Rights and Responsibilities: Where did they Go?

Feminism is a dirty word, especially if you are a pro-establishment columnist. Recently the mass media have spurned the safety of homebirth. Dr’s were outraged at the death of 4 babies, without revealing any case facts. Many have regarded women as incubators. Not one mainstream piece has explored why a number of women feel the need to give birth without any health professional, nor have they explored simple tested legal concepts of informed consent and right of refusal. It would seem far more sensible to herd all women into hospitals where they can be controlled. Women cannot be trusted, especially those who challenge the fierce medical domination of childbirth.

As an owner of a female body I have taken it for a test run seven times.  I have chosen to use limited medical technologies, and resisted others.  I took ultimate control of my body and became responsible for the life growing within me. As a parent I continue to tread that path of rights and responsibilities. I paid a price however.  My decision to give birth at home with a registered midwife was not respected or funded.  At the same time my taxes paid for a system controlled by medicine.  A system with virtually no accountability, that allegedly enabled gross sexual assault under Dr Graeme Reeves.  These assaults were extreme but lower level violence continues in maternity wards every day. Miranda Devine, a conservative apologist columnist mocked this violence.  How can this be tolerated?

With this environment how could a woman previously damaged by the system feel safe?  We have a maternity health system that leaves one in 4 women experiencing birth as a ‘battlefield’ and suffering debilitating post natal depression or even post-traumatic stress disorder, usually reserved for soldiers and victims of crime. Whilst women cry out for a mainstream midwifery option that puts their needs first, the medical establishment remains largely unaccountable.

Federal Health Minister, Nicola Roxon put her toe in the water, by announcing the Maternity Services Review last September. As expected the women who have been denied their rights and are funding others, provided submissions in the hundreds, over 900, an unprecedented number.  Pro-establishment columnists denounce them as a ‘vocal minority’ and continue to deny them equity. Sadly so did the Department of Health and Ageing when they released their review report, saying the following about homebirth:

While acknowledging it is a preference for some women, the Review Team does not propose Commonwealth funding of homebirths as a mainstream option for maternity care at this time.

The Review also considers that moving prematurely to a mainstream private model of care incorporating homebirthing risks polarising the professions rather than allowing the expansion of collaborative approaches to improving choice and services for Australian women and their babies. ^[1]

As a woman and lawyer, Nicola Roxon is well placed to oversee the design of a maternity system with the established principles of informed consent and right of refusal at the centre. Arguments of safety and wellbeing are thin guises of tightly held power and control by medical lobby groups. They have no track record of respecting women’s rights.  Instead they engage in shroud waving and cripple women with unnecessary fear.

I attended a roundtable meeting of key stakeholders as part of the Maternity Service Review last year.  The topic discussed was ‘high-risk pregnancy’.  Many instantly think of pre-eclampsia, placenta praevia, prematurity and disease. While a minority of women experience serious illness and intervention, many women and babies are classified as ‘high-risk’ by an obstetric community that is largely dogged by fear and distrusts women.  This assessment is made after many years and informed by hundreds of stories. 

My conclusion was sadly confirmed at the roundtable meeting, when a senior obstetrician said without hesitation “He would be loathed to think a woman would have the final say in her care.”  I nearly choked on my shortbread biscuit, as I scanned the room for reaction. I found only one raised eyebrow. A number of midwifery advocates seemingly let this comment pass. As a consumer, passionate about the rights of women to make informed choices, I believe the paternalism that pervades obstetrics and the widespread midwifery practice of maintaining the status quo pose a major threat to reform.

This view is in direct contradiction to common law in Australia.  Kim Forrester, a member of the Queensland Bar states: “all adults who are of sound mind and considered legally competent have an absolute right to consent, or refuse to consent, to medical intervention and/or treatment. This is the case regardless of the opinion of health professionals as to what is in the ‘best interests’ of the patient or client.”^[2]

Those with knowledge and interest in the law would see this as a very cut and dried case, A US appeal case heard in 1914 made a landmark decision still quoted today^[3] Schloendorff v Society of New York Hospital, clearly articulates— “Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without the patient’s consent, commits an assault”

The culture of fear and control in obstetrics has enabled these legal principles to be ignored.  Women are consistently misled about procedures performed on them.  Ironically most women are grateful and believe that either their own or their baby’s life was saved, often after an unnecessary intervention.

