Analysis: A new report on maternity care in Ireland highlights concerns around informed decision-making, patient choice and consent
A new survey on birth in Ireland highlights that there are significant issues with informed consent in the Irish maternity system. Routine interventions, such as inductions, episiotomies and continuous electronic monitoring of the baby’s heart during labour, are frequently presented as the only option, making women and birthing people feel like they cannot refuse. The information given about risks and alternatives is often not sufficient.
The stories women shared with us give examples of risks being downplayed by care providers or not mentioned at all, benefits of routine interventions being over-emphasised, and no alternatives being offered. Significant numbers of women and birthing people do not feel they were respected as the decision-makers during labour.
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From RTÉ Radio 1's Today with Claire Byrne, Dr Susann Huschke from University of Limerick on a new report on maternity care which highlights concerns around informed decision-making, patient choice and autonomy
There are clear guidelines on consent based on the HSE national consent policy, but our survey shows this policy is frequently not adhered to in practice. For consent to be valid, the woman needs to have received relevant information about the proposed intervention and the involved risks, benefits and alternatives. While some women felt well informed by their care providers about the pros, cons and alternatives – particularly those who had a private obstetrician and those planning a homebirth – a significant proportion did not, as many as three in four for some interventions.
Vaginal examinations are one example. Nearly 92% of respondents had at least one, usually more, vaginal examinations before or during labour. Vaginal examinations are used widely to measure cervical dilation as a way of assessing labour progress. If women dilate "too slowly", interventions to speed up labour will be suggested, such as breaking the waters with a small metal hook or increasing the strength and frequency of labour contractions with syntocinon, a synthetic hormone drip.
As with many routine interventions during labour, the research evidence for this practice is problematic and is mainly based on outdated research from the 1950s. Recent evidence demonstrates that cervical dilations rates vary between women and frequently do not match a linear timeline and therefore cannot be used to determine labour progress. Routine and repeated vaginal examinations to measure cervical dilation are an unnecessary intervention with no proven benefits. They come with risks, too, including infection, premature breaking of the waters and significant discomfort or pain for the labouring woman.
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In our survey, just over a quarter (28%) felt they were given all the information about the risks, benefits and alternatives to vaginal examinations by their care providers, as per HSE consent policy. The remaining 72% either informed themselves or stated that they agreed to vaginal examinations without feeling well informed.
In addition to having all the information about an intervention, the service user also needs to be aware that they have the right to decline any intervention for consent to be valid. Healthcare providers have to respect informed refusal, even if it goes against their recommendation, and even if the refusal may have adverse consequences, including death. It is the right of the birthing person to make these decisions.
However, we found that a proportion of women did not know they could decline interventions. For example, for vaginal examinations, four in ten women said they did not know they could decline them. By definition, if women feel they cannot decline, their consent is not valid. If we cannot say no, our yes means nothing.
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The HSE consent policy also states that decisions need to be made without feeling under duress. Duress is defined in the policy as "pressures or threats improperly imposed by others such that the person believes he or she has no alternative but to consent". Consent obtained in this manner is not valid. In the survey, we included open ended questions in addition to quantitative questions.
Respondents shared their experiences with us in free text responses. The stories they shared include numerous examples of duress – feeling that they had to agree to interventions whether or not they wanted to. Words that women used to describe their experiences of duress included feeling: "pressure", "pushed", "rushed", "dismissed", "bullied", "lied to", "stressed", "forced", "threatened", "gaslit" and "scared into it".
41% of respondents stated that they did not feel comfortable declining care that was offered
To assess patient-provider interactions in the Irish maternity system and their impact on a birthing person’s sense of comfort, behaviour and perceptions of discrimination, we included an international scale in the survey, the Mothers on Respect index (MOR). While the majority of respondents (56%) felt they chose the care options they received, two in five birthing people (44%) felt pushed into accepting options that their care providers suggested.
The results also show that saying no to interventions feels difficult for many women in the current maternity system. 41% of respondents stated that they did not feel comfortable declining care that was offered. Disagreeing with a care provider has consequences for the treatment women receive. Nearly one in five respondents (19%) felt that having a different opinion from their care providers about the right care for themselves or their baby led to them being treated poorly. This indicates that many birthing people do not feel supported to make active choices in regards to their care if this means declining what is offered.
This survey was conducted by a team of midwives, doulas and mothers who are members of the Birth Rights Alliance Ireland (BRAI). Anyone who gave birth in Ireland between 2018 and 2023 was invited o fill out the survey. A total of 3,824 people started the survey, respondents completed 77% of the survey on average and 2,522 respondents (66%) completed the entire survey
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The views expressed here are those of the author and do not represent or reflect the views of RTÉ
