- Email: [email protected]
The paradox of choice in maternity care
Journal of Neonatal Nursing (2012) 18, 60e62
www.elsevier.com/jneo
SPECIAL ARTICLE: PERINATAL MEDICINE HARROGATE JUNE 2011
The paradox of choice in maternity care* Julie Jomeen Faculty of Health and Social Care, University of Hull, Dearne 103, Hull HU6 7RX, UK KEYWORDS Maternity care; Choice; Women’s experiences; Maternity policy
Available online 18 February 2012
Introduction Current policy advocates choice and control for women within maternity care and promotes women as active childbirth consumers and decision-makers (DH, 2007; DH, 2004) This model equates choice to increased quality of experience and improved emotional outcomes, in the recognition that pregnancy and childbirth are both a physical and psychological experiences. This is a response to the critique of the traditional biomedical model of pregnancy, which prioritises the physical aspects of pregnancy and advocates monitoring and surveillance to ensure fetal well-being. However, what informed choice means and whether it is desirable or possible remains central to debates within maternity care (Kirkham, 2004). Choice requires a weighing up of risks and benefits and an ordering *
Summary of an Invited Conference paper ‘The Paradox of Choice in Maternity Care’ presented at the Perinatal Medicine Conference. 17th June 2011. Harrogate: UK. Adapted from: Jomeen, 2007, 2010; Jomeen and Martin, 2008. E-mail address: [email protected].
of preferences based on their utility (Allingham, 2002). Choice within such a frame would seem less straightforward than policy assumes and appears to require women to balance their desire for a fulfilling birth experience with reasoned and rational decisions about their experience as a whole. Tensions exist between the medical model of risk and the more contemporary discourse of normality, leaving women often caught in the middle as both consumers and recipients of care. Policy makers, have led us to believe that choice and control is always both desired and possible for women accessing maternity care (Hunt and Symonds, 1995). In 2003, a decade after Changing Childbirth, had first introduced the concepts of choice and control, a House of Commons Health Committee report on maternity services was still questioning maternity choice as ‘an illusion’ and urging the Department of Health to ensure women received genuine and informed choice. It seems that little in this regard has changed, with a number of authors continuing to highlight barriers to choice and question its authenticity (Hollins-Martin, 2007; Jomeen, 2007;
1355-1841/$ - see front matter ª 2012 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jnn.2012.01.010
The paradox of choice Kightley, 2007). Despite the official focus upon woman-centred childbirth and a move to encourage women to make decisions about their care in both physical and social terms, there remains a lack of consistent evidence with regard to expected benefits or the ‘reality of choice’ for women making choices for the management of childbirth. A UK DoH Survey found whilst 80% of women were pleased with the care they received they would have preferred more choice about the type of care they received. Choice, however, is not an equitable concept and some women have more choices than others (DoH, 2007). Low income, poor housing, limited education are all inequalities acknowledged to restrict choice. Barber et al. (2007) showed how midwives restrict information to certain groups of women based on personal judgement. Indeed, the model of choice presupposes that pregnant women are a homogeneous category, which remains ignorant of the individual, complex and multi-dimensional nature of women’s experiences of childbirth.
Choice in childbirth study The model of choice presented through recent UK maternity policy presupposes a model, which links choice to sense of increased control for women, leading to perception of a better quality of experience and improved psychological health and wellbeing. Moreover, robust evidence of the improvement in psychological outcomes that might have been expected as a result of choice of maternity care, had failed to transpire a decade after its inception as a central tenet of maternity policy (Renfrew et al., 2003). Investigating the impact of choice of care on psychological health outcomes, in a more contemporary context, across a number of psychological domains, including depression, anxiety, locus of control, worry, self-esteem and quality of life, the results of which have been reported elsewhere (Jomeen and Martin, 2008), failed to reveal any differences between groups of women who had made the following choices for maternity care Midwifery led antenatal care with birth in a hospital based maternity unit Midwifery led antenatal care with birth in a birth centre Consultant led antenatal care with birth in a hospital based maternity unit Indeed, parallel changes in psychological status across time were revealed within all the groups, suggesting that pregnancy presents all women
