Jacqueline A Nicholls1, Anna L David2,3,4, Joseph Iskaros3, Dimitrios Siassakos2,3,4,5, Anne Lanceley2. 1. EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, Medical School Building, 74 Huntley Street, London, WC1E 6AU, UK. j.nicholls@ucl.ac.uk. 2. EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, Medical School Building, 74 Huntley Street, London, WC1E 6AU, UK. 3. Elizabeth Garrett Anderson Wing, University College London Hospital NHS Foundation Trust, 25 Grafton Way, London, WC1E 6DB, UK. 4. NIHR University College London Hospitals Biomedical Research Centre, Research & Development, 149 Tottenham Court Road, London, W1T 7DN, UK. 5. Wellcome / EPSRC Centre for Interventional and Surgical Sciences, University College London, Gower St, Bloomsbury, London, WC1E 6BT, UK.
Abstract
BACKGROUND: How to best support pregnant women in making truly autonomous decisions which accord with current consent law is poorly understood and problematic for them and their healthcare professionals. This observational study examined a range of ante-natal consultations where consent for an intervention took place to determine key themes during the encounter. METHODS: Qualitative research in a large urban teaching hospital in London. Sixteen consultations between pregnant women and their healthcare professionals (nine obstetricians and three midwives) where ante-natal interventions were discussed and consent was documented were directly observed. Data were collectively analysed to identify key themes characterising the consent process. RESULTS: Four themes were identified: 1) Clinical framing - by framing the consultation in terms of the clinical decision to be made HCPs miss the opportunity to assess what really matters to a pregnant woman. For many women the opportunity to feel that their previous experiences had been 'heard' was an important but sometimes neglected prelude to the ensuing consultation; 2) Clinical risk dominated narrative - all consultations were dominated by information related to risk; discussion of reasonable alternatives was not always observed and women's understanding of information was seldom verified making compliance with current law questionable; 3) Parallel narrative - woman-centred experience - for pregnant women social factors such as the place of birth and partner influences were as or more important than considerations of clinical risk yet were often missed by HCPs; 4) Cross cutting narrative - genuine dialogue - we observed variably effective interaction between the clinical (2) and patient (3) narratives influenced by trust and empathy and explicit empowering language by HCPs. CONCLUSION: We found that ante-natal consultations that include consent for interventions are dominated by clinical framing and risk, and explore the woman-centred narrative less well. Current UK law requires consent consultations to include explicit effort to gauge a woman's preferences and values, yet consultations seem to fail to achieve such understanding. At the very least, consultations may be improved by the addition of opening questions along the lines of 'what matters to you most?'
BACKGROUND: How to best support pregnant women in making truly autonomous decisions which accord with current consent law is poorly understood and problematic for them and their healthcare professionals. This observational study examined a range of ante-natal consultations where consent for an intervention took place to determine key themes during the encounter. METHODS: Qualitative research in a large urban teaching hospital in London. Sixteen consultations between pregnant women and their healthcare professionals (nine obstetricians and three midwives) where ante-natal interventions were discussed and consent was documented were directly observed. Data were collectively analysed to identify key themes characterising the consent process. RESULTS: Four themes were identified: 1) Clinical framing - by framing the consultation in terms of the clinical decision to be made HCPs miss the opportunity to assess what really matters to a pregnant woman. For many women the opportunity to feel that their previous experiences had been 'heard' was an important but sometimes neglected prelude to the ensuing consultation; 2) Clinical risk dominated narrative - all consultations were dominated by information related to risk; discussion of reasonable alternatives was not always observed and women's understanding of information was seldom verified making compliance with current law questionable; 3) Parallel narrative - woman-centred experience - for pregnant women social factors such as the place of birth and partner influences were as or more important than considerations of clinical risk yet were often missed by HCPs; 4) Cross cutting narrative - genuine dialogue - we observed variably effective interaction between the clinical (2) and patient (3) narratives influenced by trust and empathy and explicit empowering language by HCPs. CONCLUSION: We found that ante-natal consultations that include consent for interventions are dominated by clinical framing and risk, and explore the woman-centred narrative less well. Current UK law requires consent consultations to include explicit effort to gauge a woman's preferences and values, yet consultations seem to fail to achieve such understanding. At the very least, consultations may be improved by the addition of opening questions along the lines of 'what matters to you most?'
Authors: Michael C Klein; Robert Liston; William D Fraser; Nazli Baradaran; Stephen J C Hearps; Jocelyn Tomkinson; Janusz Kaczorowski; Rollin Brant Journal: Birth Date: 2011-03-10 Impact factor: 3.689