Education for Informed Choice

by Andrea Robertson

“Informed Choice” – the buzz words of the moment in maternity care circles! How often are women exhorted to make an “informed decision”? How many times do these words appear in policy documents and procedure manuals? The reality is that this concept, of parents making truly considered decisions about their care, is a mirage. Too many times parents lack the information they need, are asked to make a decision under duress, or are presented with options in such a way that they are gently led to make decisions that fit comfortably with caregiver’s and hospital’s protocols, rather than the parents expressed needs or desires.

The childbirth educator has a key role in preventing abuse of the concept of informed choice.

Their position in the health care team and the access they have to women during an extended period of their pregnancy provides incomparable opportunities for education and discussion around these issues. The prenatal educator’s role is unique in several ways:

• they are not directly involved in the woman’s maternity care, therefore they have no direct influence over what happens to her,
• their educational role provides a neutrality that means all aspects of an issue can be canvassed and dealt with openly,
• their commitment to this educational role means they will be up-to-date with current research and thinking, which many clinicians may not be,
• their focus on the whole person encourages exploration of emotional issues which often complicate decision making for expectant parents, who view situations not just from a purely physical standpoint, and
• they have an extended period of time with their clients, often many hours over several weeks, which is far more time than most caregivers can offer (unless the parents are receiving care from a caseload holding practitioner).

In many ways, the prenatal educator can also be the conscience of the health care team. By presenting all the information a parent needs to make a decision, issues around the provision of this care may arise, perhaps prompting a change in policy or service direction from the hospital or caregiver. Remember how rooming – in came to be a standard procedure? How fathers were “allowed” into the labour wards? How waterbirths came to be accepted in many hospitals? These innovations stemmed from consumer pressure from parents who had obtained the vital facts and details from a prenatal educator or other source outside the system of direct care. In many places, birth centres have been established and homebirths have been provided as a result of parents being told of options for care not normally available in their area. A prenatal educator doing her job properly will always explain the full range of options, even if they are not immediately available, because to do otherwise would be unprofessional and neglectful of her duty of care to expectant parents.

This approach may lead to a number of dilemmas for the diligent educator. Many are employed directly by hospitals to “prepare parents for birth in our institution”. They are expected to present the hospital policies rather than discuss options that the hospital would prefer not to provide. Many educators are told that if they stray from the party line they face dismissal, a ploy designed to keep parents in the dark and educators submissive.

Educators may also find themselves receiving abusive phone calls from other midwives and doctors demanding to know “what you are telling these women in the classes?”. This can be very intimidating specially for the educator who does not have a clear concept of her role or a ready rejoinder.

Another potential problem reflects a fear of the parents – “what if I tell them about services they can’t get at the hospital? Won’t they then be angry with me for raising their hopes when they find their wishes are not respected?”

Further concerns may arise regarding the parent’s relationship with their caregiver: “what if I tell them about practises not favoured by their caregiver? The caregiver will be angry with me and the parents might lose confidence in the care being offered – I don’t want to be accused of undermining the parent’s trust in their doctor or midwife!”

These are all valid points, and strategies for dealing with them need to be prepared. First, the educator needs to have a clear idea of their role, which is, I believe:

• Different from any other job that the person may also undertake, such as that of the midwife, physiotherapist, doctor or any other professional. It requires separate and particular skills, a focus on facilitating learning and self-awareness and a thorough knowledge of maternity care issues, practices and research.
• To inform parents fully of their choices and options regarding all aspects of their care even if those choices are not readily available to them in their chosen birth place. It is not appropriate for the educator to filter, censor or otherwise alter this information to protect another person, themselves or the parents.
• To facilitate discussion around the issues involved and the process of making the decisions being faced by the parents. This will involve using problem-solving strategies and counselling techniques to enable a satisfactory outcome.

If you are challenged about your role, be ready with appropriate responses:

“I realise that I am telling parents about services we don’t offer. It is important that parents are fully informed so they can choose the services that best fit their needs. If we deny them information, we may later stand accused of deliberately withholding details they needed to know in order to choose wisely. Perhaps we should look at providing the desired services as a means of attracting clients?”

“When I give the parents in my prenatal classes all the pros and cons of the various drugs and interventions, I am aware that the basis for most litigation is a failure to provide accurate details of the treatments being offered. I don’t want parents to sue us later because “we didn’t tell them” about the potential outcomes of their choices. I see my educational role as being vital in making sure that other team members are getting fully informed consent when they carry out the treatments later.”

“If a parent decides to change doctors or midwives, or use an alternative service altogether as a result of something I have told them, then that is their right. I am aware I have a responsibility to make sure that my information is accurate and based on the research/data and parent feedback, and that it does not reflect my own personal views. If there is other data I should know about, please let me have it so I can give a complete picture.”

Other strategies will include: keeping abreast of the research around maternity care (MIDIRS is an excellent source of this information); being informed yourself about the services available in your area, local contacts, points of referral and practitioner’s names; finding out about programs on offer in other hospitals and Trust areas so that points of comparison can be made accurately; and being aware of your own biases so that you do not unwittingly direct parents in a particular way.

These are difficult issues for educators to face. They need careful thought and consideration, and talking them over with other educators is a very valuable way of gaining support and insight. They are also thorny issues for parents too, and they will need a chance to debrief after the event to sort through their feelings and reactions to the care they received. Providing a listening ear for new parents will often help clarify the situation for you as well, and help you form a broader view of the importance and pivotal role you play at this critical time in their lives.

Published in The Practising Midwife Vol 3, No 5, May 2000