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Autonomy, Paternalism, and Informed Consent
Taken in part from “Midwifery Ethics” by Ida Darragh
Autonomy is an individual’s right to make choices on their own behalf; Being able to exercise autonomy is seen as having the ability to understand, reason, evaluate options and make decisions for yourself.
Paternalism is making choices on behalf of the client without seeking or heeding their views.
Paternalism is usually seen as the opposite of autonomy, but it is usually not harmful in INTENT. People who behave paternalistically do so in the true belief that they know what is best for the client. Paternalism is Utilitarian- based on the belief that the end (good outcome) justifies the means (disregarding the client’s will or not seeking the client’s input).
Whether power is real or perceived is irrelevant; the fact that someone feels less powerful than someone else means that any relationship that develops is unequal. Those with less power (real or imagined) will always react differently and there is the very real risk of coercion and paternalism creeping into a relationship. When clients are unable or unwilling to act or speak for themselves, midwives are taking on an advocacy role in their behalf. Advocacy is speaking on another’s behalf; paternalism is acting on another’s behalf.
The ethical doctrine of informed consent contains the mandate to explain, to offer alternatives, to discuss risks and benefits of a particular choice or action, to make sure the information is understood by the client, to encourage the client to choose the action best for her.
Much of the information shared with the client is “filtered” by and through the values of the teacher, whether it be midwife, childbirth educator, doula, or physician.
- Sometimes the woman doesn’t want to make the decision.
- Sometimes the provider is not aware of her or his own value biases.
- Sometimes the emergency nature of the situation does not allow time for fully shared decision-making.
Legally, a mentally competent patient has an absolute right to refuse consent to medical treatment for any reason, rational or irrational, or for no reason at all, even when that decision will lead to death. (Jones, Ethics in Midwifery, 2000, quoting Judge Wall, 1996)
Key word is “competent.” Competent means that the person can
· Comprehend and retain treatment information
· Believe the information
· Weigh information to make a decision
Permission granted under duress is not true consent.
From Myles (2000) quoting Brown (1992):
Enabling informed consent to occur and empowering women to decide what is best for them are fundamental parts of respect for autonomy.
What happens when a client’s wishes differ from the midwife’s professional judgment? Ethical dilemma: when compliance with a woman’s choice would lead to self-compromise for the midwife. One action could lead to higher risk or to unnecessary complications, while another action breaches the autonomy of the client.
Foster and Lasser, Professional Ethics in Midwifery Practice, Jones and Bartlett, 2010
Walsh, Linda; Midwifery; Community Based Care During the Childbearing Year; Saunders 2001
Myles Textbook for Midwives; Churchill Livingstone, 2003
Sweet, Betty; Maye’s Midwifery; Bailliere Tindall, 2002
Joens, Shirley; Ethics in Midwifery, Mosby 2003
For more reading on informed consent:
"Sure, the goal of birth is a healthy mom and a healthy baby. Absolutely. But that's like saying the goal of life is to keep breathing; it's SO much more than that! It's what you do with those breaths- HOW you feel and experience and remember your labor- that makes all the difference."
"Whenever a woman is in labor she has pain, because her hour has come; but when she gives birth to the child, she no longer remembers the anguish because of the joy that a child has been born into the world."
Labor and birth are among the most important and impacting events of a woman’s life. Whether things go smoothly or are completely different than expected, a woman can still have a good childbirth experience. The satisfaction of the birth largely depends on the labor support she receives. If she is well supported (both emotionally and physically), respected, and informed, even the most unexpected turn of events in labor can end up being a positive memory which a woman can carry with her for the rest of her life. On the other hand, if a woman lacks this support it can cause emotional scarring that can be difficult to overcome.
Labor support comes in many forms: doctors, midwives, nurses, doulas, family, and friends. Medical personnel such as doctors, midwives, and nurses focus their attention on the health and safety of the mother and baby. Family and friends help with emotional and perhaps physical and spiritual aspects. A doula acts as a support person that incorporates a little of both roles. Although not medically trained, she is knowledgeable and experienced in the process of childbirth. She often spends time getting to know her client—her wants and needs, ideals and fears, and what’s important to her. A doula gathers information so that her client can make informed choices both before labor and during, but she never makes decisions for the woman. She gives continuous emotional support during labor and has ideas for what may help the woman in whatever situation she may find herself in. A good doula encourages other people important to the woman to be part of the process by helping them be as involved as they are comfortable. “Doula” is the perfect word for this role, since its meaning is Greek for “a woman who serves.”1 This is the purpose of a doula: to serve the laboring woman and those involved so that a mother receives care that will allow her to view her birth experience in the most positive way possible.
The benefits of having a doula are profound. “Introducing a doula into the labor room not only improves the bond between mother and infant, but also seems to decrease the incidence of complications.”2 When trials and analysis of labor support were done in North America, rates of medical intervention were 26-41% less when a doula was present, and “obstetric outcomes were most improved and intervention rates were most dramatically lowered by doulas in settings where the women had no loved ones present, the intervention rates were routinely high (as indicated by the data for the control groups) and the doulas were not health care professionals.”3 Women who incorporate a doula into their birth report higher levels of satisfaction and rate their birth experience higher than those who don’t.4 Because it is important for a woman to feel completely relaxed and at ease during labor, it is imperative that she choose a doula with whom she is comfortable and can build a relationship of trust.
A doula reduces the work load for the medical professional, because a supported woman is less likely to need medical intervention.5 For the family or friends of a laboring woman, the doula can be immensely helpful. She can guide the husband (or partner) who may not be familiar with the process of childbirth. Many times, a husband is able to enjoy the birth more if he is not the sole support for his wife. A doula often has ideas for non-medical physical support that are based on experience. For the well-informed partner, she can be a second pair of hands for him, getting things to make his supporting role easier. Another invaluable benefit the doula provides is knowledge of or access to information when decisions need to be made. She can help a woman feel encouraged and validated if she chooses a different labor than her ideal. She often has skills to enhance communication between the laboring woman and her medical team.6
A doula must be careful not to overstep her bounds when it comes to her role and responsibilities. She must not take on medical or clinical responsibilities such as vaginal exams or offering second opinions.7
“Given the clear benefits and no known risks associated with intrapartum support, every effort should be made to ensure that all labouring women receive support, not only from those close to them but also from specially trained caregivers. This support should include continuous presence, the provision of hands-on comfort, and encouragement.”8 When looking at the cost of a doula, one must consider the recommendation given above. Though considered “a luxury” or “unnecessary” to some, the benefits of lower medical interventions (including Cesarean sections), help to the other members of the maternity care team, and higher satisfaction rate make a doula an invaluable asset to any woman expecting a child.
1. Simkin P, and Way, K. “DONA International Position Paper: The Birth Doula’s Contribution to Modern Maternity Care,” (2005), 1
2. Ibid, 3
4. Ibid, 2
6. “DONA International: Standards of Practice, Birth Doula” (2008), 1
8. Simkin P, and Way, K., 4