Making Decisions during Pregnancy

From the moment you discover that you are pregnant, you begin to make decisions as a parent. The first decisions you make will be about your lifestyle and the sort of changes you might need to make in order to support your baby's development. You will also need to make decisions about who will provide your maternity care during pregnancy and birth. Some options for care are popular with women e.g. birth centre care or a specific private obstetrician and therefore book up very quickly. The more personalised your care is, the easier your decision making task becomes, as your midwife or doctor will make recommendations based upon what is right for you and your baby, rather than purely upon protocols or formal guidelines.

In team based models of care, midwives and doctors may be managing competing pressures whilst providing your care, in these situations it is important to ask your midwife or doctor questions about recommendations, in order for you to be able to make the right informed decision for you and your baby. Using the acronym BRAIN can help you to structure your questions, B - what are the benefits? R - what are the risks? A - what are the alternatives? I - what is your intuition? N - what are the risks of doing nothing? This process places you at the centre of decision making and slows things down enough to enable you to make an informed choice.

What decisions need to be made during pregnancy?

During pregnancy you will find yourself starting to make decisions as a parent. You will need to make decisions for yourself and on behalf of your child. The first decisions you make once you know that you are pregnant will be about your lifestyle and sort of changes you might need to make in order to support your baby’s development.

Almost immediately you will need to begin considering which type of maternity care best fits with your own ideas about pregnancy and birth. Some models of care e.g. private obstetrics, are over-subscribed and making a booking with the doctor of your choice will require you to make a decision within the first month of your pregnancy. This can be challenging because your choice of care will impact not only your experiences during pregnancy but it will have a major influence on how you give birth; and you may not yet have thought through what is important to you about your baby’s birth. There is more information about who can look after you during labour and where you can have your baby here.

Then there will be decisions about which prenatal screening and diagnostic tests to have for your baby. It is important to realise that you have the right to make the decisions which affect you and your baby during pregnancy. This is your right to an informed choice. Everything is optional, from participating in prenatal care, having blood tests and going for ultrasound scans, to accepting an induction of labour if your baby is overdue at the end of your pregnancy.

Why is it important to ask questions?

Whom ever you choose to look after your during pregnancy, your doctor or midwife want the best outcome for you and your baby. However some doctors and midwives are more able to focus upon caring for you as an individual due to the model of care they are practicing within, whilst for others this is more difficult as they are managing competing pressures as well as your care.

The more personalised your maternity care is, the easier your decision-making role becomes. The most personalised care a pregnant woman can receive sits within the Caseload Midwifery model of care. This is when one woman and one midwife are able to work together throughout pregnancy, labour and birth. The relationship this creates, leads to high levels of mutual understanding and trust. Being able to completely trust your midwife or doctor is important. Through this 1:1 relationship, the woman comes to understand the midwife’s values and attitudes around pregnancy and birth, and decides whether these are a good fit for her, choosing a different caregiver if she finds that the fit is not good. This close working relationship also means that the midwife develops a good understanding of what the woman wants for her pregnancy and her baby’s birth. She develops a confidence in the woman from their relationship and her detailed knowledge of the pregnancy to date. When decisions have to be made, the woman trusts the midwife’s recommendations because the level of her care is very personal and based on her needs and those of the baby.

Research from studies around the world are indicating that this is the Gold Standard in maternity care (Sandall et al. 2013). However, caseload midwifery is not yet the standard model of maternity care in Australia, though many services are beginning to move in this direction as research shows how good the outcomes of this model are for mothers and babies.

In models of care where women are looked after by a team of professionals, their doctors and midwives will also be juggling a number of other competing pressures whilst providing care. There will be guidelines and protocols which they are obliged to follow according to the hospital or clinic they are working in. Hospital protocols are not always based upon the best available evidence. Sometimes they are the way they are because that is the way things have always been done, or they are based upon what works best for the hospital in terms of managing the facility’s work load.

The individual doctor or midwife, may also be caring for other women and babies at the same time as providing your care, and so they may need to consider the needs of others as well as your own.

It might be useful to remember that your midwife or doctor are experts in the average pregnancy and birth, whereas you are the expert in the lived experience of your own pregnancy and birth. When you collaborate, your decisions can include the best from both sources of experience and knowledge, the personal and the professional.

Sometimes decisions are not always presented as choices. Your midwife or doctor might simply book you in for a procedure because that is what the average woman does. However, you are the Chief Executive Officer of your body and your pregnancy, and you have the right to decide what you would like to do.

It is not your doctor or midwife’s role to ensure that you follow their advice or the hospital’s policy. Your doctor or midwife’s role is to provide you with information so that you are able to make the decisions that are right for you and your family. Once you have made an informed choice, your doctor or midwife should support you emotionally, whether you have consented to or refused a recommendation.

Making decisions

You have been making decisions all the way through your life. You gather information about the pros and the cons of each option and then make a choice. During pregnancy, emotions can run a little higher than usual and so having a tool to support this process can be helpful.

BRAIN Decision-making Tool

BRAIN is an acronym which stands for each element of information you might wish to include in considering your decision:

B – Benefits ‘What are the benefits of this course of action for me and my baby?’

R – Risk ‘Are there any risks or negative consequences associated with this course of action?’

A – Alternatives ‘What other options are available to me?’

I – Intuition ‘How do I feel about the recommended course of action and the alternatives.’

N – Nothing ‘If I did nothing right now, what would be the benefits or risks of that course of action?’

You probably apply this questioning process every time you make a decision. BRAIN provides you with a structure for your questions, so that you can be sure that you have covered all the relevant information required to support your decision making process.

Many midwives or doctors will encourage you to come to your prenatal appointments with questions. However when you question their recommendations for care, this is slightly different and the way in which they respond will provide you with a useful insight into who they are as an individual as well as a professional.

If you practice using BRAIN every time the need to make a decision arises, you will not only become very skilled in the process, but also more comfortable in questioning your doctor or midwife, which does not always feel like an easy thing to do.

References

• Sandall, J., Soltani, H., Gates, S. et al (2013). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of System-atic Reviews, Issue 8. Available online at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004667.pub3/abstract [accessed on 31 October 2013].