I Do Not Consent: A Sequel

I wrote a post almost a year ago now entitled “I Do Not Consent,” and I noticed it was getting a lot of traffic (for my blog, anyway!) the past few days. As I reread the post, I felt as though it needed to address some additional issues in order to give a complete picture of my views. Some comments I received also confirmed this need.  I feel that further exploration of the topic of non-consent is an important pursuit.

If you haven’t read the original post, you can go ahead and read it here first so that we’re on the same page before continuing. Okay, here we go…

1) Non-consent is a serious decision.

I did say this in my original blog, However, it appeared as though some readers missed it, so I quote: “I will say… that this phrase should probably not be taken lightly. Weigh your caregiver’s experience against your own intuition. Is your baby still ok? Are you still ok?  Find out whether the caregiver is recommending a procedure out of medical necessity, or because of convenience or a hospital policy.”

I am not– I repeat- I am not recommending anyone deny a procedure that is truly medically necessary for themselves or their baby. This is utter foolishness. I am also not recommending that you go into the hospital (or at your home) throwing this phrase around at the drop of a hat. This probably will not be helpful to your cause. This leads me to my next point…

2) Communication is key!

I am not much for fighting during a birth. I am not suggesting that you argue with your care provider. Keep an open line of communication with your doctor or midwife before and during the birth. Ask for things politely. Discuss your preferences first. If you come to a disagreement, then you can can implement my suggestion from my previous post:

“You can always say, ‘Wait. I do not consent yet.’ Go on to ask these four questions:

1) Is this an emergency? (If no, move on.)

2) What are the benefits of this procedure?

3) What are the risks of this procedure?

4) What happens if we do nothing?”

If you disagree with a procedure, talk through your options with the doctor or midwife (provided that #1 is answered with a no). Goodness, you could even compromise if you’re both comfortable with it! Even non-consent to an unnecessary procedure, however, doesn’t have to be rude.

3) Consider your relationship with your care provider early on.

Please do not go into a birthing situation planning on being “up-in-arms” about everything. If you think all OBs are surgical monsters who don’t know how to let a woman labor, then why did you sign up for their care? If you think your home birth midwife is full of fluff and incompetent, why are you paying her to attend your birth?

In most cases (with some well-acknowledged exceptions), you chose your care provider. Don’t plan on not trusting them from the start. If every appointment you are thinking how much your midwife makes you mad or uncomfortable, then you should switch providers.

As one reader commented, “You should never discount your providers education, training and experience. There are times during birth when a caregiver must make life and death decisions and may not have time to offer a 30 min. consult on the pro’s/con’s of their decisions. I am not saying that there will be an emergency in every situation, however, If you do not trust your provider and their judgement to do what is best for you and your baby, you should find a different one! Yes, be well informed. Ask lots of questions PRIOR to the birthing room when there is time to go over all the nuts and buts of why things are done a certain way – but waiting to be informed until you are in the middle of your birth is…well, negligent on your part.”

Ideally, you should choose a  provider who respects your preferences as much as is possible, AND whose  expertise and training you can respect in situations that you are unsure of. However, less-than ideal situations sometimes can come up in the company of an on-call doctor, or a nurse, or with the midwife’s assistant (or what have you!), no matter how well-prepared you are.  In this case, non-consent should still be considered a reasonable option.

4) Don’t leave the hospital in the middle of a c-section.

Yes, I know I’m being silly. When I wrote in my original post that it’s never too late to switch care providers or birth sites, I guess there was an actual limit to that. Pushing and surgery are probably cutting it pretty close. However, I have heard of many women who have requested new providers, left their home birth, or traveled to a different hospital in order to find the respect, courteousness, and medical sensibility they lacked in the first place.

4) Women need to have the option of non-consent.

Women still need to have the option of non-consent. Why?

