Talking Risk: Counsel and Coercion
It is well known that our experiences influence our beliefs and philosophies. These same beliefs, in turn, influence our behaviors and choices. It follows that in birth, as in any area of life, women often have established a set of ideas and beliefs based on their unique experiences. Sometimes this may be called a “birth worldview” or “birth philosophy.” One such example of two different “birth philosophies” is to compare the midwifery vs medical models of maternity care. All childbirth professionals, from high-risk physicians to doulas, have established a conscious or subconscious framework for their own beliefs about childbirth. This framework can have a profound impact on the care and services that the professional provides.
When the birth philosophy of the mother comes into conflict with the birth philosophy of her care provider, uncomfortable or stressful situations may follow. When childbirth professionals encounter these situations, it is best to remain professional and use sensitivity to help educate and support the mother. It is not within a doula or educator’s scope of practice to offer medical advice, nor is it ever appropriate to encourage a client or student to ignore or disregard her care provider’s advice. However, when disagreements or conflicts occur between a client and her care provider, and a childbirth educator or doula is asked to offer up some wisdom, it is helpful to suggest that parents ask several important questions:
In my situation, what is the absolute risk (not the relative risk)?
For example, imagine being told that using a cell phone triples your risk of developing a brain tumor. This sounds scary and fraught with danger. You might be tempted to throw out your cell phone immediately. This statement is an example of relative risk (vaguely comparing no cell phone use to some undisclosed amount of cell phone use). Now imagine being told that while the average risk in the general population for developing a brain tumor is 1:30,000 or about a .00003% chance, several studies have concluded that for heavy cell phone users (who spent 3+ hours a day with the phone in close proximity to the head), the risk is 3:30,000 or about .0001% chance. Three people is indeed triple, but this more complete, thorough and concrete information probably makes it less likely that you would run home and chuck your cell phone.* Presenting information this way is an example of disclosing absolute risk; absolute risk uses concrete numbers to provide information. Discussing absolute risk allows parents to have the information they need within context and in perspective. When making important decisions during pregnancy, labor and birth, this is a very important distinction for parents. See more about professional guidelines for discussion of risk here.
The second question directly ties into the first:
Is the care provider giving directive counsel or using coercion?
The vast majority of maternity care providers want to support mothers in their goals and ensure everyone stays safe and healthy. When situations arise that could affect this, a sensitive discussion about risks and benefits of various choices should occur when possible. However, sometimes fear or frustration may cloud discussions. When a care provider uses emotional manipulation or coercion to try to persuade a mother into a certain direction or choice, the care provider has 1) begun to lose credibility and 2) stepped into unethical territory.
The unfortunate reality is that because of the huge amount of fear of liability in obstetrics, coercion is extremely common, especially for women in labor who find themselves vulnerable. An example of directive counsel might begin with the provider stating his or her desire to discuss the benefits and (absolute) risks of waiting until 42 weeks before a medical induction. A statement or interaction that results in guilt, fear or shame in the mother is unacceptable. An example of coercion might sound something like: “I understand that you prefer not to be induced, but it’s my job to make sure your baby is born alive and I need to be able to do my job.” Or coercion may be more subtle, such as telling the mother a story about a patient who “didn’t listen to my advice” in the past and had an undesirable outcome of some kind. Coercion is often the cause when a woman feels guilty, manipulated, shamed, belittled or bullied. It is possible that the care provider may be presenting correct information, but the way a woman is treated - the way the information is presented - is every bit as important as the substance of the information she is given. In June of 2016, ACOG published a Committee Opinion stating: “The use of coercion is not only ethically impermissible but also medically inadvisable because of the realities of prognostic uncertainty and the limitations of medical knowledge. As such, it is never acceptable [emphasis added] for obstetrician–gynecologists [or any maternity care provider] to attempt to influence patients toward a clinical decision using coercion. Obstetrician–gynecologists are discouraged in the strongest possible terms from the use of duress, manipulation, coercion, physical force, or threats, including threats to involve the courts or child protective services, to motivate women toward a specific clinical decision… Pregnancy does not lessen or limit the requirement to obtain informed consent or to honor a pregnant woman’s refusal of recommended treatment.”
This is a strong statement and applies to the relationship between pregnant women and their care providers at every stage of pregnancy, labor and birth. When asked for assistance by the mother, birth professionals should encourage her to ask herself the two questions above. The answers will make plain some very important pieces of information that can have a lifelong impact.
*This example is presented as a purely fictional illustration. We have not done any research on cell phone use and brain tumors.
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