By Nadine Edwards
Kruske S, Young K, Jenkinson B and Catchlove A (2013) Maternity care providers' perceptions of women's autonomy and the law. BMC Pregnancy and Childbirth 2013, 13:84
Pregnant women, like anyone else, have the right to make decisions about their health care, including declining medical advice and treatment. They do not need to follow guidelines or policies. But what this means in practice is not necessarily well understood by doctors and midwives, especially if they believe that a woman's decision might harm her unborn baby. This research was designed to find out about doctors' and midwives' 'attitudes and beliefs towards women's right to make autonomous decisions during pregnancy and birth, and the legal responsibility of professionals for maternal and fetal outcomes'.
The researchers surveyed 336 midwives and doctors in Queensland, Australia about their views on decision making, women's autonomy and legal responsibilities for poor birth outcomes. Both groups showed 'a poor understanding of their own legal accountability, and the rights of the woman and her fetus'. They believed the final decision should rest with the woman; but at the same time also believed that the needs of the woman may be overridden for the safety of the fetus. Doctors believed that they are legally accountable for the outcomes of women and babies, despite the legal position which makes clear that health care professionals are responsible only for adverse outcomes caused by their own negligence.
Because doctors and midwives can influence women's decisions, the researchers suggest that it is important to understand their perceptions of women's autonomy, so that women can be supported in their decisions.
The doctors and midwives were asked to rate their agreement with, 'In collaborative practice, working with primary carers, the final decision should always rest with the woman' and 'Collaboration involves midwives and doctors working together but the doctor is the most competent in making the final decision'. They all generally agreed that the final decision should rest with the woman, but midwives agreed significantly more often. But with the second statement, there was a significant difference between doctors and midwives: with doctors agreeing that they were the most competent to make a final decision.
They were also asked to rate their agreement with, 'For the safety of the baby, the maternity care team sometimes need to override the needs of the woman' and 'Encouraging women to have more control over their childbearing compromises safety'. Doctors agreed that the needs of the woman sometimes have to be overridden, while midwives were neutral. Both groups disagreed that woman having control over their childbearing would compromise safety, but midwives disagreed more often. Lastly, they were asked to rate their agreement with, 'Legally, doctors are ultimately responsible, even in collaborative models' and 'The current maternity care system allows all to be legally accountable for their own actions in a collaborative team'. Midwives disagreed that doctors are ultimately responsible, but doctors believed that they are. Midwives expressed a neutral response to the second statement while doctors disagreed with it.
Both professional groups indicated that they supported women's right to autonomous decision making during pregnancy by agreeing that the final decision should always rest with the woman, but this was not supported by the conflicting view (or neutrality) that women's decisions could be overridden for the safety of the baby.
Previous research suggests that both midwives and obstetricians only support women to make final decisions about an aspect of their care when this agrees with their own preferences and this research supports this. The researchers comment that if doctors erroneously believe that they are responsible for outcomes following the woman's decision, and that if health practitioners do not understand that they are responsible only for the care their provide, it is difficult for them to support women's decisions that they disagree with. They suggest that 'care providers are poorly informed about this subject.'
The research shows a 'clear ambiguity around clinicians' understanding and beliefs of women's autonomy and the rights of the fetus' and it is suggested that 'some care providers may need to be supported to reflect on how aspects of woman-centred care may conflict with their broader values and beliefs on the rights of the fetus, and the legal and regulatory responsibilities of health professionals'. They also call for guidelines to inform practitioners - especially when women make decisions which they disagree with - and 'policy direction on how these concepts can be applied in evidence-based, woman-centred care'.
It is no surprise that the study found inconsistencies among practitioners regarding women being decision makers about their care. Nor that midwives and doctors had different views. It does show us what women are up against if they want to make decisions outside the policies, guidelines and medical and midwifery preferences. Not only are they unlikely to get full information, but even if they do, they are unlikely to be supported in certain circumstances. This is an open access article and worth reading, as it shows the tensions around rights and autonomy.
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