A friend told me a story recently about an online consent module she completed during her uni degree. It was one of those tests that fails you until you memorise the answers and get 100 percent. My friend kept failing due to one question. It was a short answer, ‘fill in the blank’ style question that stated:
Consent is _____. She realised after some investigation (i.e. actually reading the source material) that the answer was supposed to be ‘consent is simple’.
I believe this statement to be patently false.
My friend also believes it to be false and wrote a spontaneous 2000-word email-essay to the coordinator on why we should not be teaching people that consent is simple. My experience has shown me that consent is anything but simple. And in our attempts to drill the importance of consent into our culture, we make the mistake of over-simplifying what it means to obtain and give consent.
One place that showcases the complexity of consent is the birth room. The landmark parliamentary inquiry into birth trauma in NSW beginning in 2023 received more than 4000 submissions of women’s stories of trauma in the birth room. Research shows that one in three women experience birth trauma in Australia, all of which lends credence to the need for wider discussions on consent.
Time and again research and women’s stories tell us that birth trauma stems from how a woman feels about her birth experience: whether she felt in control of her decisions, and whether she felt respected and heard by those in the birth room with her.
For the vast majority of women in NSW and Australia, their birth room is a hospital room on the birthing unit. So, simple maths would tell us that things need to change in our hospital maternity system to allay the rampant trauma impacting mothers. As a result of the NSW Birth Trauma Inquiry, the committee has now released 43 recommendations for change to improve the experience of women in our maternity system, including increased education for care providers on informed consent. The recommendations and government response can be found here.
The statement ‘consent is simple’ attempts to polarise the complexity of consent into a yes or no question. The problem is, consent does not appear in a vacuum. The context in which consent is being garnered impacts the decisions made. Obtaining and giving consent is coloured by power imbalances between the two parties (e.g. an obstetrician and a birthing mother), the level of psychosocial privilege afforded to the parties, and the environmental context in which consent is being sought.
Added to this, is the significance of care provider self-awareness, knowledge bias and social-emotional sensitivity. Women and families are not always given the full range of options when care providers are seeking consent. This can occur when providers often conflate agreement of their professional opinion with consent.
Often, the scenario goes like this: the care provider has a professional opinion about something that is occurring during pregnancy, labour or birth and feels invested in one course of action to mitigate the proposed risk. The care provider then approaches the woman and asks for consent to complete this action. The woman is then beholden to either say yes and agree with the care provider's assessment of the situation, or say no and be left with no alternative course of action.
Consent is not a simple yes or no question. Through the work of Catherine Bell, PhD candidate whose work focuses on “facilitating communication and maternal decision making in birth preparation”, I have come to understand consent as a decision point.
At this decision point, there are many paths that are available to women regardless of the situation (life-saving extenuating circumstances aside). Rarely are these pathways presented. Take the example given above. A care provider expresses a professional opinion about something that is occurring with a pregnant or birthing mother. Instead of presenting one pathway that forces the woman to either assent or dissent to the care provider's assessment, it is the care provider's responsibility to provide all possible pathways and all relevant information so that the woman and family can make an autonomous, informed choice.
Once a recommendation is given, the patient is under no obligation to agree with and consent to the care provider's course of action, even if doing so leads to injury or death. This is what it means for a person to have medical autonomy, a basic human right that is protected by law.
Too often, the choice to simply wait 10 minutes, an hour, a day, is not presented and so, added to the lack of alternate pathways is a feeling of being time pressured into providing consent for whatever the care provider is pushing. Of course, in an extreme emergency, time may be pressured, but these scenarios are exceedingly rare and still require sensitivity and patient autonomy, where capacity for consent is still able to be given. The discussion of what constitutes an emergency in the birth room is a whole other can of worms, which I’ll refrain from opening in this particular article.
Research shows that women who have continuity of care with a known care provider, from pregnancy to postpartum, experience the best outcomes in maternal and infant health and wellbeing. Most women in Australia do not experience continuity of care. Seven out of 10 women in the Illawarra are denied access to continuity of midwifery care otherwise known as Midwifery Group Practice (MGP) due to a lack of resourcing.
Thus, most women experience our fragmented care system, which results in women meeting their birth care-provider when they are already in labour. It also means that care providers are having to assess the needs and wants of multiple birthing women at once and in the moment. This system naturally leads to miscommunication, misplaced assumption and an imbalanced power dynamic between a labouring mother in her most vulnerable state, and overworked, under-resourced medical staff. It also adds to the feeling of being time-pressured into obtaining and giving consent by the care provider and birthing mother, respectively.
Labour and birth is, by its very nature, unpredictable, which is why continuity of care is so vital. During pregnancy in a continuity of care model, care providers are able to give information for possible scenarios, testing or procedures that women may encounter. In advance, they can listen to women's needs and their values around their pregnancies and any medical care required. There is an opportunity for developing a mutually trusting relationship born out of deep understanding of the woman’s values as well as the protection of the woman’s dignity as an autonomous human capable of making her own informed choices about her maternal care. There is simply not enough time or bandwidth for this to occur in our fragmented care system.
The NSW Birth Trauma Inquiry is the first step toward reducing the rate of birth trauma in Australia. My experience as a mother in the maternity care system and as a doula witnessing the women in my care has shown me that widespread change is needed in medical culture to re-centre patients and clients as the drivers of their own medical care.
Consent is not simple. Consent is a deeply nuanced concept that requires empathetic understanding of patient dignity, self awareness of the care provider and consideration of the larger culture of our maternal and medical care systems.