61 with a psychological challenge not mediated by choice. A finding, which at first glance, seems to present a negative and somewhat disappointing message to both policy makers and maternity service providers. However qualitative work within the same study revealed interesting interpretations as to why choice as a single independent variable might fail to achieve its anticipated impact on psychological health outcomes. Several narrative themes emerged from interviews with women in both early and late pregnancy and the early and later stages of the postnatal period. The results of this study have already been published (Jomeen, 2010, 2007), this paper summarised those key thematic areas which highlight and illustrate the complexity of choice. From early pregnancy women accept ownership of and subsequent responsibility for their pregnancies. This sense of responsibility for the pregnancy then fundamentally underpins the decisions that women make, which under the continued dominance of a medical model within maternity care are often informed by perceptions of risk, hence women defer to experts to inform their decisions. Numerous examples, including ones from this study, exist of women’s experiences when they resist expert advice and make choices deemed to be irresponsible or unsafe (Edwards, 2004). What is also clear is that women make choices for numerous reasons, such as accessibility to pain relief, fear of hospital environments and the desire to achieve a ‘normal and/or natural birth’ amongst others. Whilst, these choices may be underpinned by differing rationales, in most cases, they still rely on expertise in the form of doctors or midwives. In fact, the embedded nature of expertise makes resistance of dominant discourse difficult and so choices rather than reflecting women’s desires, involve a weighing up of benefits, risks and consequences as they are presented by the experts with whom women come into contact. One of the difficulties for women of making choices, is that choice offers the promise of an experience for women that may not or cannot, in reality be met. For example, those women who choose the birth centre option, but because of a failure to remain within the ‘normality criteria’ outlined in trust guidelines are unable to birth there. Whilst in clinical terms this decision may be perfectly legitimate, there are clear emotional consequences of unfulfilled choice for these women and their partners. ‘Yea I’m over it now, it’s still upsetting but I’m still not planning another one .we don’t dwell on it but if it’s brought up its still distressing... I would still choose to have a natural one at the
62
J. Jomeen
Birth Centre I’d still like to experience that and I feel a bit robbed in a way that I haven’t experienced it.[Jane_4]
responsibility and ask if and how we can make it a reality.
Acknowledgement Discussion and conclusion What women’s narratives illustrate is that choice is both complex and multifaceted and creates a paradox for women as they are simultaneously assigned active and passive roles. Despite a desire to articulate their wishes, the responsibility to their fetus invested from the earliest point in pregnancy and informed often by medicalised notions of risk, does not enable them to do so. It also leaves them at risk of blame and censure if those choices made are perceived to be the ‘wrong ones, which in turn then engenders guilt and positions women as ‘bad mothers’. This creates a lucid explanation of why choice as a single variable cannot account for improved psychological health outcomes for pregnant and postnatal women. Choice, however, is here to stay. As practitioners, therefore, we need to acknowledge that women are subject to numerous circulating discourses and influences when ‘making choices’. Whilst some of these discourses/influences offer the promise of choice, others clearly restrain it. Establishment of choice as another idealised norm, can be seen to create additional pressures for some women as they strive to make the right choices. Unfulfilled or wrong choices may be more harmful in psychological terms than no choice at all. Choosing midwifery led options for care does not automatically lead to increased personal control for women if midwives and other health care professionals are not aware of how they can reinforce dominant childbirth norms and the influence they assert over women’s choices. Overall, this invests us, as those practitioners, with a need to acknowledge choice with integrity and
The study presented in this paper was funded by the Economic and Social Research Council.
References Allingham, M., 2002. Choice Theory: A Very Short Introduction, first ed. Oxford University Press, New York. Barber, T., Rogers, J., Marsh, S., 2007. Increasing out of hospital birth: what needs to change? Br. J. Midwifery 15 (1), 16e20. Department of Health, Department of Education and Skills, 2004. National Service Framework for Children, Young People and Maternity Services: Maternity Services. Department of Health, London. Department of Health, 2007. Maternity Matters: Choice, Access and Continuity of Care in a Safe Service. Department of Health, London. Edwards, N.P., 2004. Why can’t women just say no? And does it really matter? In: Kirkham, M. (Ed.), Informed Choice in Maternity Care. Palgrave Macmillan, Basingstoke. Hollins-Martin, C.J., 2007. How can we improve choice provision for childbearing women? Br. J. Midwifery 15 (8), 480e484. Hunt, S., Symonds, A., 1995. The Social Meaning of Midwifery, first ed. Macmillan Press, Baisingstoke. Jomeen, J., 2007. Choice in childbirth: a realistic expectation? Br. J. Midwifery 15 (8), 485e490. Jomeen, J., 2010. Choice, Control and Contemporary Childbirth: Understanding through Women’s Experiences. Radcliffe, Oxford. Jomeen, J., Martin, C.R., 2008. The impact of choice of maternity care on psychological health outcomes for women during pregnancy and the postnatal period. J. Eval. Clin. Pract. 14 (3), 391e398. Kightley, R., 2007. Delivering choice: where to birth? Br. J. Midwifery 15 (8), 475e478. Kirkham, M., 2004. Informed Choice in Maternity Care. Palgrave Macmillan, Baisingstoke. Renfrew, M.J., Green, J.M., Spiby, H., 2003. Evidence Submitted to the House of Commons Health Committee Maternity Subcommittee 1st Inquiry (2003:03). Mother and Infant Research Unit: University of Leeds.
