Health knowledge made personal
Join this community!
› Share page:
Search posts:

Informed Consent and REFUSAL

Posted Jul 13 2009 10:37pm

Last month I "attended" a webinar entitled Informed Consent and Refusal in Maternity Care given by the Coalition for Improving Maternity Services.  I always felt that there was something wrong about a care provider walking into a hospital room declaring, "it is time for your IV," and there is.   Informed consent is not a declaration, it is a process of information dissemination (see below).  Informed consent means giving the mom space to make an informed refusal (how many of us have attended births where mom's attempts to refuse an intervention have swiftly been pushed aside).  The best part is that we all benefit when informed consent and refusal is respected, mothers, babies, AND providers.  Please read the below handout prepared by the webinar presenters and pass this information along to your friends.  Pregnant moms need to know that they are the decision makers.  Healthcare providers can be sued for failure to obtain sufficiently informed consent (examples below).   Care providers should provide  diagnosis, prognosis, and alternatives, including choice of no treatmentWithout true informed consent and refusal, empowered birthing is not possible.  A big thank you to the Coalition for Improving Maternity Services for creating the below handout!

Informed Consent & Refusal in Maternity Care 


Session Presenters: Tabaré Depaep, Esq., Holly Goldberg, BA, PhD-c, Cordelia Hanna-Cheruiyot, MPH, CHES, CCE, CBA 


The research supporting this educational activity is published inThe Journal of Perinatal Education

Volume 18, Number 1, 2009, pp. 32-40.  


What is informed consent and refusal? 

Informed consent is a process of information dissemination.  It involves providing the patient with 

sufficient, evidence-based information so she can make a decision that reflects self-determination, 

autonomy, and control.  

 It is a process of information exchange. 

  It is based upon involving patients in the decision making process.  


Every pregnant woman has the right to make informed decisions about the care for herself and 

her fetus.  Examples of judicial interventions that support patient rights: 

 Schloendorff v. Society of New York Hospitals, 1914. 

Health care provider held liable for failure to get patient’s consent to surgery.  

 Salgo versus Leland Stanford Jr. University Board of Trustees, 1957. 

Health care provider held liable for withholding information necessary for making an informed 



The essential components of informed consent and refusal 

Numerous national and international professional associations promote patients’ rights to informed 

consent and refusal, including the American College of Physicians, American Medical Association, and 

March of Dimes, among others.  The American College of Obstetricians and Gynecologists’ (ACOG) 

publication Ethics in Obstetrics (2004) included the ACOG Committee on Ethics’ statement on 

Informed Consent (PDF).  This document details the following essential components of informed 

consent and refusal. 

 Adequate Information 

o Provider gives diagnosis, prognosis, and alternatives, including choice of no treatment. 


o Provider is aware of and understands the patient’s situation/possibilities; 

o Provider uses language that is understood by the patient; 

o Patient’s consent is given freely, intentionally, and voluntarily. 

 Freedom of Choice 

o Patient is free of coercion/free from outside pressures;  

o Patient chooses among options and has the right to choose other than what is 


o Patient gives provider the right to perform action. 


The benefits of informed patient decision making: 


Benefits for Providers: 

 Better patient/provider relationships 

 Enhanced trust in providers 

 Higher patient evaluation of providers 

 Increased patient recommendations of provider to others 


Benefits for Patients: 

 Improved quality of life and physical and social functioning 

Enhanced emotional well-being, increased sense of empowerment and self-esteem 

 Increased satisfaction 

 Increased adherence to treatment plan and improved clinical outcomes 

Shorter recovery periods 


Benefits for Childbearing Women: 

 Lower levels of fear 

 Less depressive and post-traumatic stress symptoms after birth 

More positive feelings toward newborn 


About the Coalition for Improving Maternity Services (CIMS) 

CIMS is a coalition of individuals and national organizations with concern for the care and well-being of 

mothers, babies, and families.  Our mission is to promote a wellness model of maternity care that will 

improve birth outcomes and substantially reduce costs.  This evidence-based mother-, baby-, and 

family-friendly model focuses on prevention and wellness as the alternatives to high-cost screening, 

diagnosis, and treatment programs.  CIMS is a not-for-profit organization recognized as tax-exempt 

under Internal Revenue Code section 501(c)(3).  CIMS abides by the WHO-UNICEF “International 

Code of Marketing of Breast-milk Substitutes.” 


