This article focusses on the issue of making decisions in pregnancy, childbirth and early parenthood. It considers aspects of informed choice and risk and explores the BRAIN decision making tool.

Informed choice

There are many decisions to make in pregnancy, birth and parenthood. What’s best for you may be different to what’s best for someone else. It might change over time. What’s important is that you have the information you need to make an informed choice. Then you should have the support you need to enable that choice to happen.

There are lots of ways to access the information you need to help you make the right decision for you. You might talk to your midwife, doctor or other parents. Or you could examine research evidence. There are also links to some great websites with information about many of the decisions pregnant women have to make at the end of this article.

You should never be coerced into making a decision that someone else thinks is best for you. Nor do you have to follow any guidelines. Hospitals often have guidelines, but these are for their staff, not you. Your midwife may have to recommend a certain course of action according to a guideline. But it is up to you to decide whether to follow that recommendation or not (and you don’t need to justify your decision). The role of your midwife is to enable your informed decision making and to respect and advocate for your wishes.

Risk

Risk is a key aspect of maternity care. Midwives and doctors aim to reduce risk by identifying situations where risk may be increased and introducing measures to reduce those risks.

However often the measures which aim to reduce risk have side effects and introduce new risks. So it’s often not as easy as it might sound. What’s important is that you are aware of the risks so that you can make the decision that’s right for you and your baby.

Risk is everywhere, there is no such thing as a zero-risk option. So considering the variety of risks – to mum and baby, to physical and mental health – and coming to a balance that you are happy with is what’s important.

Risk is quite an emotive word. This can make it difficult to make a decision which suggests you are ignoring a ‘risk’. You may find it more useful to think of the word as ‘chance’ rather than ‘risk’. A 1 in 100 chance of an infection sounds a bit different to a 1 in 100 risk of an infection. But it’s the same thing.

Individuals have very different attitudes to risk, it’s a subjective issue. An unacceptably high risk to one person would be an acceptably low risk to another. There is no right or wrong. What matters is that you decide for yourself how you feel about any risks that you encounter. Here are some suggestions to help you ensure you have the information you need about risks so that you can make an informed decision.

  • Consider how specific information is. It’s not enough to know that a risk is low, moderate or high because these are subjective evaluations. Is it 1 in 2, 1 in 100, 1 in 10,000? Ask for the detail, not just a vague description of the risk.
  • Comparative risk is also unhelpful. If a risk doubles, does it go from 1 in 10 to 1 in 5 or from 1 in 10,000 to 1 in 5,000?  Again it’s important to get the detail to understand the nature of the risk.
  • Always consider the flip side of the risk, the chance of it not happening. If there is a 1 in 100 risk of vomiting, that means there is a 99 in 100 chance it won’t happen. For every 100 doing this, 99 will not vomit and 1 will.
  • Be specific about what the risk is. If an intervention might lead to ‘foetal distress’, what actually is that? It sounds very scary. But you can’t make a decision unless you know what foetal distress actually is.

Often when making a decision, there are different sets of risks to consider. For instance, an option which reduces the risk to the baby might increase the risk to the mother. Or an option to reduce the risk of physical side effects might increase the risk of poor mental health. It’s difficult if you’re comparing such different risks. That’s why it’s important to take your time in making decisions (unless you’re in an urgent or emergency situation – if you’re not sure if you are, ask!). Having someone to talk about it with, who won’t try to influence your decision but will offer non-judgemental support, can be very helpful.

Often physical risks are most concerning for medical professionals. However they may not fully consider the psychological and mental health risks. But they are important too, especially if you know that you have had difficulties with your mental health before. Prioritising your mental health is very important as a good birth can be powerful in a positive way, having a positive impact on the months and years that follow with your baby. But a distressing birth can have a negative impact, possibly leading to PTSD or postnatal depression and difficulties bonding with your baby. These problems may last for years, impacting on your life in many ways. However, the immediate, dramatic risks may seem more pressing than risks that are less dramatic, less visible or occur in the future, even if those risks are more serious. So this can lead to biased information and regretting your decisions later on.

Similarly perception of risk can be influenced by how familiar something is. The risks of a caesarean or forceps birth might be down-played because these are an every day occurrence for a doctor. Conversely an unusual situation, such as having a home birth if you’ve got a complex medical history, may be portrayed as being far more risky than it actually is. Because it’s a less common choice, it seems scarier.

Sadly birth trauma affects many women in the UK. This is associated with a variety of interventions in childbirth as well as feeling that you are not in control during birth. This can lead to intense, distressing symptoms that may last for years. Making informed decisions, considering the options and deciding what is best for you (and having a midwife who supports you in your choices), is important to help reduce the risk of this happening. Birth and becoming a mother are life-changing events. So they are very important for the woman experiencing them, and her partner and family. Mothers remember the births of their children for ever and these events can have a very powerful, positive or negative, impact on their lives. To quote Milli Hill from The Positive Birth Movement, a health baby is not all that matters.

If you are interested in exploring the concept of risk further, this article is a great starting point.

Research and evidence-based maternity care

Research evidence provides insight into the benefits and risks of certain things, such as medical interventions. Maternity services should provide care that is evidence-based, using research evidence alongside experience and valuing your beliefs and opinions as the basis for recommendations.

