Patient-centred consent in women's health: does it really work in antenatal and intra-partum care?

BACKGROUND: Legal and social changes mean that information sharing and consent in antenatal and intrapartum settings is contentious, poorly understood and uncertain for healthcare professionals. This study aimed to investigate healthcare professionals' views and experiences of the consent process in antenatal and intrapartum care. METHODS: Qualitative research performed in a large urban teaching hospital in London. Fifteen healthcare professionals (obstetricians and midwives) participated in semi-structured in-depth interviews. Data were collectively analysed to identify themes in the experiences of the consent process. RESULTS: Three themes were identified: (1) Shared decision-making and shared responsibility -engaging women in dialogue is often difficult and, even when achieved, women are not always able or do not wish to share responsibility for decisions (2) Second-guessing women - assessing what is important to a woman is inherently difficult so healthcare professionals sometimes feel forced to anticipate a woman's views (3) Challenging professional contexts - healthcare professionals are disquieted by consent practice in the Labour ward setting which is often at odds with legal and professional guidance. CONCLUSIONS: Results suggest that there is a mismatch between what is required of healthcare professionals to effect an antenatal or intrapartum consent process concordant with current legal and professional guidance and what can be achieved in practice. If consent, as currently articulated, is to remain the barometer for current practice, healthcare professionals need more support in ways of enabling women to make decisions which healthcare professionals feel confident are autonomous whatever the circumstances of the consultation.

Pregnancy in incarcerated women: need for national legislation to standardize care.

OBJECTIVES: This review examined prenatal care provided to incarcerated women to identify areas where improvement is needed, and examined current legislative gaps such that they can be addressed to ensure uniform templates of care be instituted at women's prisons. METHODS: Data were compiled from 2000-2021 citations in PubMed and Google Scholar using the keywords: prison AND prenatal care AND pregnancy. RESULTS: Although the right to health care of inmates is protected under the Eight Amendment to the United States Constitution, the literature suggests that prenatal care of incarcerated individuals is variable and would benefit from uniform federal standards. Inconsistency in reporting requirements has created a scarcity of data for this population, making standardization of care difficult. Although incarceration may result in improved access to care that women may not have had in their community, issues of shackling, inadequate prenatal diet, lack of access to comprehensive mental health management, and poor availability of opioid use disorder (OUD) management such as Medication Assisted Therapy (MAT) amd Opioid Treatment Programs (OTP), history of post-traumatic stress disorder (PTSD) are just a few areas that must be focused on in prenatal care. After birth, mother-baby units (MBU) to enhance maternal-fetal bonding also should be a prison standard. CONCLUSIONS: In addition to implementing templates of care specifically directed to this subgroup of women, standardized state and federal legislation are recommended to ensure that uniform standards of prenatal care are enforced and also to encourage the reporting of data regarding pregnancy and neonatal outcomes in correctional facilities.

State Policymaking and Stated Reasons: Prenatal Care for Undocumented Immigrants in an Era of Abortion Restriction.

Policy Points States can create policies that provide access to publicly funded prenatal care for undocumented immigrants that garner support from diverse political coalitions. Policymakers have used a wide range of moral and practical reasons to support the expansion of care to this population, which can be tailored to frame prenatal policies for different stakeholder groups. CONTEXT: Even though nearly 6% of citizen babies born in the United States have at least one undocumented parent, undocumented immigrants are ineligible for most public health insurance. Prenatal care is a recommended health service that improves birth outcomes, and some states, including both traditionally "blue" and "red" states, have opted to provide publicly funded coverage for prenatal services for people who are otherwise ineligible due to immigration status. This article explores how courts and legislatures in three states have approached the question of publicly funded prenatal care for undocumented immigrants and its relationship to the abortion debate, with a particular focus on the moral and practical justifications that policymakers employ. METHODS: We employed a review and qualitative analysis of the documents that comprise the legislative histories of prenatal policies in three case states: California, New York, and Nebraska. FINDINGS: This review and analysis of policy documents identified moral reasons based on appeals to different conceptions of moral status, respect for autonomy, and justice, as well as prudential reasons that appealed to the health and economic benefits of prenatal care for US citizens and legal residents. We found that much of the variation in reasons supporting policies by state can be traced to the state's position on the protection of reproductive rights and whether the policymakers in each state supported or opposed access to abortion. Interestingly, despite these differences, the states arrived at similar prenatal policies for immigrants. CONCLUSIONS: There may be areas where policymakers with different political orientations can converge on health policies affecting access to care for undocumented immigrants. Future research should explore the reception of various message frames for expanding public health insurance coverage to immigrants in other contexts.

