An example story based on the many complaints we assist with each year...
Sophie's story - In Pregnancy
Sophie is pregnant with her first child. She has had a normal, healthy pregnancy but now at 36 weeks she has been told her baby is measuring larger than normal. She is booked in to birth at her local public hospital under the care of a team of midwives, which is overseen by obstetricians if necessary (the standard of maternity care in Australia). The midwife has told her an early induction will be best so she can avoid delivering a “big” baby, especially as a first time mum.
Sophie feels a bit worried about induction, because she doesn't know much about it. She has also heard about “big babies” being over-diagnosed in the hospital setting.
At her next weekly appointment, she is seen by another midwife from the team, who repeats that her baby is measuring large and says she can book in for an induction in two weeks’ time, when she will be 39 weeks pregnant. Sophie reluctantly agrees to make the booking but really doesn’t want to go ahead with it.
What are Sophie's options?
1. Know her rights
Like any pregnant woman, Sophie has the same human rights to bodily autonomy as any other person (Universal Declaration of Human Rights and Australian Charter of Healthcare Rights). A longstanding common law principle holds that her baby does not have separate rights to her until the baby is born alive. Sophie has the right to receive evidence based information about her care, free from coercion by her carers. She does not have to do what the hospital tells her to do. They can only make recommendations, even though it may not feel that way.
So when the midwife said "an early induction will be best" for Sophie, she wasn't saying Sophie has to have the induction for any legal reason. The midwife is recommending this course of action.
However, hospital staff are not required to make recommendations. They are required by law to give Sophie unbiased, evidence based information about the risks and benefits of induction. Sophie also needs to be given the time to think about this choice. She may even want to seek a second opinion before making a final decision to say yes or no.
Without being given unbiased evidence regarding induction, Sophie will not be giving valid consent. A test for freely given consent is whether Sophie feels she can say no at any time to the procedure without fear of neglect or harassment by the staff. If hospital staff proceed with induction without Sophie’s full and free consent, they could be committing assault.
2. Ask for more information
In order to feel comfortable with her decision to proceed with, or decline the offer of induction, Sophie needs information from her midwife. A helpful tool for this conversation is the BRAIN acronym. She could ask the midwife:
What are the Benefits of induction?
What are the Risks?
What are the Alternatives?
(To ask herself later) What does Sophie's Intuition tell her to do?
What if she does Nothing?
We also recommend Sophie have her partner or a friend attend the appointment with her for moral support. If another person can't attend with her, she can ask to have the conversation by phone, with her support person with her on speaker phone.
Sophie should also take a notepad or she can ask if she can record the conversation.
If these requests aren't permitted, Sophie can ask to have this conversation with the midwife's manager. She can keep going up the chain of command until she can have her questions answered. This approach often works.
At the end of the conversation, Sophie does not need to give her final answer. She can thank the staff for their time and say that she now needs time to think about her next steps. Bear in mind, even after Sophie makes a decision, she can change her mind at any time - even moments before the procedure is about to start.
3. State her decisions
After having the time to make her choice, Sophie then needs to state clearly what she wants for her birth. If she wants to decline an induction she could say something like “Thank you for the information you have given me, but I have decided I want to go into labour spontaneously. Please do not ask me again if I want to be induced.”
The hospital is then required to accept Sophie's decision. Legally they have met their obligations to her because they have provided her with evidence based, unbiased information of any risks they have detected.
4. Go up the chain
However, if the hospital midwives continue to coerce Sophie into an induction she can ask to meet with the Head of Obstetrics and the Midwifery Unit Manager to inform them of her intentions and ask that they direct their staff to respect her choices. The higher up the chain Sophie goes, it is more likely she will encounter a person who 1) understands her rights and 2) is senior enough in the hospital to uphold them without fear of repercussions. Sophie should seek their assurances in writing and have them printed out to show on request.
5. Seek external support
If hospital management is unreceptive to Sophie’s requests, she could complain to the health service that runs the hospital (eg, HHS in Queensland or LHD in NSW) and seek an urgent response. She could also write to her state Health Minister, her state MP, the Federal Health Minister and cc the national and local media. This is obviously a stressful step to take, especially so late in pregnancy, but nonetheless a viable option. The more these complaints are sent up the chain of command, the more they will be listened to.
Sophie may also want to consider birthing at home, which is of course her right, and should have been made available to her by her local health service in the first place. Unfortunately this option is not widely available, in spite of it being Commonwealth Health Department policy that women be given the option to birth in or near their homes under the continuous care of a known midwife.
In the absence of a hospital funded home birth service, and if Sophie is sufficiently resourced, she might like to seek the assistance of a privately practising midwife, who at short notice could attend her at home. At this late stage in her pregnancy, this could be difficult to organise due the lack of private midwives, as they are usually booked out for many months in advance. This option also requires considerable up front payment compared with birthing at a public hospital, which is free.
If a private midwife is available, Sophie could seek the support of her local MP who might be willing to pay for the midwife’s services, demonstrating their commitment to the needs of their community. While this is an unusual step, it has worked before.
These steps can be taken by any pregnant woman who is seeking the care that she wants for her and her baby. It is easy for the hospital system to prioritise its policies and procedures over women’s rights, especially more junior staff who might feel worried about repercussions from other staff if they see her supporting a woman who’s not going along with hospital policy.
This work environment can mean staff can lose sight of the fact that no one else is literally putting their current and future health prospects on the line than the baby’s mother. No one else is more concerned about the baby’s safe arrival than her.
And, as decades of safety and quality in healthcare research shows, the best and safest outcomes are achieved when women are given evidence based information and supported to make their own best decisions, even if the clinician disagrees. Women and babies (indeed, anyone in the health system) are more likely to be harmed if they simply do what their clinician tells them to do. This is why we have the Australian Charter of Healthcare Rights, 5 Questions to Ask your Doctor and Standard 2: Partnering with Consumers.