Choice - an abused concept that is past its sell-by date

AIMS Journal 2005, Vol 17 No 4

Beverley Beech considers how the public is deceived into believing that choice exists when in reality choice is an illusion

Perhaps I should begin with a history lesson. When I had my baby in the 1970s nobody talked about choice, indeed some London teaching hospitals had a statement printed inside the cover of the woman's case notes:

"The Union does not consider that a maternity patient need give her written consent to any operative or manipulative procedures that are normally associated with childbirth. When she enters hospital for her confinement it can be assumed that she assents to any necessary procedure including the administration of local or general anaesthetic"¹.

By the simple act of walking through the door women were expected to comply with what the staff intended doing. The Medical Defence Union (the source of such advice) was challenged by AIMS to give the legal justification for such claims - it did not reply, but the statement did not appear in its next Annual Report and slowly changes in attitude began.

In February 1992, following an investigation into maternity services by the Health Committee of the House of Commons the Winterton Report was published². The Members of Parliament's investigation revealed that the majority of women and babies were receiving care that was inappropriate for their needs. The report noted that the majority of women were required to deliver their babies in high technology, centralised, hospitals and as a result the women and babies had more interventions, more problems and were less fit and healthy than they would have been had the women given birth in midwifery run maternity units or at home. Everyone involved in maternity care should read that report. The tragedy is that it could be published today and barely a word would need to be changed.

The Government of the day responded to the Report by publishing Changing Childbirth³ where it set out proposals for change, but it did not allocate any additional money to enable change to take place. Changing Childbirth stressed the importance of 'choice', so everyone was happy. Even the obstetricians who had been sidelined in the Winterton Report (primarily because they could not produce any scientific evidence to support their assertions) were able to stress how important it was for women to be able to choose their own obstetrician should they wish to do so.

The illusion of choice

Choice has become one of the most abused words in the English language.

• You can choose to have your baby at home - providing a midwife is available - what women are not told is that a midwife is always available because the Trust has an obligation to provide one.
• You can choose which hospital to go to - providing it is in your catchment area -what women are not told is that if they want to choose a hospital outside their area they will have to argue their case and make a fuss.
• You can choose to have a water birth - providing there is a midwife trained to assist birth in water - what women are not told is that if the midwife is not trained she has a responsibility to get trained or find a midwife who is.
• You can choose to have your husband, partner, friend with you when you are induced and in early labour - providing it is within hospital visiting times - what women are not told is that the woman can insist that she needs their support and does not wish to be left on her own.
• You can choose to have a second support person with you (and the research shows this is beneficial) but only if there is adequate space to accommodate them - what women are not told is that this is the woman's decision, not the hospital's.

Meanwhile, women are encouraged to complete their birth plans in the happy expectation that their intentions will be respected and acted upon, unaware that those women who do complete birth plans could end up with more interventions⁴.

Then there are the choices that woman may be "encouraged" to make

• You can choose an epidural, in which case the hospital staff will probably fall over themselves to ensure that you get one unless you feel strongly about having one, in which case it might be withheld⁵.
• You can choose to have your baby's heart beat intermittently monitored, but should you be labelled as high risk and refuse continuous electronic fetal monitoring, you are likely to be accused of putting your baby's life at risk, despite the evidence that this is not the case.
• You can choose not to have your baby injected with vitamin K - providing you fully understand that you will be put under pressure to comply⁵. and the paediatrician may be called to 'persuade' you.
• You can choose not to see a health visitor - they provide a service and you are under no obligation whatsoever to accept it, but again, you might be referred to social services if you do refuse, as women keep telling us (see AIMS Journal, Vol 16, No 3).
• You can refuse the offer to see a social worker, but if you do you then risk the possibility that they will claim that they have concerns about the baby and start waving Court Orders around. George Orwell's 1984 has arrived with a vengeance.

Choice in maternity care is severely restricted to what the Trusts and the staff choose to provide. Those women making choices outside a very restricted menu face opposition and a variety of tactics to 'encourage' them to comply. For those with doubts that this is indeed the case, Mavis Kirkham's book, Informed Choice in Maternity Care makes sober reading on these issues⁷.

Knowing your rights

Unfortunately, it is not enough to know what your rights are, you also have to know how to deal with the lies, ignorance or misinformation handed out with total confidence by some professionals who ought to know better.

Good birth experiences

We know that there are thousands of women in the UK who have the kind of birth experiences that one would hope that every woman would have. In an ideal world all women would have the support of kind, confident, and knowledgeable midwives who would be responsive to their needs and be with them for their antenatal care, their labour and birth, and provide postnatal care and support. Those women who have complications and problems would, in addition to their midwifery support, have the support of their GP, with whom they should already have a trusting relationship and the attention of an obstetrician who would provide them with the first class service they need. There would be good communication between these professionals about the women's condition and her choices for care.

The reality, however, is that growing numbers of women are feeling neglected and unsupported. We are receiving increasing numbers of calls from worried women anxious about having little or no antenatal care early in pregnancy (one woman reached 21 weeks and still had not been able to see a midwife or doctor despite her frantic attempts to do so). We hear from women who have laboured alone for hours with no-one to hold their hands, support them or even give them a smile; and of women discharged after 24 hours who are telephoned by the midwives to check that they are OK, rather than visit them at home to check that they are indeed well. We also hear from some women who feel that the purpose of the visit has more to do with checking that she is not 'abusing' her baby rather than supporting her to enable her to care for her baby with confidence.

Consulting the consumers

The Government has poured millions of pounds into the NHS in an attempt to improve care. Consumers and consumer groups have been encouraged to take part in 'consultation', and hundreds of consumers have given thousands of hours of their precious time for free in the hope that changes would emerge. Too many Government quangos present an illusion of consultation but in reality they do not intend to involve consumers in any meaningful way. In reality, consumers' efforts are similar to the labour of Hercules, the boulder may have been pushed up the mountain but it has not got very far and in many cases it has rolled back down again.

There is no doubt that there are thousands of midwives and doctors who are doing all they can to improve care. The failure of the NHS, however, to provide a service that is truly 'women centred', has an enormous affect on staff behaviour and their ability to provide the quality of care one could reasonably expect and which is now being made worse by the shortage of midwives. The institutionalised attitudes of the 'grey suits' will not be changed while we have large, centralised, maternity units and Trusts that are not answerable to the public nor will change occur while the Royal College of Midwives continues to fail to listen to what many of its members want or to negotiate robustly for better conditions of service and adequate pay levels for its members.

This journal will highlight some of the problems, but do not make the mistake of believing that these are isolated cases. They are not - they are the tip of a very large iceberg.

References

1. Medical Defence Union (1974). Consent to Treatment.
2. Winterton, N (1992). House of Commons Health Committee, Second Report, Maternity Services, Vol 1, HMSO.
3. Department of Health (1993). Changing Childbirth, Part 1: Report of the Expert Maternity Group.
4. Jones MH, Barik S, Mangune HH et al (1998). Do birth plans adversely affect the outcome of labour? British Journal of Midwifery, Vol 6, No1, p38-41.
5. Bevan V (2003). Vitamin K in Lincoln: consumer choice or no voice? AIMS Journal, Vol 15, No3, p18-20
6. Green J et al (1998). Great Expectations, Books for Midwives Press.
7. Kirkham, M (ed.) (2004). Informed Choice in Maternity Care, Palgrave Macmillan