Medico-legal implications of the fetal inflammatory response syndrome.

Babies who sustain long term neurologic injury and disability are frequent subjects in medical malpractice litigation. In the United States, the tort system enables adjudication of claims through a proscribed system. This paper will review salient elements of the tort system-duty, breach, causation, and damages- and how they apply to encephalopathic infants whose injuries are believed to be the result of fetal inflammatory response syndrome (FIRS) and/or hypoxic-ischemic damage. FIRS may confound the diagnosis of neonatal encephalopathy but may be a credible explanation for it as well. The ways in which FIRS may impact malpractice lawsuits are presented.

Legal Considerations in Genetic Screening and Testing: Three Case Studies: ACOG Committee Opinion Summary, Number 805.

The rapidly evolving genetic technologies that are available to patients and obstetrician-gynecologists have transformed the practice of clinical medicine. From cell-free DNA screening technologies in pregnancy to expanded carrier screening and hereditary cancer gene panels, obstetrician-gynecologists often are faced with questions about their legal responsibilities regarding genetic information as well as the legal ramifications of this information for their patients.The Committee on Genetics has constructed the following case studies to highlight some of the legal issues an obstetrician-gynecologist may encounter when performing genetic testing. These cases do not cover the breadth of legal issues affecting clinical genetics, but rather they illustrate certain legal concepts and principles as well as key pieces of legislation that are pertinent to clinical care. These case descriptions are not intended to serve as legal advice. Obstetrician-gynecologists are strongly encouraged to seek expert legal assistance to resolve questions involving legal rights or responsibilities.

Legal Considerations in Genetic Screening and Testing: Three Case Studies: ACOG Committee Opinion, Number 805.

The rapidly evolving genetic technologies that are available to patients and obstetrician-gynecologists have transformed the practice of clinical medicine. From cell-free DNA screening technologies in pregnancy to expanded carrier screening and hereditary cancer gene panels, obstetrician-gynecologists often are faced with questions about their legal responsibilities regarding genetic information as well as the legal ramifications of this information for their patients.The Committee on Genetics has constructed the following case studies to highlight some of the legal issues an obstetrician-gynecologist may encounter when performing genetic testing. These cases do not cover the breadth of legal issues affecting clinical genetics, but rather they illustrate certain legal concepts and principles as well as key pieces of legislation that are pertinent to clinical care. These case descriptions are not intended to serve as legal advice. Obstetrician-gynecologists are strongly encouraged to seek expert legal assistance to resolve questions involving legal rights or responsibilities.

Barriers and enablers for midwives using endorsement for scheduled medicines: A literature review.

PROBLEM: There are currently 429 midwives in Australia who hold the Nursing and Midwifery Board of Australia's Endorsement for scheduled medicines for midwives. Little is known about how midwives are using the endorsement and what factors impact on its use. OBJECTIVE: To critically examine the literature to discover what the barriers and enablers are for midwives to use the endorsement. METHOD: A search was undertaken examining literature published since 2004. Due to a lack of articles specific to midwifery, the search was widened to include literature related to similar non-medical health professions. The search was divided into two streams: accessing the Medicare Benefits Schedule and accessing the Pharmaceutical Benefits Scheme and prescribing. Twenty-six primary articles from 2009 onward met the review criteria. FINDINGS: Although singular barriers and enablers to both streams were identified, many of the themes act as both enabler and barrier. Themes common to both the Medicare Benefits Schedule focus and the Pharmaceutical Benefits Scheme and prescribing focus are that of medical support, scope of practice, ongoing support from health care consumers and management, and endorsement processes. Barriers occur approximately three times more frequently than enablers. CONCLUSION: Barriers and enablers occur for various reasons including legislative, regulatory, organisational, and the individual's support for and attitude towards these roles. To overcome barriers and facilitate the success of emerging non-medical extended practice roles, significant buy-in and investment is needed across all levels of the health system. The review highlights a significant gap in knowledge about the endorsement's use in midwifery.

Professional Liability and Gynecology-Only Practice: ACOG COMMITTEE OPINION, Number 790.