The Mother-Friendly Childbirth Initiative 

CIMS Evidence Basis for the Ten Steps of Mother-Friendly Care(PDF),The Journal of 

Perinatal Education, Winter 2007 


Additional Links 


 The Six Care Practices that Support Normal Birth, Lamaze International 

 Listening to MothersSurveys and Reports, Childbirth Connection 


References Related to Informed Consent and Refusal 

1. Cahill, J. (1998). Patient participation – A review of the literature. Journal of Clinical Nursing, 7(2), 


2. Christiaens, W., & Bracke, P. (2007). Assessment of social psychological determinants of 

satisfaction with childbirth in a cross-national perspective. BMC Pregnancy and Childbirth, 7, 26. 

3. Declercq, E. R., Sakala, C., Corry, M. P., & Applebaum, S. (2006). Listening to mothers II: Report 

of the second national U.S. survey of women’s childbearing experiences. New York: Childbirth 


Coalition for Improving Maternity Services (CIMS) Webinar Handout June 2009 

Informed Consent & Refusal in Maternity Care  Page 3 



4. Elwyn, G., Edwards, A., Gwyn, R., & Grol, R. (1999). Towards a feasible model for shared decision 

making: Focus group study with general practice registrars. British Medical Journal, 319(7212), 


5. Goodman, P., Mackey, M. C., & Tavakoli, A. S. (2004). Factors related to childbirth satisfaction. 

Journal of Advanced Nursing, 46(2), 212–219. 

6. Green, J. M., & Baston, H. A. (2003). Feeling in control during labor: Concepts, correlates, and 

consequences. Birth: Issues in Perinatal Care, 30(4), 235–247. 

7. Green, J. M., Coupland, V. A., & Kitzinger, J. V. (1990). Expectations, experiences, and 

psychological outcomes of childbirth: A prospective study of 825 women. Birth, 17(1), 15–24. 

8. Hack, T. F., Degner, L. F., Watson, P., & Sinha, L. (2006). Do patients benefit from participating in 

medical decision making? Longitudinal follow-up of women with breast cancer. Psycho-oncology, 

15(1), 9–19. 

9. Hammond, K., Bandak, A., & Williams, M. (1999). Nurse, physician, and consumer role 

responsibility perceived by health care providers. Holistic Nursing Practice, 13(2), 28–37. 

10. Harrison, M. J., Kushner, K. E., Benzies, K., Rempel, G., & Kimak, C. (2003). Women’s 

satisfaction with their involvement in health care decisions during a high-risk pregnancy. Birth: 

Issues in Perinatal Care, 30(2), 109–115. 

11. Hindley, C., & Thomson, A. M. (2005). The rhetoric of informed choice: Perspectives from 

midwives on intrapartum fetal heart rate monitoring. Health Expectations: An International Journal 

of Public Participation in Health Care and Health Policy, 8(4), 306–314. 

12. Hodnett, E. D. (2002). Pain and women’s satisfaction with the experience of childbirth: A 

systematic review. American Journal of Obstetrics and Gynecology, 186(Suppl. 5), S160–S172. 

13. Jomeen, J. (2004). The importance of assessing psychological status during pregnancy, childbirth 

and the postnatal period as a multidimensional construct: A literature review. Clinical Effectiveness 

in Nursing, 8, 143–155. 

14. Jung, H. P., Wensing, M., & Grol, R. (1997). What makes a good general practitioner: Do patients 

and doctors have different views? British Journal of General Practice, 47, 805–809. 

15. Knapp, L. (1996). Childbirth satisfaction: The effects of internality and perceived control. Journal of 

Perinatal Education, 5(4), 7–16. 

16. Krupat, E., Hsu, J., Irish, J., Schmittdiel, J. A., & Selby, J. (2004). Matching patients and 

practitioners based on beliefs about care: Results of a randomized controlled trial. The American 

Journal of Managed Care, 10(11, Pt. 1), 814–822. 

17. Lavender, T., Walkinshaw, S. A., & Walton, I. (1999). A prospective study of women’s views of 

factors contributing to a positive birth experience. Midwifery, 15(1), 40–46. 

18. Levy, V. (1999a). Maintaining equilibrium: A grounded theory study of the processes involved 

when women make informed choices during pregnancy. Midwifery, 15(2), 109–119. 

