Antepartum Preparation and Consent for Intrapartum Events: An Ethical Gap

Informed consent describes a deliberative process in which a competent individual provides intentional and voluntary authorization (or refusal) for a proposed medical intervention, about which a health care provider has disclosed information regarding risks, benefits, and alternatives.1 The process of informed consent represents a cornerstone of respectful perinatal care, an expression of a patient's autonomy and of a provider's respect for that autonomy.2 Shared decision-making (SDM) is a process of active engagement and collaboration between a provider and an individual that explores the available options for a medical intervention and in which the choice of intervention is based on the available evidence and is congruent with the individual's values.1 As dimensions of an informed choice framework, SDM and informed consent represent essential components of respectful patient-centered care.3, 4 Perinatal care providers’ obligation to engage with pregnant individuals in a manner that supports the human right to dignity is reflected in the application of respectful maternity care and trauma-informed frameworks to perinatal care and the awareness of the effects of systemic racism in the midwifery and obstetric professions.4, 5 However, translation of these concepts to clinical practice has been challenging, despite the well-recognized links between disrespectful care, including lack of informed consent and SDM, and poor outcomes, obstetric violence, and obstetric racism.1, 4-6 Pregnant individuals report incidents of minimal or absent informed consent for birth procedures, planned and unplanned, such as induction of labor (IOL), episiotomy, and assisted vaginal birth (AVB).7, 8 People of color, individuals without private insurance, and those with lower educational levels report relatively fewer SDM discussions.8, 9 Continuing education (CE) is available for this article. To obtain CE online, please visit http://www.jmwhce.org. A CE form that includes the test questions is available in the print edition of this issue. One strategy suggested to mitigate the unethical occurrences of unconsented or minimally consented procedures is to increase antepartum education and preparation for planned and unplanned intrapartum events. An exploration of the current literature regarding antepartum preparation as an approach to supporting informed consent and SDM reveals key ethical gaps and challenges. The ethical gaps include a dissonance between provider and patient prioritization of information and risk perception and persistent barriers to achieving SDM. These can be examined in the context of childbirth education, birth plans, and SDM for planned intrapartum events. Patient education regarding an individual's health condition is considered an essential aspect of patient-centered care, and individuals are encouraged to be engaged in all aspects of their own care.10 As part of preparation for labor and birth, antepartum childbirth education (CBE) has been shown to increase knowledge and self-efficacy and to decrease decisional conflict.11 However, the extent to which CBE addresses potential complications for both planned and unplanned events varies widely. A recent systematic review of digital platforms for antepartum education (eg web-based videos) identified that 12 of 55 studies included general antepartum topics (eg nutrition), only 6 focused on labor-related events (eg labor after cesarean), and none included information on IOL or other intrapartum interventions such as operative birth or episiotomy.11 Overall, antepartum CBE appears to be inconsistent in providing information about potential complications in labor and birth that might ultimately improve intrapartum informed consent. In addition, the primary focus of studies on the effect of CBE is on planned intrapartum events rather than on unplanned events. Pregnant individuals report conflicting attitudes toward CBE. For some patients, more information leads to more autonomy, feeling better informed and able to contribute to decisions.12 For others, CBE can provide too much information, leading to information overload. They are unable to integrate the information or recall information during labor or birth.12 In addition, some patients choose to avoid information altogether, as a way of coping with the unknown. Information about potential interventions may be associated with increased anxiety and feelings of disempowerment; avoiding information is then a strategy for protection from fear.12 Still other individuals experience the unpredictable nature of labor and birth in such a way that more information or data is unnecessary; unplanned events will happen, no matter the preparation.13 The link between an individual's preference regarding the type and amount of information they receive about potential intrapartum events and their subsequent experiences of SDM and consent during labor and birth remains understudied. Whereas CBE content is fundamentally developed from the health care provider's point of view, giving patients the information