medical Tests. Gale Cengage: Farmington Hills, MI. Retrieved March 22, 2009: http://www.answers.com/topic/informed-consent
Click here for a PDF version that you can print and bring with you to interview your potential provider. This PDF version has just the questions without the extended notes.
Click here for a PDF version of the questions and the extended notes.
©2009 Solace for Mothers, Inc. Permission granted to copy for personal use provided content remains unchanged and copyright and contact information is included.