Obstetric dominance pervades midwifery. Virtually all models operate with exclusion criteria that are not based on evidence.  A woman with a previous caesarean section is unable to give birth in a bath in a birth centre with a midwife sometimes only seconds from operating theatres.  Her safety can only be assured in a ‘labour ward’ sometimes only metres away from the birth centre.  The capacity for a healthy woman to deliver her placenta without oxytocics is doubted and feared.  A woman who refuses foetal surveillance but rather listens to her body and baby, is branded irresponsible and dangerous.

This reform process is likely to bring with it guiding principles. The Australian College of Midwives developed guidelines for establishing midwifery models.^[4]  The recent 2nd edition was mindful of the need to enshrine informed consent and right of refusal. They state

Ethical principles underlying health care and health law emphasize the importance of respecting the autonomy of those receiving health care and the rights of individuals to choose among alternative approaches, weighing risks and benefits according to their needs and values. Midwives, like all health professionals, are responsible for being clear about their scope of practice and limitations, giving recommendations for care if appropriate and for informing women about risks, benefits and alternative approaches.

Should a situation arise in which the woman chooses care outside the recommendations in the Guidelines the midwife must engage with the woman and her family and with hospital staff through identified channels where applicable, in a thorough discussion of the request, looking for options

The Royal Australian New Zealand College of Obstetricians  and Gynaecologists (RANZCOG) do not accept these guidelines despite being operational for nearly five years. In recent days they have released their own guidelines. Interestingly this is their take on informed consent

These guidelines acknowledge that a woman may choose not to follow a recommended course of action.  In some circumstances, this will follow the provision of inaccurate or inadequate information.  Subtleties of wording or emphasis can be critical in this respect.

Where lack of “informed consent” is the reason given for non-adherence to guidelines, documentation should occur in a way that appropriate clinical audit is able to identify patterns of practice where this may be a repeated problem, perhaps reflecting the nature &/or method of information provision.

Information should always be provided appropriate to the patients’ social and cultural background, and in an unbiased manner.  Written information is often helpful. ^[5]

It would seem that unless a woman conforms to obstetric dominance she is not informed. If this wasn’t so serious it would be funny.

For too long we have chanted that birth needs to come back to women. Now is the time to empower women with rights too often denied. How can we have a maternity system that largely treats women as incubators where emotional wellbeing is dissected from her uterine cavity; and yet come post-natal discharge the same woman walks out into the world to make major life decisions for her child for the next 16-18 years? As with maternity reform empowering women will take time, but if the reform process respects the rights of midwives to practice a full scope of practice and that of women that determine how and by whom their bodies are handled (if at all) a true woman centred approach is possible.

Neither the church nor the state has the right to control a woman’s body.  Maternity reform must be based on the 3 R’s - rights, responsibilities and respect.  Consumers have the right to a funded registered health professional in any setting, and the responsibility to demonstrate they have made informed decisions. They deserve these decisions be respected.  Health professionals have the right to funding and to provide clinical advice and services based on evidence. They have a responsibility to be satisfied that consent/refusal was informed. They deserve the respect of the woman as an educated professional but ultimately this respect must be reciprocated to provide healthcare according to the woman’s intent.

References:

1. Department of Health and Ageing (2009) Report of the Maternity Services Review
2. Forrester, K Refusal of Treatment: An absolute right of the patient or client. The QLD Nurse,April 2007 p10-11
3. 211 N.Y. 125, 105 N.E. 92 (1914), New York Court of Appeals
4. Australian College of Midwives Inc (2008) Practice Guidelines National Midwifery Guidelines for Consultation & Referral 2nd Edition
5. RANZCOG (2009) Guideline: Suitability Criteria for Models of Care and Indications for Referral within & between Models of Care