Available online at www.sciencedirect.com
www.elsevier.com/jneo
SPECIAL ARTICLE: PERINATAL MEDICINE HARROGATE JUNE 2011
The paradox of choice in maternity care* Julie Jomeen Faculty of Health and Social Care, University of Hull, Dearne 103, Hull HU6 7RX, UK KEYWORDS Maternity care; Choice; Women’s experiences; Maternity policy
Available online 18 February 2012
Introduction Current policy advocates choice and control for women within maternity care and promotes women as active childbirth consumers and decision-makers (DH, 2007; DH, 2004) This model equates choice to increased quality of experience and improved emotional outcomes, in the recognition that pregnancy and childbirth are both a physical and psychological experiences. This is a response to the critique of the traditional biomedical model of pregnancy, which prioritises the physical aspects of pregnancy and advocates monitoring and surveillance to ensure fetal well-being. However, what informed choice means and whether it is desirable or possible remains central to debates within maternity care (Kirkham, 2004). Choice requires a weighing up of risks and benefits and an ordering *
Summary of an Invited Conference paper ‘The Paradox of Choice in Maternity Care’ presented at the Perinatal Medicine Conference. 17th June 2011. Harrogate: UK. Adapted from: Jomeen, 2007, 2010; Jomeen and Martin, 2008. E-mail address: [email protected].
of preferences based on their utility (Allingham, 2002). Choice within such a frame would seem less straightforward than policy assumes and appears to require women to balance their desire for a fulfilling birth experience with reasoned and rational decisions about their experience as a whole. Tensions exist between the medical model of risk and the more contemporary discourse of normality, leaving women often caught in the middle as both consumers and recipients of care. Policy makers, have led us to believe that choice and control is always both desired and possible for women accessing maternity care (Hunt and Symonds, 1995). In 2003, a decade after Changing Childbirth, had first introduced the concepts of choice and control, a House of Commons Health Committee report on maternity services was still questioning maternity choice as ‘an illusion’ and urging the Department of Health to ensure women received genuine and informed choice. It seems that little in this regard has changed, with a number of authors continuing to highlight barriers to choice and question its authenticity (Hollins-Martin, 2007; Jomeen, 2007;
1355-1841/$ - see front matter ª 2012 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jnn.2012.01.010
The paradox of choice Kightley, 2007). Despite the official focus upon woman-centred childbirth and a move to encourage women to make decisions about their care in both physical and social terms, there remains a lack of consistent evidence with regard to expected benefits or the ‘reality of choice’ for women making choices for the management of childbirth. A UK DoH Survey found whilst 80% of women were pleased with the care they received they would have preferred more choice about the type of care they received. Choice, however, is not an equitable concept and some women have more choices than others (DoH, 2007). Low income, poor housing, limited education are all inequalities acknowledged to restrict choice. Barber et al. (2007) showed how midwives restrict information to certain groups of women based on personal judgement. Indeed, the model of choice presupposes that pregnant women are a homogeneous category, which remains ignorant of the individual, complex and multi-dimensional nature of women’s experiences of childbirth.
Choice in childbirth study The model of choice presented through recent UK maternity policy presupposes a model, which links choice to sense of increased control for women, leading to perception of a better quality of experience and improved psychological health and wellbeing. Moreover, robust evidence of the improvement in psychological outcomes that might have been expected as a result of choice of maternity care, had failed to transpire a decade after its inception as a central tenet of maternity policy (Renfrew et al., 2003). Investigating the impact of choice of care on psychological health outcomes, in a more contemporary context, across a number of psychological domains, including depression, anxiety, locus of control, worry, self-esteem and quality of life, the results of which have been reported elsewhere (Jomeen and Martin, 2008), failed to reveal any differences between groups of women who had made the following choices for maternity care Midwifery led antenatal care with birth in a hospital based maternity unit Midwifery led antenatal care with birth in a birth centre Consultant led antenatal care with birth in a hospital based maternity unit Indeed, parallel changes in psychological status across time were revealed within all the groups, suggesting that pregnancy presents all women