that providers believe is the most relevant, birth plans are generated by the patient from their perspective, addressing expectations and exploring potential scenarios. Divall et al found that pregnant individuals viewed birth plans as a strategy to mitigate the uncertainty inherent in the unpredictable nature of labor and birth through a combination of exploring options, maintaining flexibility, and retaining a sense of control.14 Birth plans may reflect the birthing individual's perception of risk related to potential intrapartum procedures. Birth plans can help to improve communication between the patient and provider by revealing the patient's understanding and preferences and by identifying knowledge gaps. Providers can address knowledge gaps, ultimately better preparing a patient for intrapartum SDM.12 To date, however, studies on the use of birth plans have shown mixed results regarding patient satisfaction and perinatal outcomes.15 Patients who create, prepare, and, critically, discuss their birth plans with their providers are more likely to report increased satisfaction with their birth experiences and higher levels of perceived support and autonomy.16 That is, the effectiveness of a birth plan to improve satisfaction and autonomy lies in its dual function as a tool for education and communication, both essential for SDM.16 However, providers’ negative attitudes toward birth plans may discourage use of this approach, potentially undermining SDM and leading to decreased patient satisfaction and increased risk of trauma.15, 16 As part of antepartum preparation for intrapartum events, it is appropriate for perinatal care providers to introduce and facilitate discussions about proposed intrapartum interventions during antepartum care. Engaging in SDM provides the opportunity to explore values and risk perception, set and manage expectations, create a personalized care plan, and contextualize care. When evidence-based information about potential medical interventions is shared in a manner that encourages patient participation and explores beliefs and risk perception, patients report increased resiliency and trust in their care teams.12 Research into the experiences of pregnant individuals with SDM for perinatal events confirms that lack of detailed information, lack of discussion about risks associated with perinatal procedures, and lack of participation in decision-making lead to feelings of mistrust.17 Risk perception is a multifactorial process combined of feelings of dread, worry, or vulnerability; the deliberative consideration of the likelihood of a negative outcome; and an appreciation of the consequences of the event.18 In other words, risk perception is as much an emotional process as it is an intellectual one. Pregnant individuals are consistently asked to make choices based on their risk perception in potentially new and evolving situations. In addition, the provider may have their own risk perception that influences their communication of information about the risks or benefits of a procedure.19 Tension between the patient and provider's risk perception can threaten the effectiveness of SDM. Despite repeated recommendations for SDM to be a key part of patient-centered care, the integration of SDM into perinatal care has continued to be met with substantial barriers.20, 21 Patient decision aids (PDAs), accompanied by antepartum SDM discussions, are recommended tools for exploring risk perception, for increasing congruity between choices and values, and as a path to building trust. Although few PDAs are available that address planned intrapartum events, such as IOL, one study found that PDA use improved provider standardization of risk communication and decreased provider bias.22 Alternative antepartum care frameworks, such as group prenatal care, have been shown to increase satisfaction, improve self-esteem, improve coping skills, lower obstetric interventions, and increase feelings of being listened to.23, 24 However, more research is needed to determine the impact of PDAs and alternative antepartum care frameworks on the experience of SDM, particularly for planned or unplanned intrapartum events.22 Although antepartum informed consent for planned intrapartum events is the expected standard of care, even if not always well executed, there is less scholarship on the efficacy of antepartum preparation for unplanned or emergent events in labor, such as episiotomy or AVB. Unplanned intrapartum events are associated with negative childbirth experiences.25 Birthing individuals consistently report increased trauma with AVB when compared with those experiencing spontaneous vaginal birth, leading to almost one-third of individuals reporting a fear of childbirth itself.26 Negative feelings toward unplanned AVB are influenced by the birthing individual's interactions with their health care team.13 Interactions that lack compassion, are characterized by poor communication, or do not involve the birthing individual in decision-making lead to mistrust and fear.13 Evidence specifically examining patient views, communication, and informed consent13 