I recently and unexpectedly reconnected with a past midwifery client, ‘Jenna’, who allowed me to share elements of her care story in a book chapter that I wrote a few years ago. Jenna was, of course a pseudonym and both she and her partner ‘Dev’ (who, for reasons that Jenna and I never quite got to the bottom of, insisted on being named after the keeper of the corner shop in a certain British soap opera) had been through a journey of decision-making around so-called post-term pregnancy.
It was in writing about Jenna and Dev’s story that I first started paying attention to the importance of being really clear about what is being decided when decisions are made. Because the nature of my practice (and, to be honest, my ideology, which underpins my practice) means that I have worked with many couples who have decided to decline certain interventions which are offered routinely at a particular point. I’m talking about things like induction of labour, vitamin K, antenatal (and sometimes postnatal) anti-D and managed third stage. It’s probably not coincidental that I have ended up researching and writing about these topics. I have been inspired to do so by these women.
But there is an important nuance here, which I think is sometimes missed. Because in almost every case, these women and their families are not actually declining the intervention completely; they are saying that they do not want to have it routinely, or unless they need it.
Jenna and Dev decided to decline routine induction of Jenna’s labour. But they always remained open to considering it if the results of our ‘watchful waiting’ had suggested that this might be indicated. By the same token, many of the parents I know who have declined routine vitamin K would have been more than happy to have it if their baby showed any sign of needing it in their first few days of life (and you can find out more about vitamin K here). I have worked with a woman who declined routine antenatal anti-D but who called me and asked for it after she had been in a minor traffic accident in which her airbag deployed. She considered anti-D advisable after a potentially sensitising event, but not routinely. And I have cared for several women who had decided to have a physiological placental birth rather than a managed third stage but who were more than happy to have an oxytocic when they lost more blood than average.
It’s not always about a yes/no, accept/decline dichotomy. Often, there is a middle ground. This middle ground is about making decisions as and about an individual within their own context and according to need. Just not routinely. Or based on what the guideline says. We’ve seen a shift – at least in some circles – from using the word ‘refuse’ (which is often deemed confrontational) to using the word ‘decline’. We still have much to debate there. Some people feel that the shuft to saying ‘decline’ is playing into the idea that we should be polite and not stress our needs too strongly. But, whatever we decide on that one, wouldn’t it be great if we could take the next step. What if we could expand the discussion and our vocabulary further? To indicate that many of those who are seen by some as declining intervention are actually actively seeking individualised care which might well include deciding to have those very same interventions, but on a deployed-when-needed rather than routine basis?