Statistics from Altmetric.com
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.
- Ethics- Medical
- Maternal mortality
- Health Workforce
- Informed Consent
- Health Care Economics and Organizations
In ‘The ethics of consent during labour and birth: episiotomies,’ van der Pijl et al 1 respond to the prevalence of unconsented procedures during labour, proposing a set of necessary features for adequate consent to episiotomy. Their model emphasises information sharing, value exploration and trust between a pregnant person and their healthcare provider(s). While focused on consent to episiotomy, van der Pijl et al contend their approach may be applicable to consent for other procedures during labour and beyond pregnancy-related care.
One feature of their model for adequate informed consent is trust in the systems in which prenatal and labour and delivery care are provided. Yet, for some pregnant persons, mistrust in health systems is a reasonable sequela of experiences like racism and epistemic injustice. For a programme in which trust is central to adequate consent, it is important to identify—and counter—forms of mistrust toward pregnant persons within healthcare and acknowledge and rectify reasonable mistrust of pregnant persons toward healthcare.
Like other kinds of healthcare disparities, van der Pijl et al note that ‘the burden of unconsented procedures is not evenly distributed over groups’ and tracks with ‘racial, socioeconomic and other disparities in maternity care’. They are drawing on data from a less diverse context than the one in which we work and live in the USA, where racial disparities in prenatal and birthing outcomes due to historical and structural racism and injustice are stark.
To realise the kind of trust in systems essential to the informed consent model van der Pijl et al propose, we argue for two necessary conditions for mutually trusting systems between pregnant patients and healthcare providers. One is broad accessibility of meaningful options for pregnancy and birthing care, including care setting and type of provider(s). The other is that any maternity care setting and practice be explicitly trauma informed.
Mistrust and maternity care
Intersectional awareness of how sex and gender compound with race, socioeconomic, education, age, (dis)ability and other identity markers helps to understand how pregnant persons can experience multiple forms of oppression impacting their trust of and in maternity care. As women, trans or non-binary individuals, pregnant persons are more likely to experience epistemic injustice in healthcare settings.2 In the US context, studies consistently show racial disparities in access to and utilisation of prenatal and maternity care.3 Economic inequities contribute to inadequate health insurance and limited access to health facilities in rural or underserved areas. Yet, racism is a driver of these inequities, and disparate maternal and infant outcomes persist even when adjusting for income.4
That van der Pijl et al note disparate ‘burdens’ of unconsented procedures in labour according to race and socioeconomic factors illustrates how structural racism creates conditions in which healthcare providers fail to view ‘minoritised’ patients as having standing as agents to provide informed consent. Racism and other forms of bias in healthcare contribute to mistrust of healthcare systems by already marginalised individuals, and to lower utilisation of healthcare when experiences of racism in healthcare settings diminish patient trust in health systems.
Despite mistrust of and by birthing people due to intersecting forms of oppression and structural and epistemic injustice in healthcare, van der Pijl et al lean on ‘the important role of trust in ethical consent procedures’ including ‘trust in self, trust in the relationship and trust in the system’. Empowering trust in self and building trusting relationships and trusting systems require concerted effort especially considering deeply rooted historical and intersectional legacies of mistrust. Said differently, the alarmingly common nature of unconsented episiotomies and other procedures is a byproduct of the meta-structures of untrustworthy care.
Access to (trustworthy) maternity care
The concept of reproductive justice5 suggests that addressing unjust reproductive outcomes during labour and delivery involves, in part, ensuring equitable access to respectful, culturally aware maternity and birthing care that aligns with one’s values and preferences. Reproductive justice therefore entails investment in, among other things, developing a culturally congruent and sensitive workforce within health systems, and availability, accessibility and affordability of meaningful options for maternity care setting, model and practitioners.
Birthing people could then make real choices about the kind of maternity care and providers that best concord with their values and preferences, enhancing their trust in the system of care and, ideally, the relationships internal to that system. Programmes supporting increased training, accessibility and affordability of a culturally, racially and regionally diverse birth workforce are the kinds of structural changes necessary for trusting relationships in labour and delivery settings and improved birth outcomes that would yield maternity systems worthy of patient trust.
Trust and trauma-informed care
Trauma-informed principles, which include promoting trust; physical and emotional safety; empowerment, voice and choice; levelling hierarchy; peer support; and attention to bias and difference,6 provide a complimentary framework for enacting more trusting relationships and health systems. They respond to awareness of pervasive individual and collective trauma histories, including trauma experienced due to oppressive environments like racism or misogyny. As guiding principles, they offer a systemic approach to providing personalised, attentive, trauma-aware care that cannot ensure trust but can create conditions to foster it, rather than merely committing to the value of trusting relationships and systems.
Trauma-informed care is implemented at individual and organisational levels, providing a structured pathway to approach labour and delivery within healthcare institutions, as sociomedical phenomena. Crucially, it does not abdicate the collective responsibility to provide medically appropriate care by relying on the labouring person and their sociopolitically concordant advocates to avoid unconsented care.
Moreover, trauma-informed principles can and should be layered onto any healthcare environment and healthcare settings are increasingly adopting trauma-informed practices. Thus, providing trauma-informed care is not a radical undertaking but part of a shift already occurring across healthcare systems. Increasing access to a wider range of maternity and birthing options in line with reproductive justice requires significant structural change. In the meantime, birthing providers and facilities can become trauma informed to enhance trusting relationships and trust in existing health systems.
Contributors EL proposed and drafted the initial manuscript. LL-N provided additional conceptualisation and edited the manuscript for critical revisions. Both authors reviewed and approved the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.