• Because sometimes there really are flat-out medically unnecessary procedures being performed out of habit, preference, liability, or policy. I’m not saying it’s happening all the time or that this is the primary motivation for most care providers. I’m just saying it happens sometimes, and it shouldn’t.
• Because even for the most well-prepared mom, unpleasant surprises can arise during labor. Sometimes its from an on-call staff member that she just didn’t have time to talk to before the birth.
• Because sometimes there are situations that are just plain assault. Like the mother whose doctor cut an episiotomy “just to teach her a lesson.” Or the two doctors who ripped a mothers perineum with their hands when she asked them not to cut her. Or the midwife who emotionally abuses her patient by scolding her for not handling pain. No woman should have to feel that she should sit through something like this for the sake of being a “good patient.” If we don’t allow women the right to stand up for themselves at this point, then when will we?

I felt that expansion and clarification of “I Do Not Consent” was necessary, especially if you are not a regular reader who understands my broader views on birth and providers. I hope that my list of “qualifiers” wasn’t too long, and I hope that it was clear. Please feel free to ask questions/give input in the comment section. I’ll summarize with a reply I wrote to a commenter on my original post. Thanks for reading, as always. 🙂

“Birth should ideally be a partnership between birthing mother and caregiver. Only when the mother is being coerced or attacked for non-medical reasons should refusal be resorted to. I am sorry this didn’t come across more clearly in [my original] article… I don’t want to encourage recklessness. But I do firmly stand behind the protection of a woman’s intelligence and dignity during birth, and that means that she has to still have her rights in the birthing room.”

*Not to be taken as medical advice.

You, The Consumer.

You are a mother. You are also a patient, or a client, depending on your care provider’s terminology. But, primarily, you are a consumer.

Photo Credit

Most of us don’t think of maternity care in this way- deciding to pay a specific birthplace and provider, rather than just going to the place that’s cheapest or where your friends went. But primarily, you are purchasing a service, not merely sitting under nonnegotiable care.

I am not writing this to undermine trust in your provider, or to encourage being a “bad” patient who is never satisfied. However, I think that there is enough variance in opinions, management styles, and routines among qualified providers to say that it’s fair to search for one who jives the most with your ideals. Let’s look at some examples.

Hospitals & Birthing Centers- First, look at the time limitations of  your hospital or birthing center. For example, our local hospital is the only one in about a 30-45 minute radius that provides maternity care, and only has 16 OB/GYNS who practice there, delivering around 3000 babies a year (at a 36.9% c-section rate). This means that this place is, in the words of several women I know who have birthed there, “a baby factory.” There is nothing wrong with choosing to have a baby there, but the implications of doing so must be considered. When there are literally not enough beds in the mother/baby unit and new moms are being made to share rooms with elderly men in the general sick patient area, you know that the hospital might be too busy. You know you won’t be receiving care from newborn nurses. You know there’s a possibility of  exposing your newborn to strange germs. You know you will lack privacy. You know you will lack sufficient one-on-one care. Yes, this hospital has a good NICU, round-the-clock anesthesiologist and cesarean availability, and a history of generally good outcomes (by American hospital standards), but does the high number of healthy babies at the end justify the means of care in helping them arrive?

Let it be known that not all hospitals are like this. I attended one about 2 hours from me that was much less busy, had only a 21.6% c-section rate, was quiet and calm, and had enough staff that the nurses could pop in whenever mom wanted them. Which of these two hospitals would I rather pay for their services? Certainly the latter.

One must also consider monetary influences on practices. (Before I write this, you must know that I don’t think all doctors/hospitals only want more money! I really do believe that they DO care about their patient’s well being!) It is worth noting that c-section rates are notably higher at for-profit hospitals than at non-profit institutions. Check out this news story for one example of this disturbing trend.

Home Birth Midwives

Time and money are also considerations for your midwife, though not as frequently as a big organization. How much does she charge? Does this correspond to her training and experience? How many clients does she take on a month? What is her back-up plan if she has two women in labor at once? You must know the answers to these questions before you hire her for your birth.

