Maternity healthcare professionals' experiences of supporting women in decision-making for labour and birth: a qualitative study.

OBJECTIVES: To explore and characterise maternity healthcare professionals' (MHCPs) experience and practice of shared decision-making (SDM), to inform policy, research and practice development. DESIGN: Qualitative focus group study. SETTING: Large Maternity Unit in the Southwest of England. PARTICIPANTS: MHCPs who give information relating to clinical procedures and pregnancy care relating to labour and birth and are directly involved in decision-making conversations were purposively sampled to ensure representation across MHCP groups. DATA COLLECTION: A semistructured topic guide was used. DATA ANALYSIS: Reflexive thematic analysis was undertaken. RESULTS: Seven focus groups were conducted, comprising a total of 24 participants (3-5 per group). Two themes were developed: contextualising decision-making and controversies in current decision-making. Contextual factors that influenced decision-making practices included lack of time and challenges faced in intrapartum care. MHCPs reported variation in how they approach decision-making conversations and asked for more training on how to consistently achieve SDM. There were communication challenges with women who did not speak English. Three controversies were explored: the role of prior clinical experience, the validity of informed consent when women were in pain and during life-threatening emergencies and instances where women declined medical advice. CONCLUSIONS: We found that MHCPs are committed to SDM but need better support to deliver it. Structured processes including Core Information Sets, communication skills training and decision support aids may help to consistently deliver SDM in maternity care.

Vaginal birth core information set: study protocol for a Delphi study to achieve a consensus on a 'core information set' for vaginal birth.

INTRODUCTION: Studies have shown that women are often underinformed about potential benefits and risks of vaginal birth. This is in contrast to other modes of birth, such as caesarean birth, for which the risks/benefits are often conveyed prior to undergoing the procedure. A core information set (CIS) is an agreed set of information points that should be discussed with all patients prior to undergoing a procedure or intervention. This CIS could improve the quality of information given regarding mode of birth options, as women will be given information prioritised by patients and stakeholders regarding vaginal birth, empowering them to make informed decisions about their birth. We aim to describe the protocol for the development of this vaginal birth CIS. METHODS AND ANALYSIS: We will develop the CIS by: (1) Compiling a 'long-list' of information points about vaginal birth by: undertaking a scoping review of studies and patient information leaflets; interviews with antenatal/postnatal women, an online survey of stakeholders. (2) Collating the 'long-list' of information points and developing the Delphi survey. Think-aloud interviews will refine the survey. (3) Conducting a two-round Delphi survey. 200 stakeholder participants will be recruited. Items rated critically important by ≥80% of participants in one stakeholder group, or with no consensus, will be carried through to a stakeholder consensus meeting to decide the final CIS. Planned start date is 1 June 2022. Planned end date is 31 August 2023. ETHICS AND DISSEMINATION: This project has been given a favourable ethics opinion by the University of Bristol Research Ethics Committee (Ref: 10530). Approval from the ethics committee will be sought for any protocol amendments, and the principal investigator will be responsible for these changes. Findings will be presented at relevant conferences and published in a high-impact journal. We will disseminate the CIS, via Policy Bristol, to clinical policy and guideline developers.

Effective Communication Following Pregnancy Loss: A Study in England.

Each year in the UK there are approximately 250,000 miscarriages, 3,000 stillbirths and 3,000 terminations following a diagnosis of fetal-abnormality. This paper draws from original empirical research into the experience of pregnancy loss and the accompanying decisionmaking processes. A key finding is that there is considerable variation across England in the range of options that are offered for disposal of pregnancy remains and the ways in which information around disposal are communicated. This analysis seeks to outline the key features of what constitutes effective communication in this context, where effective communication is taken to mean that patients are provided with the key information necessary, in an appropriate manner, so that they are fully able to make a decision. A primary source of evidence includes interviews with the bereaved and pregnancy-loss support workers, in order to understand how the options available, and associated necessary procedures, are communicated. In addition, patient information leaflets are also analyzed as they offer an important tool for information delivery at a difficult and emotionally charged time. Following this, an overview is provided of the information that these leaflets should contain, along with guidance on effective presentation of this information.

Prevention of Transnational Transplant-Related Crimes-What More Can be Done?

