Further to our post yesterday, Whose Body Is It Anyway, Jene Kelly, co-chair of Association for Improved Maternity Services in Ireland (AIMSI), writes:
This case has led to widespread debate on the issue of consent in the Irish maternity services. On one side, the argument is that no medical professional would perform an invasive procedure without obtaining consent – that medical professionals must be given scope to practice as they see fit, as the trained expert.
On the other, it is recognised that many of the practices used in Irish maternity services are not based on evidence nor best practice but routine hospital policy and that this judgement has stripped a woman of agency over her decisions and body; her right to consent.
The issue of consent in Irish maternity services is not new, but, it remains largely unexplored in mainstream society or media outlets. Sometimes, the issue of consent reaches our living rooms, in individual cases like this one or in group actions such as the Symphysiotomy survivors, giving the public a perception that consent breaches are rare, extraordinary, and perhaps even historical events confined to a darker chapter of Irish history.
The reality is that Ireland’s maternity consent issues haven’t gone away. Stories are shared everyday in private closed groups between women, over tea with friends, at the local toddler morning, on parenting forums, and in the dead of the night when everyone sleeps. While not the majority, a significant proportion of women will have experienced consent breaches at some stage of their maternity care, often with physical and psychological consequences.
Ireland has difficulties when it comes to pregnant women and rights. Every Irish citizen has the right to informed consent during medical treatments. This means tests, procedures, and interventions are to be discussed clearly with an individual in an unbiased manner, based on the highest quality evidence available, both the benefits and risks of opting in or opting out, in order for them to make the best decision for themselves at that time. For pregnant women in Ireland, these rights are challenged by the Irish Constitution and Article 40.3.3 – which gives equal rights to the woman and foetus. This conflict is highlighted in the National Consent Policy.
The National Consent Policy states:
Page 41: 7.7.1 Refusal of Treatment in Pregnancy.
The consent of a pregnant woman is required for all health and social care interventions.
However, because of the constitutional provisions on the right to life of the “unborn” (12), there is significant legal uncertainty regarding the extent of a pregnant woman’s right to refuse treatment in circumstances in which the refusal would put the life of a viable foetus at serious risk. In such circumstances, legal advice should be sought as to whether an application to the High Court is necessary.
Citation: (12) Article 40.3.3 of the Irish Constitution (1937)
Relevant factors to be considered in this context may include whether the risk to the life of the unborn is established with a reasonable degree of medical certainty, and whether the imposition of treatment would place a disproportionate burden or risk of harm on the pregnant woman.
The result of this policy is it leaves women and medical professionals with a degree of uncertainty which is open to interpretation. Expert recommendations are often based on personal opinion, biases, and previous experience, not necessarily evidence. As a result, practice and policy varies not only between individual units, but individual providers. This latest High Court ruling brings a new component to this conflict by suggesting that routine practice is the benchmark for negligence cases, not evidence-based care, and that the medical professional can over-ride a woman’s right to consent/refusal regardless of the presence of serious risk.
Is consent an issue of concern in Irish maternity services?
In autumn of 2007, AIMS Ireland ran an online survey on the topic of Availability of Information and Consent. It was open to any one who wished to fill it in. Respondents who completed the survey were anonymous. The survey was small (161 women) and self-selecting.
The survey consisted of Quantitative (statistics) and Qualitative (comments) data. A larger survey by AIMS Ireland, What Matters to YOU 2014 , with nearly 2,000 respondents, will be published this autumn.
More than half of respondents (61%) said that in pregnancy (outside of antenatal classes), they had no opportunity to discuss choices and information regarding hospital policies, routine procedures and common procedures, tests or treatments which you may need to make a decision about during your pregnancy, labour or birth. Of the 39% who responded that they did have opportunities, over half (53.1%) had to be the one to initiate the discussion to gain access to information.
Information was seen to be based on hospital policy, rather than objective evidence-based sources. Women who tried to challenge this were put in a difficult and unfair position, for example:
“Information given is usually hospital-based policies only, rather than a full benefit/risks/alternatives etc analysis. My experience was that this information was presented in a very biased way and that, even if you refused and had the evidence to justify your position, you were still made to feel that you were in someway putting your baby at risk and were made to feel difficult or unreasonable. It takes a very strong person to be able to stand your ground in these circumstances especially for a first-timer”
They also perceived that information was used as a source of pressure on them:
“I feel that every woman needs to have access to all information. I was very
informed but it was due to research done by myself. However when you are in the hospital there is a subtle pressure put on you saying you want your baby to be safe”
This information was also felt to be very negative and undermining of women’s abilities:
“There is too much focus on what could go wrong with labour and birth and so
starting from a negative position – instead of building the expectant mother’s
confidence that things have as much chance of going well and what she can do to maximise this. This is particularly prevalent in hospital ante-natal classes which seem to overly focus on the pain of labour, need for interventions, etc instead of providing positive examples. Also, you are not made to feel that your body is capable of a successful and natural birth and so there is less trust and confidence going into labour.”
In this survey, 75.6% of respondents stated that they felt that consent is an issue of concern in the Irish maternity system. Further questions on the survey have unfortunately illustrated how key an issue consent is with only 38% of women in labour and 33% of women during birth responding “Yes, my consent was fully sought and given”.Continue reading →