When hiring a home birth midwife, I think the most important consideration is finding out if you are paying for a qualified provider. As much as I support home birth midwifery,you  must remember that there are different breeds of midwife (CNM, CPM, and DEM), and there is currently no standard of certification for direct entry midwives. I’m not saying you shouldn’t hire one (my own midwife was direct entry), but you should make darn well sure that she is qualified to attend your birth before doing so. Find out her training and experience. Where and with whom did she complete her apprenticeship? Does she have references? Does she have a back-up doc?What is her hospital transfer rate, and what percentage is emergencies? What is her relationship to local hospitals? What are her maternal/infant/perinatal mortality rates, and for what reasons? How would she handle a hemorrhage? What equipment does she bring to a birth? Does she practice with legal integrity? I am not trying to scare anyone out of a home birth, but the safety of a home birth has been shown to depend upon the presence of a qualified attendant. Make sure that yours is.

Birth Philosophies– Remember, you are consuming services. Would you pay for a protestant pastoral education at a local college where the professors are Buddhist? Would you go to McDonald’s to purchase an organic beef hamburger? Would you go to the chiropractor’s office for heavy painkillers? No! Of course these are silly propositions.

Yet we do this over and over again when purchasing birth services. You might want a VBAC, but your provider’s successful VBAC rate is only 15%. “Too bad,” you say. “This is where our insurance takes us. I guess we’ll just work with it.” You have to think through how important your birth preferences are to you, and then choose (and sometimes actually pay for) a provider with a similar birth philosophy as you. You, the consumer, are responsible for picking a provider and birth place that support your desires. If you do not, then it shouldn’t be a surprise when things go differently than you’d hoped. Of course there are always aspects beyond your control, but you can make every effort within your power to ensure that you have purchased like-minded maternity care.

It has been said before that most people put more research into choosing a car or a stereo system than they do in choosing a care provider or birth place. Don’t let this statement be true of you. Make every effort to be an informed consumer.

I Do Not Consent

After you finish reading this post, please head on over to the sequel to get the full picture here. And remember, this (or any other blog) should not be taken as medical advice- it’s just my opinion. I know it should be common sense, but I’ve gotta post it anyway! Thanks!

If you are in a birthing situation and you find that your caregiver is about to do something you don’t want (e.g. an episiotomy, pulling out the forceps, putting pit in your IV, etc.), you may want to remember these four little words:

“I do not consent.”

 

Saying, “I’d really rather you not cut me,” or, “I don’t want a vacuum delivery if the baby is still ok,” or “Please don’t up the pit” may or may not work. However, if you say that you do not consent to a certain procedure, then the doctor or midwife cannot legally proceed wth it.

I only say this because I have heard many, many horror stories of women being on the receiving end of what in any situation other than a birth would be considered assault. Make sure you are absolutely clear with your intent and tell your caregiver if you do not consent to a procedure. I will say, however, that this phrase should probably not be taken lightly. Weigh your caregiver’s experience against your own intuition. Is your baby still ok? Are you still ok?  Find out whether the caregiver is recommending a procedure out of medical necessity, or because of convenience or a hospital policy.

If nothing else, you can always say, “Wait. I do not consent yet.” Go on to ask these four questions:

1) Is this an emergency? (If no, move on.)

2) What are the benefits of this procedure?

3) What are the risks of this procedure?

4) What happens if we do nothing?

Remember that it is never, ever too late- even in the middle of labor- to change your caregiver or birth site. If a nurse is trying to do something you do  not want, request a different one. If you are home with a midwife who has suddenly turned sour on you, it’s okay to leave and go to the hospital. If you are at the hospital and there is no acceptable caregiver, it is okay to leave the delivery room and drive to the next hospital. Again, these actions should be taken only with real cause, not at the drop of a hat.

Remember, it is YOUR birth. Yes, doctors and midwives are trained for birth. But sometimes procedures, liability issues, and yes, even sometimes the convenience of the caregiver can get in the way of letting your body do what it does best. You should always be treated with respect and dignity. Remember, with careful consideration, it is okay to utter those four words: “I do not consent.”