Patient-centred consent in women’s health: does it really work in antenatal and intra-partum care?

Informed consent is an integral part of good healthcare practice in which autonomous patient-centred choice-making is central [1, 2]. In the United Kingdom, echoing a decision taken by the Australian Courts in the 1990’s [3], the decision in Montgomery and subsequent cases [5‐9] reflects increasing legal endorsement of the importance of consultation dialogues which foster patient autonomy and so act as an ethical counter-balance to possibly unhelpful paternalistic or autocratic professional practices. In the landmark case of Montgomery [4] which concerned the failure of an obstetrician to inform a woman of the risk of shoulder dystocia associated with vaginal delivery the court stated that a doctor has a duty to ensure a patient is made aware of any material risks involved in treatment and of reasonable alternatives. What is material is determined both by reference to what a reasonable person in the patient’s situation might want to know and what the particular patient would be likely to attach significance to according to her concerns, beliefs and values. Underpinning the Court’s decision was the insistence that the dynamics of the healthcare professional-patient relationship should be characterised by respect for patient autonomy defined in the broadest of terms. Rather than relying on a classic model of autonomy in which a woman is conceived atomistically as an in-control moral agent who, as a rational recipient of adequately communicated complex risk information, is free to respond as she thinks fit, these terms point towards a recognition that women’s decision-making occurs within multiple relational and social contexts which may shape their decision-making [10‐12]. While striking a further blow to medical paternalism the decision provoked fierce debate between those who felt information-sharing practice was radically changed in potentially uncertain ways and those who felt that the judgment merely restated the guidance set out in the General Medical Council’s Good Medical Practice [13]

 Determining what high quality patient consent looks like has become a key contemporary professional challenge [14]. Our aim was to explore the experiences of healthcare professionals (HCP) in relation to the challenge posed by antenatal and intrapartum consent consultations.

This study is reported with reference to the consolidated criteria for reporting qualitative research (COREQ) [15]. A previously described interpretive qualitative methodology using in-depth interviews was used to understand how the consent process is viewed [16].

Study participants.

A convenience sample of HCP was recruited from an urban teaching hospital providing antenatal healthcare to approximately 6500 women annually. Eligible HCP were practicing obstetric doctors or midwives responsible for managing consultations involving consent for healthcare interventions such as caesarean section, cervical cerclage, instrumental delivery, episiotomy, and prenatal procedures. HCP were informed of the study via internal staff communications and were provided with an Information Sheet which detailed the researcher’s aims and interests in conducting the study. Participants were invited to ask questions prior to written informed consent.

All procedures were in accordance with the Declaration of Helsinki and ethical approval was obtained from the UK Health Research Authority.

Data collection.

All semi-structured one-on-one interviews were conducted using a pilot-tested interview schedule (Table 1) by author JN, an associate professor and experienced female researcher with interests and research experience in women’s health and health law. Field notes were made immediately after each interview to contribute to analytic reflections and reflexive research considerations.

All participants were committed to shared decision-making but recognised it was sometimes challenging to engage women in dialogue. Concerns related to women who either did not want to receive much information or else wanted the HCP to decide for them about the proposed intervention. Included in the former group were concerns about women who were very passive - ‘just seem to be going along with whatever I say’.

I think they [women] need to be at the centre of it but it’s difficult because quite often they want to be more passive I suppose than that … I mean not necessarily in a bad way but … they do in some way feel they want us to tell them what they should do (HCP 10, female midwife).

I sometimes think they don’t really want to know, and I think sometimes we do just go with that which isn’t very good from a consent point of view but it’s just very difficult, so you just have to make sure you write it down (HCP 02, female midwife).

Conversely, some clinicians felt they were being asked to do the impossible – supporting women who wanted to make their own decisions provided that the responsibility lay firmly with the HCP if things went wrong.

it sometimes feels as though a woman wants to make all her own decisions, which is fine, but she doesn’t want to take any responsibility if it all goes pear-shaped’ (HCP 08, female obstetrician).

Allied to these were some concerns about women who were considered to be lacking the capability to decide.

there are women who are just undecided or who feel emotionally overwhelmed and sometimes they really just want you to make the decision for them … I’ve had patients who really struggle because they haven’t really got the ability, mentally speaking that is, to get their head round their situation … I think there are some women particularly on labour ward but not only there where at least at some points I feel uncomfortable about consenting them because on any normal understanding it would be very hard to say they are in a position to make an autonomous decision (HCP 13, female obstetrician).

it’s very interesting about capacity because you get women with some sort of obvious learning disability or psychiatric order and they can be quite tricky so you sometimes need to get the psychs in but also, those cases aside, the ones that also bother me are where an apparently ‘normal’ woman seems not to be taking on board what I’m saying either because she’s in pain or frightened or for some other reason and I sometimes think we don’t think about that enough when we consent them (HCP 06, female obstetrician).

the woman is panicking the partner is panicking and the doctors say just sign this so they just sign it and you can see they haven’t a clue what they’ve signed (HCP 03, female midwife).