61 with a psychological challenge not mediated by choice. A finding, which at first glance, seems to present a negative and somewhat disappointing message to both policy makers and maternity service providers. However qualitative work within the same study revealed interesting interpretations as to why choice as a single independent variable might fail to achieve its anticipated impact on psychological health outcomes. Several narrative themes emerged from interviews with women in both early and late pregnancy and the early and later stages of the postnatal period. The results of this study have already been published (Jomeen, 2010, 2007), this paper summarised those key thematic areas which highlight and illustrate the complexity of choice. From early pregnancy women accept ownership of and subsequent responsibility for their pregnancies. This sense of responsibility for the pregnancy then fundamentally underpins the decisions that women make, which under the continued dominance of a medical model within maternity care are often informed by perceptions of risk, hence women defer to experts to inform their decisions. Numerous examples, including ones from this study, exist of women’s experiences when they resist expert advice and make choices deemed to be irresponsible or unsafe (Edwards, 2004). What is also clear is that women make choices for numerous reasons, such as accessibility to pain relief, fear of hospital environments and the desire to achieve a ‘normal and/or natural birth’ amongst others. Whilst, these choices may be underpinned by differing rationales, in most cases, they still rely on expertise in the form of doctors or midwives. In fact, the embedded nature of expertise makes resistance of dominant discourse difficult and so choices rather than reflecting women’s desires, involve a weighing up of benefits, risks and consequences as they are presented by the experts with whom women come into contact. One of the difficulties for women of making choices, is that choice offers the promise of an experience for women that may not or cannot, in reality be met. For example, those women who choose the birth centre option, but because of a failure to remain within the ‘normality criteria’ outlined in trust guidelines are unable to birth there. Whilst in clinical terms this decision may be perfectly legitimate, there are clear emotional consequences of unfulfilled choice for these women and their partners. ‘Yea I’m over it now, it’s still upsetting but I’m still not planning another one .we don’t dwell on it but if it’s brought up its still distressing... I would still choose to have a natural one at the
62
J. Jomeen
Birth Centre I’d still like to experience that and I feel a bit robbed in a way that I haven’t experienced it.[Jane_4]
responsibility and ask if and how we can make it a reality.
Acknowledgement Discussion and conclusion What women’s narratives illustrate is that choice is both complex and multifaceted and creates a paradox for women as they are simultaneously assigned active and passive roles. Despite a desire to articulate their wishes, the responsibility to their fetus invested from the earliest point in pregnancy and informed often by medicalised notions of risk, does not enable them to do so. It also leaves them at risk of blame and censure if those choices made are perceived to be the ‘wrong ones, which in turn then engenders guilt and positions women as ‘bad mothers’. This creates a lucid explanation of why choice as a single variable cannot account for improved psychological health outcomes for pregnant and postnatal women. Choice, however, is here to stay. As practitioners, therefore, we need to acknowledge that women are subject to numerous circulating discourses and influences when ‘making choices’. Whilst some of these discourses/influences offer the promise of choice, others clearly restrain it. Establishment of choice as another idealised norm, can be seen to create additional pressures for some women as they strive to make the right choices. Unfulfilled or wrong choices may be more harmful in psychological terms than no choice at all. Choosing midwifery led options for care does not automatically lead to increased personal control for women if midwives and other health care professionals are not aware of how they can reinforce dominant childbirth norms and the influence they assert over women’s choices. Overall, this invests us, as those practitioners, with a need to acknowledge choice with integrity and
The study presented in this paper was funded by the Economic and Social Research Council.
References Allingham, M., 2002. Choice Theory: A Very Short Introduction, first ed. Oxford University Press, New York. Barber, T., Rogers, J., Marsh, S., 2007. Increasing out of hospital birth: what needs to change? Br. J. Midwifery 15 (1), 16e20. Department of Health, Department of Education and Skills, 2004. National Service Framework for Children, Young People and Maternity Services: Maternity Services. Department of Health, London. Department of Health, 2007. Maternity Matters: Choice, Access and Continuity of Care in a Safe Service. Department of Health, London. Edwards, N.P., 2004. Why can’t women just say no? And does it really matter? In: Kirkham, M. (Ed.), Informed Choice in Maternity Care. Palgrave Macmillan, Basingstoke. Hollins-Martin, C.J., 2007. How can we improve choice provision for childbearing women? Br. J. Midwifery 15 (8), 480e484. Hunt, S., Symonds, A., 1995. The Social Meaning of Midwifery, first ed. Macmillan Press, Baisingstoke. Jomeen, J., 2007. Choice in childbirth: a realistic expectation? Br. J. Midwifery 15 (8), 485e490. Jomeen, J., 2010. Choice, Control and Contemporary Childbirth: Understanding through Women’s Experiences. Radcliffe, Oxford. Jomeen, J., Martin, C.R., 2008. The impact of choice of maternity care on psychological health outcomes for women during pregnancy and the postnatal period. J. Eval. Clin. Pract. 14 (3), 391e398. Kightley, R., 2007. Delivering choice: where to birth? Br. J. Midwifery 15 (8), 475e478. Kirkham, M., 2004. Informed Choice in Maternity Care. Palgrave Macmillan, Baisingstoke. Renfrew, M.J., Green, J.M., Spiby, H., 2003. Evidence Submitted to the House of Commons Health Committee Maternity Subcommittee 1st Inquiry (2003:03). Mother and Infant Research Unit: University of Leeds.
Available online at www.sciencedirect.com