19. Levy, V. (1999b). Protective steering: A grounded theory study of the processes by which midwives 

facilitate informed choices during pregnancy. Journal of Advanced Nursing, 29(1), 104–112. 

20. Loh, A., Leonhart, R., Wills, C. E., Simon, D., & Hoter, M. (2007). The impact of patient 

participation on adherence and clinical outcome in primary care of depression. Patient Education 

and Counseling, 65(1), 69–78. 

21. MacDorman, M. F., Declercq, E., Menacker, F., & Malloy, M. H. (2006). Infant and neonatal 

mortality for primary cesarean and vaginal births to women with no indicated risk, United States, 

1998–2001 birth cohorts. Birth, 33(3), 175–182. 

Coalition for Improving Maternity Services (CIMS) Webinar Handout June 2009 

Informed Consent & Refusal in Maternity Care  Page 4 



22. March of Dimes. (2006, March). Cesarean sections may be contributing to the rise in late preterm 

births. Retrieved December 6, 2008, from 

23. March of Dimes (2008, July). Induction by request. Retrieved December 6, 2008, from 

24. Marteau, T. M., Dormandy, E., & Michie, S. (2001). A measure of informed choice. Health 

Expectations: An International Journal of Public Participation in Health Care and Health Policy, 

4(2), 99–108. 

25. Martin, J. A., Hamilton, B. E., Sutton, P. D., Ventura, S. J., Menacker, F., Kirmeyer, S., et al. 

(2007). Births: Final data for 2005. National Vital Statistics Reports, 56(6). Hyattsville, MD: 

National Center for Health Statistics. Retrieved December 6, 2008, from 

26. McGregor, S. (2006). Roles, power and subjective choice. Patient Education and Counseling, 60(1), 


27. Meng, K. H. (2008). [Informed consent in public health activities: Based on the universal 

declaration on bioethics and human rights, UNESCO]. Journal of Preventive Medicine and Public 

Health, 41(5), 339–344. Korean. English abstract retrieved December 6, 2008, from 

28. Michie, S., Dormandy, E., & Marteau, T. M. (2003). Informed choice: Understanding knowledge in 

the context of screening uptake. Patient Education and Counseling, 50(3), 247–253. 

29. O’Cathain, A., Thomas, K., Walters, S. J., Nicholl, J., & Kirkham, M. (2002). Women’s perceptions 

of informed choice in maternity care. Midwifery, 18(2), 136–144. 

30. Oberman, M. (2000). Mothers and doctors’ orders: Unmasking the doctor’s fiduciary role in 

maternal-fetal conflicts. Northwestern University Law Review, 94(2), 451–501. 

31. Pelkonen, M., Perala, M. L., & Vehvilainen-Julkunen, K. (1998). Participation of expectant mothers 

in decision making in maternity care: Results of a population-based survey. Journal of Advanced 

Nursing, 28(1), 21–29. 

32. Rosen, P., Anell, A., & Hjortsberg, C. (2001). Patient views on choice and participation in primary 

health care. Health Policy, 55(2), 121–128. 

33. Rothenbacher, D., Lutz, M. P., & Porzsolt, F. (1997). Treatment decisions in palliative cancer care: 

Patients’ preferences for involvement and doctors’ knowledge about it. European Journal of Cancer, 

33(8), 1184–1189. 

34. Sakala, C., & Corry, M. P. (2008). Evidence-based maternity care: What it is and what it can 

achieve. New York: Millbank Memorial Fund. 

35. Singh, D., Newburn, M., Smith, N., & Wiggins, M. (2002). The information needs of first-time 

pregnant mothers. British Journal of Midwifery, 10(1), 54–58. 

36. Spurgeon, P., Hicks, C., & Barwell, F. (2001). Antenatal, delivery and postnatal comparisons of 

maternal satisfaction with two pilot Changing Childbirth schemes compared with a traditional model 

of care. Midwifery, 17(2), 123–132. 

37. van der Hulst, L. A., van Teijlingen, E. R., Bonsel, G. J., Eskes, M., Birnie, E., & Bleker, O. P. 

(2007). Dutch women’s decision-making in pregnancy and labour as seen through the eyes of their 

midwives. Midwifery, 23(3), 279–286. 


© 2009 Coalition for Improving Maternity Services (CIMS).  Permission granted to freely reproduce 

with attribution. 

Post a comment
Write a comment:

Related Searches