Consent and refusal of procedures during labour and birth: a survey among 11 418 women in the Netherlands

Abstract

BackgroundInformed consent for medical interventions is ethically and legally required; an important aspect of quality and safety in healthcare; and essential to person-centred care. During labour and birth, respecting consent requirements, including respecting refusal, can contribute to a higher sense of choice and control for labouring women. This study examines (1) to what extent and for which procedures during labour and birth women report that consent requirements were not met and/or inadequate information was provided, (2) how frequently women consider consent requirements not being met upsetting and (3) which personal characteristics are associated with the latter.MethodsA national cross-sectional survey was conducted in the Netherlands among women who gave birth up to 5 years previously. Respondents were recruited through social media with the help of influencers and organisations. The survey focused on 10 common procedures during labour and birth, investigating for each procedure if respondents were offered the procedure, if they consented or refused, if the information provision was sufficient and if they underwent unconsented procedures, whether they found this upsetting.Results13 359 women started the survey and 11 418 met the inclusion and exclusion criteria. Consent not asked was most often reported by respondents who underwent postpartum oxytocin (47.5%) and episiotomy (41.7%). Refusal was most often over-ruled when performing augmentation of labour (2.2%) and episiotomy (1.9%). Information provision was reported inadequate more often when consent requirements were not met compared with when they were met. Multiparous women had decreased odds of reporting unmet consent requirements compared with primiparous (adjusted ORs 0.54–0.85). There was considerable variation across procedures in how frequently not meeting consent requirements was considered upsetting.ConclusionsConsent for performing a procedure is frequently absent in Dutch maternity care. In some instances, procedures were performed in spite of the woman’s refusal. More awareness is needed on meeting necessary consent requirements in order to achieve person-centred and high-quality care during labour and birth.

Shroud waving self-determination: A qualitative analysis of the moral and epistemic dimensions of obstetric violence in the Netherlands

“…The participants, both mothers and midwives, say mothers often do not know that they can refuse vaginal examinations, neither do they know that their regular performance is a highly contested and often not evidence-based intervention [ 39 ]. While only 7% of participants in Van der Pijl’s research lists that were not asked for consent for vaginal examinations, 60% of those who refused the examination said that their refusal was overruled [ 6 ].…”

“…Two quantitative studies on obstetric violence were conducted in the Netherlands based on one survey in which approximately 13.000 people participated [ 5 , 6 ]. 54.4% of respondents reported at least one form of disrespect and abuse.…”

“…42% of the people who got an episiotomy did not give consent, 47% of people who got medication did not give consent, and around 36% did not give consent for electronic foetal monitoring or a foetal scalp electrode. Of the people who refused an intervention, many were overruled, respectively 40% in the case of vaginal examination, 60% in the case of medication, and 40% in the case of an episiotomy [ 6 ].…”

L’expérience de l’accouchement en milieu surveillé dans la province d’Essaouira au Maroc: Quelle réalité?

“…13 L’absence de demande de consentement n’est pas propre aux pays pauvres: une étude récente aux Pays-Bas a montré que le consentement pour administrer de l’ocytocine en postpartum ou pratiquer une épisiotomie n’était pas demandé dans 47.5% et 41.7% des cas respectivement. 28 Or, le manque de consentement aux soins est non seulement un aspect important des soins centrés sur le patient mais est aussi un facteur souvent mentionné par les femmes pour expliquer leur expérience traumatisante de l’accouchement. 29 Bien que le consentement soit exigé par l’article 58 du règlement intérieur des hôpitaux au Maroc, 30 34% des prestataires ont affirmé que le consentement des femmes avant les soins n’est pas toujours nécessaire .…”

“…13 The absence of a request for consent is not exclusive to low-income countries: a recent study in the Netherlands showed that consent for administering oxytocin postpartum or performing an episiotomy was not requested in 47.5% and 41.7% of cases, respectively. 28 However, the lack of informed consent is not only a crucial aspect of patient-centred care but is also frequently cited by women to explain their traumatic childbirth experience. 29 Even though consent is required by Article 58 of the internal regulations of hospitals in Morocco, 30 34% of providers stated that women’s consent before care is not always necessary.…”