Fellows of the American College of Obstetricians and Gynecologists may choose to limit the scope of their practices to gynecology and, accordingly, may choose not to carry professional liability coverage for obstetrics. The American College of Obstetricians and Gynecologists considers early pregnancy care to be within the scope of gynecology and gynecologic practice. Liability insurers that provide coverage for gynecology-only practices should provide coverage for clinical practice activities that involve the management of first-trimester and early second-trimester pregnancy and its complications.

Prenatal Care for Undocumented Immigrants: Professional Norms, Ethical Tensions, and Practical Workarounds.

This paper examines the practice implications of various state policies that provide publicly funded prenatal care to undocumented immigrants for health care workers who see undocumented patients. Data were collected through in-depth interviews with purposively sampled health care workers at safety net clinics in California, Maryland, Nebraska, and New York. Health care workers were asked about the process through which undocumented patients receive prenatal care in their health center and the ethical tensions and frustrations they encounter when providing or facilitating this care under policy restrictions. Respondents discussed several professional practice norms as well as the ethical tensions they encountered when policy or institutional constraints prevented them from living up to professional norms. Using Nancy Berlinger's "workarounds" framework, this paper examines health care workers' responses to the misalignment of their professional norms and the policy restrictions in their state. These findings suggest that the prenatal policies in each state raise ethical and professional challenges for the health care workers who implement them.

Intimate Partner Violence Screening in the Prenatal Period: Variation by State, Insurance, and Patient Characteristics.

Objective To measure the proportion of women screened for IPV during prenatal care; to assess the predictors of prenatal IPV screening. Methods We use the CDC's 2012 Pregnancy Risk Assessment Monitoring System, representative of births in 24 states and New York City (N = 28,581). We calculated descriptive and logistic regressions, weighted to deal with state-clustered observations. Results 49.2% of women in our sample reported being screened for IPV while pregnant. There were higher screening rates among women of color, and those who had not completed high school, never been married, received WIC benefits, initiated prenatal care in the first trimester, and were publicly insured. State screening rates varied (29.9-62.9%). Among states, mandated perinatal depression screening or training was positively associated with IPV screening. 3.6% of women in our sample reported prenatal IPV but were not screened during pregnancy. Conclusions for Practice Current efforts have not led to universal screening. We need to better understand when and why providers do not screen pregnant patients for IPV.

Ultrasound in rural India: a failure of the best intentions.

The Pre-Conception and Pre-Natal Diagnostic Techniques Act was written to prevent societally unacceptable harms including intentional sex selection. The pragmatism required to enforce this law has profound effects on the ability of rural Indians to access diagnostic ultrasonography. In so doing, it may have inadvertently placed a heavier burden on the poorest and worsened health inequity in India, creating serious ethical and justice concerns. It is time to re-examine and update the law such that diagnostic ultrasonography is widely available in even the most peripheral primary health and community health centres. Shorter, more accessible ultrasonography training courses should be offered; collaboration between radiologists and rural practitioners and facilities should be encouraged. Finally, modern ultrasound machines can carefully record all images via a "silent observer" modality. With some modifications to previously used silent observer modalities, this technology allows both greater access and better policing of potential misuse of ultrasound technology.

[PROBLEMS OF IMPROVING ANTENATAL MONITORING OF PREGNANT WOMEN IN THE PRIMARY HEALTH CARE SYSTEM IN GEORGIA].

The purpose of the above work is to study the trends of mothers' health condition according to the implementation of antenatal monitoring of primary healthcare programs in 1996 - 2016 in Georgia. The methodology basis of the research is the qualitative investigation, so called Desk Research: collecting statistical data, description, systematization, comparison, analyses and interpretation. Data about mothers' health indicators were derived from National Center for Disease Control and Social Health and National Service of Georgian Statistics. Dynamic of the following indicators were studied: Number of births at home and the share of births at medical institution received by the qualified medical personnel, percentage of pregnant women's timely application, covering 4 antenatal visits, full time pregnancy, timely births, physiologic and pathologic births, Caesarean sections (planned, urgent); Number and indicator of mother's deaths. In order to study the law basis, the Statements of Georgian Government, normative acts of Labour, Health and Social Security of Georgia have been used for studying. In 1996 - 2016, as the result of Healthcare reforms, implemented in Georgia up to now, several parameters of antenatal monitoring were improved. The share of timely application and covering full, 4 antenatal visits increased; Share of births, received by qualified medical personnel increased; Number of mothers' mortality significantly decreased, but it is much higher when compared with the developed countries. Following the improvement in monitoring parameters and financial and geographical availability of antenatal care services, the unfavorable outcome of the pregnancy was revealed: the percentage of pathologic births increased, share of physiologic births decreased. The share of Caesarean sections is increasing and critically high. The share of early deliveries and incomplete period pregnancies increased. The above mentioned conditions indicate that there are systemic problems in the primary healthcare: In the preconception and then antenatal period, the quality of medical service does not meet the international standard. Assessment of pregnancy and fetal risks, prevention and management are inadequate.