Although some HCP felt their practice was unchanged following the Montgomery judgment many reported being more cautious when obtaining consent and more likely to accede to a woman’s wishes than prior to the judgment.

All HCP expressed an intention to treat women as individuals and counsel them accordingly. Most also experienced difficulty in assessing what was important to an individual woman particularly within the confines of a time-limited consultation. They considered that making the sort of judgment endorsed by the Montgomery judgment required a degree of second-guessing of a woman’s beliefs and values.

someone’s situation may not be what it seems so I may not know what’s affecting their decision even though I think I do from a clinical point of view if that makes sense and that does really worry me because it feels as though I’m being asked to second-guess a woman if you see what I mean (HCP 14, female obstetrician).

I know that Montgomery tells us to think about a woman’s specific situation and obviously I try to do that but it’s really hard because as I said before I may not have met the woman before or even if I have, I may not know much about how she processes information, so it feels a bit impossible really (HCP 15, female obstetrician).

some people they’re very influenced by what is OK in their background, and for their ethnic group but obviously it’s quite hard to know really so it makes the whole consent thing a very grey area (HCP 04, male midwife).

Many HCP reported difficulty in striking a balance between fully disclosing all risks and avoiding unduly alarming a woman.

balancing the amount of information is not always easy … sometimes you have a finding and need to tell the patient what the options are, but you don’t know the patient very well, so you don’t know how she’s going to be able to process all the information you’re going to give (HCP 05, male obstetrician).

[post-Montgomery] I‘m more careful about labouring the risks more and making sure I mention everything because I do think it’s really hard to know what matters to someone - you know, their idea of risk depends on their belief system so you’re sometimes trying to really form a picture of what you think they’re like in a very short time (HCP 13, female obstetrician).

Allied to this was the difficulty in gauging a woman’s attitude to risk in general as well as their stance on risks.

it’s difficult trying to work out how risk averse they are because we get women who jump at 1 in 200 and are really upset about it and then we get women where the risk is 1 in 7 and they’re like ‘oh it’s fine don’t worry about it’ so it’s gauging how they perceive risk (HCP 01, female midwife).

These difficulties were intensified when counselling women with poor language skills and in these circumstances HCP were frequently left feeling uneasy that the requirements of valid consent had been met.

if a woman doesn’t speak any English so you’re totally reliant on Language line or quite often on family members and that’s tricky in generally understanding what matters to a woman which is difficult enough anyway let alone in terms of communicating risk … I’ve had a few women when I’ve had real doubts about whether they really get it, you know they just nod to everything and then sign the form when they’re prompted to do which obviously isn’t consent in the way we normally understand (HCP 08, female obstetrician).

Concerns relating to consent obtained for interventions in the Labour ward context such as emergency caesarean section and instrumental delivery were raised by many HCP.

it’s very difficult because consent on the labour ward is not black and white, actually category 1 emergencies and caesarean section are in a way very easy, it’s either we get your baby out or there’s going to be damage to your baby but there are some areas where it’s not that black and white and that’s quite tricky (HCP 06, female obstetrician).

on the Labour ward (pulls a face) it’s really, really not good – I mean the whole circumstances often, not always, but often, are just so rushed and not compatible with doing proper consent so I really hate that (HCP 10, female midwife).

They reported experiences in which the process of obtaining consent had been absent, cursory, or poorly-informed with negligible engagement from the pregnant woman concerned who might be suffering pain or fatigue.

I really think that consent in labour is really dodgy for lots of things, I mean take wide perineal suturing, by that stage most women are really beyond caring, and you know I’ve seen women subsequently who said they had no idea what was going on so yes, I think to say consent is dodgy is an under-statement (HCP 09, female obstetrician).

there’s quite a lot of times when it’s not [an emergency] but the woman gets consented in really what is a pretty cursory way and especially if she’s in pain or just had enough it really isn’t anything like proper consent …. it’s often the case with women who have got it firmly in their minds that they want a natural birth so you’re trying to persuade them I suppose to think about having a section and time’s pressing on so it’s quite easy if I’m honest to consent them in a fairly perfunctory way and I do think sometimes that’s a bit dodgy… it goes against everything you normally try to do in terms of professional practice. I mean obviously it is still their decision, but I think it’s in a very notional way because of the situation and I sometimes wonder if we not exactly abuse but take advantage of the situation (HCP 15, female obstetrician).

Many HCP had experienced fast moving situations where they felt lawful consent according to the Montgomery judgment had not been obtained and this left them feeling stressed and uneasy.

[Labour Ward]… it’s moving so fast and I am very conscious of all the things you normally think of with consent tend to go out of the window, you know they’re in pain it’s all a bit tense and so on I mean it’s probably one of the things I feel most uncomfortable about in all of my practice … you know you’re not in line professionally with everything that’s been drummed into you from an early stage and it’s difficult to do anything about it (HCP 14, female obstetrician).

you basically end up with what you might call kneejerk consent rather than anything that’s really appropriate, so you’re conflicted because you’re wanting to offer patient-centred care but it’s not (HCP 13, female obstetrician).