Informed decision making and consent in maternity and neonatal services

The provision of high-quality personalised care is core to the 3-year delivery plan for maternity and neonatal services. Despite informed decision-making being an ethical, professional and legal standard, the 2023 maternity survey reported that only 76% of women felt as involved as they would have liked in decisions during childbirth (1).

Informed (previously shared) decision making was first described in a national policy context in the United States in 1982 (2) and it’s worth reflecting that many of the statements in that document are still relevant 42 years later:

‘Even when clinicians and patients (sic) are sensitive to the goal of shared decision making, substantial barriers exist….including long standing professional attitudes and difficulties in conveying medical information in ordinary language’

So why is implementation of informed decision making still a challenge 42 years later? Much has been written about this from a clinician’s perspective (3,4), and these reasons come up time and again:

“I do it already”.

“I ‘d like to do it but I don’t have the time”.

“My organisation doesn’t support me to do it”.

“Patients (sic) don’t want it”.

Much less has been written about why clinicians find shared decision making so fundamentally challenging- it’s often put down to (as above) ‘attitude’ or ‘mindset’. I’m not sure I buy this- the implication being that clinicians enjoy exercising a power differential or that somehow, they have a bad attitude.

No- it’s more nuanced than that, I think.

The fact is, clinicians are trained to be problem solvers and decision makers and they are really, really good at it- indeed it’s at the core of their professional identity. And because they do it habitually, clinicians don’t tend to think about the process of decision making itself.

Decision making in healthcare has (or perhaps more correctly should have) 2 interlinked components:

Clinical decision making is the process whereby healthcare professionals diagnose a problem, organise diagnostic tests (if necessary) and formulate reasonable plans of action. In doing this, they draw on clinical reasoning: what they know about the clinical characteristics of the patient, what the evidence base says (based on evidence from populations of people like the one they are dealing with) and on their own expertise. The output from this process is often a decision or a plan and this is what most of us were trained to do. But the output should be a ‘menu of reasonable options’ that can be used to inform…
An informed decision-making conversation, leading perhaps to a consent discussion if a decision is made to proceed to intervention.

The informed decision-making conversation should be an unbiased discussion about the benefits and harms of all reasonable options (5), alongside a discussion about outcomes that matter to birthing people- outcomes for them and for their baby.

A consent conversation should be a more focussed discussion about the intervention under consideration with an emphasis on material risks- outcomes that matter to the individual and their baby should an untoward event occur.

The Montgomery ruling (6) has made clinicians think again about decision making and consent, but perhaps not think enough about how to implement high quality decision making and consent in their own practice. A starting point is to become aware of our own habits and biases and I hope that this article has gone some way towards achieving that objective.

In my next blog, I’ll talk more about how to implement high quality informed decision making and consent and sharing with you a simple model to help you improve your own practice.

References

Footnote

As an important aside, the question of ‘what is a reasonable option?’ has recently been tested in a court of law (5). What was clear from that case is that the content of the menu of reasonable options should be determined by the treating clinician and not by the (sic) patient.