Discussion of Risk: How Continuity of Carer Impacts Womens Choices

It is a woman’s human right to make choices about her care (NMC, 2015, Birthrights, 2013) and women must be provided with the information they need to make an informed choice (NMC, 2009), including discussing risks and benefits of the options available to women, which is both the legal and professional responsibility of midwives and obstetricians (The Supreme Court, 2015). It is important to be aware that the way in which risk is discussed can exaggerate risks (Van Wagner, 2016) and that lack of adequate time and follow up when discussing risks with women during pregnancy can direct care towards interventions (Van Wagner, 2016). The provision of relational continuity can counteract this and is shown to improve outcomes for women with perceived risk factors (Sandall et al 2016).

When a woman is considered high risk or her wishes fall outside of the guidelines, it is a requirement that she has access to an obstetrician to discuss her options (NICE, 2017). At a time where she is perhaps feeling stressed and anxious, it is even more important that she is able to see both professionals as a team working together to support her decisions, which is why continuity is important for all professionals involved in a woman’s care. The caseload team that I worked closely with during my training work closely with a named obstetrician who has an understanding of the way in which they work, which is what is recommended by Better Births (NMR 2016). The ‘Better Births’ way of working, in small midwifery teams, with a named obstetrician to overlook care of all women who require an obstetrician, is shown to improve safety, as well as breaking down barriers between professions. It can result in consistent advice and counselling throughout all midwife and obstetric appointments, advice that is personalised around the woman’s choice, whatever choice that may be.

Many women with risk factors who choose to birth out of the guidelines of the trust they are booked at feel intimidated and emotionally coerced into changing their mind (Lee et al 2016), but a caseload model of care that incorporates relational, management and informational continuity, supports women in a way that prevents them from being in this position. It also helps to support partners, who may well be stressed and anxious about their partner making choices that may have a risk label to them as they can view this as putting the babies life in danger and subsequently can lead to them trying to convince the woman to change her mind.

The experience of pressure using guilt or fear to change a woman’s mind is something women commonly experience from professionals who disagree with their choices (Van Wagner 2016, Lee 2016) and sometimes this pressure is felt because of women not feeling involved in the discussion of the risks factors and the way in which these risks are shared.  For example a woman being told her risk  ‘doubles’ in a certain situation, without giving the statistics behind it, that might well still be extremely low, is known to exaggerate risk estimates and causes heightened anxiety (Van Wagner, 2016).

The benefits of continuity of carer, whether Midwife or Obststrician or both, are that both the woman and her partner receive ongoing consistent support and advice and it reduces conflict of advice between professionals (NMR 2016, Sandall et al 2016). When working in a caseload model of care with close interdisciplinary relationships it is more likely that, rather than providing statistics in differing ways that suggest conflict between the interdisciplinary team and prove unsettling for the woman and her partner, the interdisciplinary team can work together to ensure they are sharing the same and most up to date information.  This means women feel listened to and central in their care and rather than a 1 way delivery of risks, it creates and encourages a 2 way discussion and make the choice that is right for them.

Please join the campaign for continuity of carer for all women, for the benefit not just of the women but for babies, for families and for the midwives too. You can do so by following the campaign on Facebook, sharing the campaign on social media using the hashtag #continuitymatters or you can email your story to share on the blog to continuitymatters@gmail.com

References

Birthrights (2013) Consenting to Treatment Factsheet. Available online at http://www.birthrights.org.uk/library/factsheets/Consenting-to-Treatment.pdf

Lee, S., Ayers, S. and Holden, D. (2016). How women with high risk pregnancies perceive interactions with healthcare professionals when discussing place of birth: A qualitative study. Midwifery, 38, pp.42-48.

National Maternity Review [NMR] (2016) Better Births: Improving Outcomes of Maternity Services in England. London. Available online https://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf

Nursing and Midwifery Council (2009) Standards for Pre-Registration Midwifery Education. Retrieved from http://www.nmc.org.uk/globalassets/siteDocuments/Standards/nmcStandardsforPre_RegistrationMidwiferyEducation.pdf

Nursing and Midwifery Council (2015) The Code. Retrieved from National Institute for Health and Care Excellence (2017a) Antenatal Care for Uncomplicated Pregnancies. London, NICE. Available online https://www.nice.org.uk/guidance/cg62

National Institute for Health and Care Excellence (2017b) Intrapartum Care for Healthy Women and Babies. London, NICE. Available online https://www.nice.org.uk/guidance/cg190

Sandall, J., Coxon, K., Mackintosh, N. J., Rayment-Jones, H., Locock, L., & Page, L. (2016). Relationships: the pathway to safe, high-quality maternity care: Sheila Kitzinger symposium at Green Templeton College, Oxford: Summary report. Green Templeton College, Oxford.

The Supreme Court (2015) Judgment: Montgomery (Appellant) v Lanarkshire Health Board (Respondent) (Scotland) available at: https://supremecourt.uk/cases/docs/uksc-2013-0136-judgment.pdf

Van Wagner, V. (2016). Risk talk: Using evidence without increasing fear. Midwifery, 38, pp.21-28.

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