Supporting women to decline standard care…

26462658026_9ec621bd0fIt is a truth universally acknowledged, that a woman in possession of a pregnancy must be in want of a standard package of care as dictated by those in charge of the local maternity services.

Except it’s not.

While some women might be OK with the standard package of medicalisd maternity care that is offered in many areas of the world, many others – very reasonably, I think – want to have personalised care which takes account of their individual needs, health and concerns. Ideally, they might also like to have a relationship with a midwife who is kind, knowledgeable and who will listen to them and help them on their journey. And some women, no matter whether or not they have any or all of the above, will decide that they want to decline some of what is offered within the standard package.

I know this, because I’ve midwifed women who have declined things for more than twenty years. And I can attest that they are lovely women who have the wellbeing of their baby uppermost in their mind. They just don’t always agree that the standardised, centralised kind of care that has become the norm in so many places is what’s best for themselves and their baby. (Neither do I, for what that’s worth).

But when it comes to getting their needs heard, met and respected, these women often get a nasty shock. They find themselves being talked down to, badly treated, sometimes bullied, and sometimes far worse. In the UK, the sad reality of the postcode lottery means that what you experience will depend at least partly on where you live. If you had the foresight to decide to live within the catchment of a Trust with a fantastic consultant midwife who makes time to see women who would like something really different from the norm, then you’ll probably have a much more pleasant experience than if you live in certain other areas of the UK that I’ll refrain from mentioning.

So I was really pleased to see the publication of a study in Women and Birth which offers information about one way of approaching the question of what we can do when women want to decline care. Jenkinson et al (2016) looked at the implementation of a structured process for developing a Maternity Care Plan (MCP) in such circumstances. The research was undertaken within an Australian hospital and, within that context, obstetricians created the plans with women. (N.B. In other settings, including many areas of the UK, midwives would be more likely to do this).

The research confirmed that this is an incredibly important issue. When women do not want the ‘default’ package of care or want to decline a specific intervention, it often causes stress all round. Caregivers often do not know what they should do in this situation, and sometimes feel unsupported by colleagues and processes, and the uncertainty and conflict that this can lead to creates unnecessary stress for women and families.

The findings of this study included that, although putting a structured process in place didn’t make everything better (for instance woman-centred practitioners still encountered less-than-favourable responses from some colleagues), clinicians “felt protected and reassured by the structured documentation and communication process and valued keeping women engaged in hospital care.” Another finding was that, “Ongoing discussions of risk, perceived by women and some midwives to be pressure to consent to recommended care, were still evident.” This is unfortunate, but it does reflect the reality in many areas.

This research, as above, was carried out within an Australian context, and some of the issues will be different in other countries. It is also clear that, while this idea is a promising one, we still have a long way to go. But it’s also important to celebrate the small steps, because it’s those that can ultimately lead to bigger changes.


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Jenkinson B, Kruske S, Stapleton H et al (2016). Women’s, midwives’ and obstetricians’ experiences of a structured process to document refusal of recommended maternity care. Women and Birth, online ahead of print. doi:10.1016/j.wombi.2016.05.005
photo credit: Giusy, wk33.6 via photopin (license)

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