However, research evidence may be of high or low quality. This depends on lots of factors, such as how many people the research included and whether or not it used rigorous methods of researching. It may not be very relevant to an individual if it over-generalises findings to the population as a whole.

It is also common for different researchers to have slightly (or wildly!) different findings. The Term Breech Trial is a good example of research evidence which was flawed. This research concluded that a caesarean birth is safer than a vaginal birth when a baby is in the breech position. It’s publication led to near-universal recommendations for caesarean birth where babies are breech. Yet many people criticised the research for being flawed. For instance, it failed to identify the importance of the level of experience of the obstetrician or midwife attending the woman during a breech birth. But upon re-examination of the evidence this seems to be a vital consideration. It has been argued that following the recommendations of these researchers has done more harm than good. You can read more about the ways in which the trial was flawed here.

So it is important to evaluate evidence carefully. Organisations such as Cochrane and NICE aim to objectively evaluate evidence and make recommendations from that evaluation. So you might find it helpful to see what they have to offer regarding the situation you are in.

It’s also important to consider how relevant the research is to your hospital, doctor or midwife. For instance, research states the average rate of successful home birth for women planning to give birth at home. But what’s the rate here? Is it higher, lower or about the same as the national average and the research being quoted?

It’s also important not to assume that if something is being advised, it must be based on research evidence. There are many areas where we simply don’t have appropriate evidence, because nobody has ever done the research. So advice may be based on opinion only. Monitoring a baby’s heart rate in labour every 15 minutes for a full minute after a contraction is a good example of this. It’s standard practice in the UK. But it’s done this way because it’s always been done this way, nobody has ever researched whether this is indeed the best option or whether more or less frequent monitoring is preferable.

The BRAIN decision making tool

When you have a decision to make, having a tool to help you identify the information you need to make an informed choice will help to ensure that you come to the decision that’s best for you. BRAIN is a simple tool that you can use to help you ask the important questions and evaluate the relevant information.

BRAIN is an acronym standing for Benefits, Risks, Alternatives, Instinct and (doing) Nothing. Ask questions addressing these 5 areas and you will get the information you need to help you make your decision.

  • Benefits
    • What are the benefits of (not) doing this, why is it being suggested? 
    • Be specific, what are the actual statistics?
    • Is this evidence-based or an opinion? What is the quality of the evidence?
    • How does this apply to me as an individual, rather than to the population as a whole?
  • Risks
    • What are the risks of (not) doing this, what is the concern?
    • Be specific, what are the actual statistics?
    • Is this evidence-based or an opinion? What is the quality of the evidence?
    • How does this apply to me as an individual, rather than to the population as a whole?
  • Alternatives
    • What are the alternatives, and the risks/benefits of those (as above)?
  • Instinct
    • What does your instinct tell you?
    • We make decisions based on our emotions all the time, we aren’t simply rational beings who weigh up the pros and cons to our health and always go with what’s ‘best’. What seems right to you, what seems wrong?
  • Nothing
    • What if I do nothing? 
    • Or if I do nothing for now and then review later/tomorrow/next week?
    • What are the risks and benefits of doing nothing (as above)?

Also consider the amount of time you have to make the decision (is this an emergency?). Ask what the suggested options involve. Let’s say you’re deciding whether or not to induce your labour. You need to know what the induction process involves and the implications for your labour. For instance, if you have the syntocinon hormone drip to induce labour, the hospital are likely to say that you are unable to use the birth pool. If you were planning a water birth, it’s important that you know this before you decide whether or not to agree to an induction.

The BRAIN decision making tool can help you gather the information you need to make an informed decision that’s right for you

If you don’t feel listened to

Your midwife or doctor is there to provide the information you need to make an informed decision that’s right for you and to then support your choice. You can never be compelled to do something you don’t want to do, regardless of risk, guidelines or anything else. But it is difficult if you feel that you aren’t being listened to, at a time when you may be feeling emotional, confused and vulnerable. Writing down your questions in advance of an appointment can be helpful, so that you can use your notes as a prompt.Your birth partner can help to be your voice, but they might find it difficult, too. Some women hire a doula to help with these difficult situations or use an Independent Midwife who they are confident will support them to make their decisions in an unbiased way.

Find out more about your rights from BirthRights and AIMS

Websites to help with your choices

There are lots of sources of information online, but it can be difficult to know which to trust. Here are some that many women find helpful.

  • Cochrane. Independent source of evidence and systematic reviews of evidence.
  • NICE. National body responsible for producing national evidence-based guidelines for healthcare providers.
  • RCOG. The professional body of UK obstetricians, produces ‘green top guidelines’, which are evidence-based guidance for obstetricians to use in practice.
  • Sara Wickham. Midwifery author and educator, writes articles on midwifery themes.
  • Midwife Thinking. Midwifery author writes articles on midwifery themes
  • Sarah Buckley. Doctor, writes on birth and parenting.
  • RCM. The UK midwifery union, produces evidence-based guidelines and statements on midwifery topics.
  • NCT. Leading UK charity for pregnancy through to early parenting, produces information for parents.