Women desiring less care than recommended during childbirth: Three years of dedicated clinic

Abstract

Background: Some women decline recommended care during pregnancy and birth.This can cause friction between client and provider. Methods: A designated outpatient clinic was started for women who decline recommended care in pregnancy. All women who attended were analyzed retrospectively.The clinic used a systematic multidisciplinary approach. During the first visit, women told their stories and explained the reasoning behind their birth plan. The second visit was used to present the evidence underpinning recommendations and attempt to reach a compromise if care within recommendations was still not acceptable to the woman. During the third visit, a final birth plan was decided on. Results: From January 1, 2015, until December 31, 2017, 55 women were seen in the clinic, 29 of whom declined items of recommended care during birth and were included in the study. After discussions had been completed, 38% of birth plans were within recommendations, 38% were a compromise, in which both the woman and the care provider had made certain concessions, and 24% did not reach an agreement and delivered with another provider either at home or elsewhere. All maternal and perinatal outcomes were good. Conclusions: Using a respectful and systematic multidisciplinary approach, in which women feel heard and are invited to explain their motivations for their birth plans, we are able to arrive at a plan either compatible with or much closer to recommendations than the woman's initial intentions in most cases, thereby preventing negative choices.

How to Make the Hospital an Option Again: Midwives’ and Obstetricians’ Experiences with a Designated Clinic for Women Who Request Different Care than Recommended in the Guidelines

“…Table S1 (Supplementary Materials) illustrates the characteristics of the participants, their role in the care process and their client’s pregnancy characteristics. At the designated clinic, requests for care outside the guidelines are very diverse [ 17 ]. However, the most common request in this study for women who visited the clinic was to be cared for by their own known (community) midwife, instead of obstetrician-led care, during a vaginal birth after a previous caesarean section, hereafter abbreviated as VBAC.…”

“…Their choices are not always against medical guidelines, but they can also be against local customs. Examples of requests outside the guidelines are: birthing without skilled attendance (freebirth, unassisted childbirth), birthing at home in a country where home birth is not well integrated into the maternity care system, declining induction of labour when indicated or declining foetal monitoring during labour [ 2 , 4 , 11 , 16 , 17 ]. Examples of requests against local customs are: a vaginal breech birth ‘on all fours’ or giving birth in a vertical position.…”

“…These guidelines stress the importance of providing sufficient information so that women can make informed decisions, practicing shared decision making and respecting maternal autonomy [ 14 , 20 ]. In addition, in the Netherlands and in the UK, designated outpatient clinics for maternity care outside the guidelines were established [ 17 , 21 , 22 ].…”

“…Since the start of this clinic in 2015, we see approximately five women per year. Van der Garde et al [ 17 ] assessed the outcomes of the clinic’s first three years. There were no serious adverse maternal or perinatal outcomes.…”

Intrapartum-related Perinatal Deaths in Births Planned in Midwifery-led Settings in Great Britain: Findings and Recommendations From the ESMiE Confidential Enquiry

“…[30][31][32][33] The potential benefits of this approach have been demonstrated in one 'maternity care outside guidelines' clinic in the Netherlands. 34 Intermittent auscultation of the baby's heart rate is a key element of monitoring and assessment during labour, with clear national guidance about the timing and frequency of IA in the first and second stages. 11,35 The issues with IA identified in this enquiry were similar to those identified in other similar enquiries.…”