Thursday, July 12, 2012

Thoughts on Informed Consent

I would like to consider myself an intelligent woman – one who is well educated and possesses a fairly high level of information literacy. I am a critical and strategic thinker. I am not a doctor – but I do have advanced training in statistics and can make my way through most scientific papers in peer reviewed journals – I have made a career out of applying my skills in the field of health. I am not generally afraid to find information out from sources who should be “in the know”. I understand risk and uncertainty – and can say that when it comes to things that really matter, like my health or the health of my child, I am not a huge fan of either risk or uncertainty. Provided I have enough information to make a decision – I am a confident decision maker and do not tend to change my mind on a decision unless some new piece of evidence has emerged that merits a change of heart. Further, I tend to be a bit of an independent who is not easily swayed by peer pressure – I do things because I think it is the right thing to do, and do not generally take to being “bullied” into doing something.

As a result, I have regretted very few of the decisions I have made – as I know at the time I made them, I based them on the best information I had available (that was critically assessed) and my own preferences. That and crying over spilled milk does little going forward – whereas cleaning it up promptly and understanding why the milk spilled can prevent a harder clean up job and future spilled milk.

So what does this have to do with anything?

I have been thinking a lot lately about informed consent and medical decisions and how that pertains to maternity care. I have come to a couple of conclusions about it in that context.

First conclusion I have come to is that I was well informed when I made my original decision about how my daughter should have entered the world – I was certainly informed enough to provide “informed consent”, and arguably much better informed than most when they consent to a vaginal delivery. I did not take the original decision lightly – it was very well considered in the context of the available information and my personal context, and looking back, if I had it all to do again – I would still have chosen to deliver by way of caesarean. I might have chosen a different hospital or different doctors – but the choice about caesarean versus vaginal would remain unchanged. That’s with the benefit of hindsight – of having had the experience of a vaginal delivery that resulted in a healthy child and relatively normal physical consequences of a vaginal delivery. I can confidently say that vaginal delivery is not something I would choose for myself – and in particular I can say that vaginal delivery absent an epidural is not something I would choose for myself. I regret still, that the choice was taken from me particularly, absent any real reason for it to have been and feel strongly that denying women informed choice when it comes to mode of delivery is a grievous deprivation of personal autonomy and a serious gap in providing quality maternity care.

The second conclusion I have come to, is that there needs to be improvement in the information provided to women regarding childbirth. The statistics and reporting that are available needs to be better. There needs to be more research on the subject with only one agenda: “improving the health and well-being of mothers and their babies”. Most childbirth education classes probably need a massive re-write to reflect the modern realities of childbirth and to enable women to make reasonable and well informed decisions with regards to their own health and the health of their children. (That being said I was a childbirth education truant for the most part, and so really haven’t sampled a lot of these “classes” but from what I have heard from others, there is more than a little bias in them – at least in BC.) The performance measures used in this area also need to be reassessed.

The third conclusion I have come to is that those women who have informed themselves on what their reasonable options are and have made certain decisions regarding those options, need to be respected and supported for the choices that they have made.

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