Designing better systems to document refusal of interventions by laboring women; addressing subsequent staff disapproval of these patients & their birth attendants

by faithgibson on March 1, 2017

in Contemporary Childbirth Politics, OB Interventions: Dubious or Detrimental

PubMed abstract

Synopsis & the study’s take-home message:

This peer-reviewed study by the Australian College of Midwives describes a plan by hospitals to create a formal documentation process for informed consent/decline conversations when childbearing families refused standard intrapartum protocols or interventions believed necessary by the staff.

Take-home message #1: The study found the new and more robust method of documenting information (a ‘paper trail’) for informed consent-decline worked better than the unorganized responses previously used by the staff. This is a ‘thumbs-up’ for other institutions to adopt similar protocols.

Take-home message #2: The study also noted that many staff members still displayed disapproval of the woman who declined the treatments and/or disapproval of the midwife who “allowed” her patient to decline interventions or treatments.

Despite the deliberative process and the woman’s signing the necessary legal documents, some staff members continued to talk to these laboring women about the advantages and greater safety of the intervention or treatment in question. On these occasions,  mother and midwife both realized that the staff person involved rejected the idea of maternal autonomy and considered the mother and/or midwife to be acting irresponsibly.

The study did not propose any readily-available solutions for this predicament.

However, it is useful for the rest of us to acknowledge that prejudice exists among maternity care providers and take this fact as an opportunity to actively address the general misunderstandings that surrounds unpopular decisions by childbearing women. The classic misperception is that such women are hedonists who are illogically risking the well-being of their baby in pursuit of an idealized birth experience.

When logically considered, we see that decisions by healthy women with normal pregnancies to forgo the ‘standard’ hospital protocols actually tracks very well with a lower Cesarean section rate and NO increase in neonatal problems. [See California Quality Maternal Care Coalition  {CQMCC} on-line publication on reducing the Cesarean rate, esp. its recommendation that auscultation of FHR (instead of EFM)  become the standard of care for all healthy women with normal pregnancies.)

When this type of statistical data is taken into account, avoiding the routine use of IVs, continuous EFM and anything else that immobilizes the mother-to-be in a labor bed is a decided advantage for healthy women and, and given the well-known dangers of major abdominal operations, is a clearly responsible choice by the childbearing family.

These situations may also provide a unique opportunity for the staff to try out other methods for satisfactorily managing normal labor by non-medical means, such as patience with nature (no arbitrary time limits), upright and mobile mother, the use of natural labor stimulating techniques,  non-drug pain relief and the right use of gravity.

An example of the development of new and more successful medical strategies can be seen in the care of Jehovah’s Witness patients who, for religious reasons, decline all blood transfusions. The ability of surgeons to successfully manage intraoperative bleeding without resorting to transfused blood was greatly advanced as a result of doing surgery on such patients.


Bottom line:

               Nevertheless, she persisted!

                                                              Enough said …

Women Birth. 2016 Dec;29(6):531-541. doi: 10.1016/j.wombi.2016.05.005. Epub 2016 Jun 8.

Women’s, midwives’ and obstetricians’ experiences of a structured process to document refusal of recommended maternity care.

Jenkinson B1, Kruske S2, Stapleton H3, Beckmann M4, Reynolds M5, Kildea S6.

Author information



Ethical and professional guidance for midwives and obstetricians emphasises informed consent and respect for patient autonomy; the right to refuse care is well established. However, the existing literature is largely silent on the appropriate clinical responses when pregnant women refuse recommended care, and accounts of disrespectful interactions and conflict are numerous. Policies and processes to support women and maternity care providers are rare and unstudied.


To document the perspectives of women, midwives and obstetricians following the introduction of a structured process (Maternity Care Plan; MCP) to document refusal of recommended maternity care in a large tertiary maternity unit.


A qualitative, interpretive study involved thematic analysis of in-depth semi-structured interviews with women (n=9), midwives (n=12) and obstetricians (n=9).


Four major themes were identified including: ‘Reassuring and supporting clinicians’; ‘Keeping the door open’; ‘Varied awareness, criteria and use of the MCP process’ and ‘No guarantees’.


Clinicians felt protected and reassured by the structured documentation and communication process and valued keeping women engaged in hospital care. This, in turn, protected women’s access to maternity care. However, the process could not guarantee favourable responses from other clinicians subsequently involved in the woman’s care. Ongoing discussions of risk, perceived by women and some midwives to be pressure to consent to recommended care, were still evident. These limitations may have been attributable to the absence of agreed criteria for initiating the MCP process and fragmented care. Varying awareness and use of the process also diminished women’s access to it.

Copyright © 2016 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.


Hospitals, maternity; Personal autonomy; Professional autonomy; Refusal to treat; Treatment refusal

PMID: 27289330 DOI: 10.1016/j.wombi.2016.05.005

[PubMed – indexed for MEDLINE]

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