BACKGROUND: Many nations are able to prosecute transplant-related crimes committed in their territory, but transplant recipients, organ sellers and brokers, and transplant professionals may escape prosecution by engaging in these practices in foreign locations where they judge the risk of criminal investigation and prosecution to be remote. METHODS: The Declaration of Istanbul Custodian Group convened an international working group to evaluate the possible role of extraterritorial jurisdiction in strengthening the enforcement of existing laws governing transplant-related crimes across national boundaries. Potential practical and ethical concerns about the use of extraterritorial jurisdiction were examined, and possible responses were explored. RESULTS: Extraterritorial jurisdiction is a legitimate tool to combat transplant-related crimes. Further, development of a global registry of transnational transplant activities in conjunction with a standardized international referral system for legitimate travel for transplantation is proposed as a mechanism to support enforcement of national and international legal tools. CONCLUSIONS: States are encouraged to include provisions on extraterritorial jurisdiction in their laws on transplant-related crimes and to collaborate with professionals and international authorities in the development of a global registry of transnational transplant activities. These actions would assist in the identification and evaluation of illicit activities and provide information that would help in developing strategies to deter and prevent them.

Medicine and abortion law: complicating the reforming profession.

The complicated intra-professional rivalries that have contributed to the current contours of abortion law and service provision have been subject to limited academic engagement. In this article, we address this gap. We examine how the competing interests of different specialisms played out in abortion law reform from the early twentieth-century, through to the enactment of the Abortion Act 1967, and the formation of the structures of abortion provision in the early 1970s. We demonstrate how professional interests significantly shaped the landscape of abortion law in England, Scotland, and Wales. Our analysis addresses two distinct and yet related fields where professional interests were negotiated or asserted in the journey to law reform. Both debates align with earlier analysis that has linked abortion law reform with the market development of the medical profession. We argue that these two axes of debate, both dominated by professional interests, interacted to help shape law's treatment of abortion, and continue to influence the provision of abortion services today.

Health, human rights and the regulation of reproductive technologies in S.H. And others V Austria (application no. 57813/00).

This case note analyses a recent judgment by the European Court of Human Rights involving two married couples who failed in their rights-based challenge to provisions of Austria's Artificial Procreation Act prohibiting heterologous techniques for in vitro fertilisation (i.e. techniques using donor ova and sperm).

Law, reproduction, and disability: fatally 'handicapped'?

Although it provides the grounds for a numerically very small proportion of abortions performed in Great Britain each year, s.1(1)(d), the disability ground, raises considerable controversy. This controversy recently culminated in the Department of Health losing an appeal against an instruction from the Information Commission to publish more detailed statistics on abortions carried out on the grounds of foetal abnormality, particularly those that occur after 24 weeks' gestation. In this paper I criticise and reject the legitimacy of this controversial section and suggest possible alternative legislative approaches to the issues raised in 1(1)(d). The purpose of the paper is to use s.1(1)(d) as a catalyst for suggesting more dramatic changes to abortion law in Great Britain. The article concludes with a consideration of the significance of s.1(1)(d) in our wider framing of disability in the context of reproductive choices. Drawing from writing in disability studies I suggest that s.1(1)(d) problematically reifies the importance of the physical aspects of disability. It is also problematic because of the presumptive effect it could have on choices following prenatal screening. Many authors argue that the statistically small numbers of abortions carried out on grounds of foetal abnormality, particularly after 24 weeks' gestation, are disproportionate to the controversy it causes. I reject this on the basis of the impact that s.1(1)(d) has had on the regulation of reproductive choice in other areas; specifically preimplantation genetic diagnosis (PGD) under the Human Fertilisation and Embryology Act 2008. I conclude by arguing that s.1(1)(d) is a relic of an overly medicalised approach to disability and abortion.

Implications of recent developments in Ireland for the status of the embryo.

One of the most significant developments in the area of reproductive health in Ireland is the Roche v. Roche [2009] case. The case concerned a woman who wished to implant cryopreserved embryos made with a former partner, against the partner's wishes. Of particular interest are questions about the status of the embryo: in Ireland the life of "the unborn" is constitutionally protected. Therefore the courts in Roche had to decide whether embryos were "unborn" within the meaning of the Irish Constitution.

Nurse research and the law in competent adults.

This article is a summary of issues which nurses face when carrying out research involving competent adults. A recent case of a nurse in Teeside who was struck off as a result of irregularities in conduct during a clinical research trial highlights the importance of standards of care in research being met. The authors focus on two aspects of research - the problems of the consent procedure and the different obligations that might arise from involvement in research. Nurses have a very important role to play in the conduct of research. They, like any other health-care professionals, must make sure that they conduct themselves in accordance with the standards of care of their profession and are accountable for their research conduct.

Best interests and pragmatism.

In this article I will show that 'best interests' is a concept that fits nicely with many of the features of pragmatism--Holm and Edgar's rejection of the principle in favour of pragmatism it will be suggested is misplaced. 'Best interests' as a principle may be considered an embodiment of the ideals of pragmatic adjudication. The paper starts by briefly introducing the concept of 'best interests' and theories of judicial and legal 'pragmatism'. This article will examine the role of the rational decision-maker in medical law and argue that this role is limited. The paper concludes by suggesting how we view the relationship between 'best interests' and 'pragmatism'.