Do mums now have the level of choice they should expect in maternity care?
There has been a lot of focus on maternal choice and informed consent in recent years, but it is clear it is still a major concern in maternity care and is still not happening how the law requires.
As a birth injury lawyer representing injured women from all over the country, concerns about consent and a lack of choice are still raised by the majority of the women I speak with. Here we look at what is happening to make maternal choice an integral part of the maternity services experience and what we can expect to see change going forward.
To help in our investigations we spoke to Professor Siassakos, Professor of Obstetrics at University Hospital London, whom we discussed the issue of consent with when we launched our #whataboutmum campaign back in May 2021.
In 2021 Prof. Siassakos had undertaken an observational research study on how consent was working in antenatal care, which highlighted concerns about how it worked in practice and the need for clinicians to ask more open-ended questions. Since then, concerns about a lack of maternal choice continued to be raised in several reports on maternity scandals and were raised last year in the Birth Trauma Inquiry Report of May 2024.
What concerns have been raised about maternal choice?
If we look at the concerns raised in the Birth Trauma Inquiry Report which collated evidence from over 1300 families, the report noted issues with maternal choice including:
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non-consensual procedures:
Numerous women reported undergoing procedures such as vaginal examinations, cervical sweeps, and forceps deliveries without their consent. This lack of informed consent was a recurring theme in the testimonies collected by the inquiry.
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denial of requested interventions:
Some women recounted instances where their requests for specific interventions, like caesarean sections, were denied.
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controversy over consent in emergencies:
The report included a statement suggesting that, except in emergencies, no procedure should be carried out without a woman’s consent. This led to concerns from advocacy groups such as (Birthrights link to website) who correctly argued that the right of pregnant women to decline treatment is well-established in UK law, even in emergency situations. The law states that consent must always be obtained, highlighting the importance of respecting women’s autonomy in all circumstances.
Overall, the Birth Trauma Inquiry report reiterated the critical need for systemic reforms to ensure that maternal choice and informed consent are upheld in maternity care across the UK.
We asked Prof. Siassakos about what he considered the biggest obstacles for clinicians explaining prospective mum’s choices when it comes to consent:
"There has been a misunderstanding of the Montgomery and other relative court rulings. Consent is not about discussing all options, even medically unreasonable ones – for example vaginal delivery with placenta previa does not make clinical sense and is potentially lethal. It is also not about discussing every possible risk of the various options. It is about establishing rapport and covering both the clinically important risks (for example shoulder dystocia with a large baby) and the ones that matter to families. Some people giving birth are very concerned about the pelvic floor, for others what matters is avoiding a caesarean."
The Birth Trauma Inquiry Report has highlighted the critical need for improvements in informed consent within maternity care. One of its key recommendations is to ensure that information and permissions are agreed upon prior to labour, eliminating the need for women to complete forms during labour. This approach aims to enhance the informed consent process by allowing expectant mothers ample time to understand and consent to potential procedures in a less stressful environment.
But in order for this to work, consent in the antenatal period needs to be working effectively and Professor Siassakos’s 2021 observational study raised concerns around consent discussion in the antenatal period. We asked him what changes have been made since your 2021 study to improve discussions with expectant mothers in the antenatal period:
"There have been many initiatives to improve discussions with expectant mothers. Many efforts are ongoing and their impact uncertain.
With regards to operative birth (forceps, ventouse, caesarean), two programmes led by UCL (ROTATE study, ART & CRAFT course) have aimed to improve consent in collaboration with public/patient engagement and involvement panels and experts. We have trained several dozen senior obstetricians across the UK."
What changes have been implemented to improve maternal choice?
It does seem that in response to the Birth Trauma Inquiry’s recommendations, there has been a move to a more widespread patient centred approach. A significant shift in NHS Trusts following the Inquiry has been the growing adoption of a more patient-centred approach within maternity care. NHS England has been working to implement personalised care and support planning. This shift has led to greater efforts to involve parents in decision-making, such as providing choices during childbirth and ensuring that mothers and families are fully informed about the risks and benefits of various options. Hospitals are also beginning to offer more flexible birthing plans that respect patients’ preferences, within medical guidelines, which helps reduce the likelihood of a traumatic experience.
Furthermore, NHS maternity staff across several units in England have begun mandatory training programs aimed at enhancing patient safety and care quality. These programs focus on equipping obstetricians, midwives, and anesthetists with the skills necessary to better identify signs of distress during labour and manage obstetric emergencies effectively. If successful, these training initiatives may be expanded nationwide, potentially leading to improved practices around informed consent and overall maternity care.
When asked if he’d seen the impact of these changes in practice, Prof. Siassakos said that the impact had not yet been formally evaluated.
What more needs to be done to ensure pregnant mothers are able to make the choices that are right for them?
While these steps indicate a commitment to addressing the concerns raised in the Birth Trauma Inquiry Report, the full implementation and effectiveness of these improvements will require ongoing evaluation and support to ensure that all women receive safe, respectful, and informed maternity care.
More support is needed to ensure better education and respect for women on birth choices, and to tackling inequalities in maternity care among ethnic minorities, particularly Black and Asian women across all aspects of maternity services.
We asked Prof. Siassakos whether he saw technology helping in future, such as electronic consent – using digital platforms to present information interactively or using visual aids, and so on:
"Technology may help, but it will never replace a discussion with a trusted experienced professional. Consent is about understanding each other and making decisions together."
Our specialist maternal birth injury solicitors are here for you when you’ve suffered injury as a result of negligent care during a birth. Contact our enquiries team today to find out how we can help.
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