reported that pregnant individuals lacked key information and inadequate consent for procedures such as AVB13 and episiotomy.6, 27, 28 Participants did not remember consenting for an episiotomy, received selective risk disclosure, felt excluded from the decision-making process, or reported not having the option to decline the procedure.6, 27, 28 Participants relied on their scant prior knowledge of the procedure, and critically, providers assumed that patients had prior knowledge.6 In contrast, perception of trust, feelings of control, feeling listened to, and inclusion in decision-making are key drivers of patient satisfaction during unplanned intrapartum events.13, 26 When a birthing individual's autonomy is threatened by an emergent situation, the sense of being a part of the team and making decisions together influences feelings of trust.26 Thus, there is a dissonance between the providers and the birthing individuals in their strategies for successfully navigating unplanned events and avoiding trauma. For providers, it is increased knowledge; for birthing individuals, it is inclusion in decision-making and feeling a part of the team. Situational urgency is cited as a common factor that exacerbates an inadequate informed consent process for unplanned intrapartum events.6 When clinical circumstances require rapid decisions and interventions, the information content of informed consent and involvement of the birthing individual in decision-making are diminished.6 Research on provider-patient communication during nonperinatal emergent situations, for example, in the emergency department (ED), demonstrates similar constraints. One scoping review showed that ED providers focused their communication on clarity and limited information dispensing, rather than establishing a rapport or demonstrating empathy.29 In addition, there is robust information in the literature regarding the importance of team cohesion and communication as key elements of safe patient care.30 Frameworks such as TeamSTEPPS30 and TeamBirth31 show promise in improving birthing individuals’ experiences through creating consistent communication strategies. However, the extent to which the patient participates as a full member of the team, and its effect on patient satisfaction and perinatal outcomes, is an area in need of further research. In addition, these frameworks have yet to be studied and evaluated specifically in emergent intrapartum events. Creating a pregnancy and birth environment and framework of care that centers the birthing individual through supporting autonomy can potentially minimize trauma. Adequate consent can only occur in a trusting environment, but for many patients, mistrust in the health care system and health care providers is justified.32 Although trust is a reciprocal and relational process, the onus is on the providers and health care systems to create an environment that actively mitigates discrimination and bias, supports birthing individuals, and diminishes the shock of the unexpected and the disappointment in unmet expectations.9, 13 By centering the birthing individual, providers actively and repeatedly assess the birthing individual's desire for information, recognize the birthing individual as an essential team member, support the birthing individual as the primary decision-maker for themselves and the fetus, and accept the birthing individual's decisions.26 Unfortunately, health care providers’ efforts to create partnerships may be stymied by inadequate communication and relational skills in urgent situations, inadequate skills in trauma-informed care, unwillingness to engage in SDM, or lack of knowledge in how to engage birthing individuals as a team member. Although coercive practices during labor and birth are ethically impermissible, birthing individuals continue to report receiving medical procedures without their consent.5 A commonly cited strategy for mitigating the risk of inadequate or absent informed consent, particularly for unplanned events, is to increase a pregnant individual's knowledge about potential procedures, ideally in an antepartum setting. However, antepartum preparation strategies, such as childbirth education, birth plans, and SDM, carry gaps in the understanding of the practical and ethical relationships between antepartum preparation and intrapartum events. A disconnect exists between providers’ assumptions of the breadth of a pregnant individual's knowledge and their actual understanding. In addition, antepartum education strategies often fail to explore differences in risk perception, particularly between providers and patients. Last, the call for increased antepartum education ignores the finding that pregnant individuals’ dissatisfaction and trauma from negative childbirth experiences stem from being excluded from decision-making, rather than solely from a lack of knowledge. Strategies such as SDM, trauma-informed care, and collaborative practice frameworks are essential aspects of the midwifery model of care, giving midwives an important opportunity to bridge these gaps.33 The authors have no conflicts of interest to disclose.