An analysis of country adoption and implementation of the 2012 WHO recommendations for intermittent preventive treatment for pregnant women in sub-Saharan Africa.

BACKGROUND: An estimated 30 million women give birth annually in malaria endemic areas of sub-Saharan Africa. Malaria in pregnancy is associated with an increased risk of adverse maternal and infant outcomes. To combat the adverse effects of MiP, the World Health Organization (WHO) recommends the provision of intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) in areas of moderate to high malaria transmission. In 2012, the WHO updated its policy with respect to IPTp administration to recommend administration at each antenatal care visit in the second and third trimesters, with a minimum of three, rather than two, doses. While rapid improvements in coverage were expected, gains have occurred more slowly than anticipated. METHODS: The President's Malaria Initiative (PMI) assessed IPTp uptake before and after countries implemented the new WHO policy, and assessed how long it took for implementation to occur, using a combination of data from household surveys, routine health management information systems, and programmatic data provided to PMI. RESULTS: It took an average of 2 years for countries to complete the process of revising their IPTp policies, and it was not until 2015 that all 17 PMI countries had updated their policies. Policy dissemination and training had not been completed in several countries as of early 2018, and only seven countries had fully implemented the new policy including updating their antenatal care registers to collect information on IPTp3+ coverage. The coverage of IPTp1+, 2+, and 3+ has increased by 19, 16, and 13 percentage points since the revised IPTp policy adoption. DISCUSSION: Overall, coverage of both IPTp2+ and IPTp3+ has improved in recent years. The change in policy from a minimum of two to a minimum of three doses has likely contributed to these improvements. Progress has been slow, likely related to the complicated process of policy adoption exacerbated by the lag in measurement through national household surveys. The impact of future policy changes may be more readily seen if the policy change and implementation process were more streamlined and coordinated between key stakeholders (National Malaria Control Programmes and Reproductive Health Programmes), with more real-time data reporting.

Parental consent: an unnecessary barrier to adolescent obstetrical care.

When adolescents in the United States become pregnant, these young mothers experience differential access to obstetrical services, including prenatal, intrapartum, and postpartum care. As of 2018, 13 states in the United States do not afford a pregnant minor rights to prenatal care without parental consent, and 13 states do not ensure confidentiality from parental disclosure. Because of this, young mothers may avoid seeking timely and medically necessary care, not to mention counseling regarding preventive health services and monitoring of underlying chronic conditions. Lack of access during these critical months leads to missed essential opportunities for intervention and increased pregnancy-related risks to the mother and infant. It is imperative for obstetricians and gynecologists to value, support, and advocate for adolescents' emerging autonomy and personal agency to make informed decisions about their own bodies during their pregnancies, but also in making the choice to prevent future pregnancies through contraception.

A Violent Birth: Reframing Coerced Procedures During Childbirth as Obstetric Violence.

In the United States, women are routinely forced to undergo cesarean sections, episiotomies, and the use of forceps, despite their desire to attempt natural vaginal delivery. Yet, the current American legal system does little to provide redress for women coerced to undergo certain medical procedures during childbirth. Courts and physicians alike are prepared to override a woman's choice of childbirth procedure if they believe this choice poses risks to the fetus, and both give little value to the woman's right to bodily autonomy. This Note proposes a solution for addressing the problem of coerced medical procedures during childbirth by importing a framework created in Venezuela and Argentina that characterizes this issue as "obstetric violence." First, this Note contains an overview of the shortcomings of the existing American legal framework to address the problem. Second, it explains the advantages of the obstetric violence framework and argues that its adoption in the United States would address many of the failures of the existing system. And third, this Note introduces a few legislative and litigation strategies that can be used to implement this framework in the United States and briefly addresses some of the challenges these strategies may pose.