It has been my experience that providers of maternity care don’t always ensure women are aware that CTG monitoring is a choice. Nor do they support women to decide whether they want it or not by providing accurate information about the options for fetal monitoring in labour. It is nice when researchers ask questions that enable us to see whether or not this is an issue in practice. A team of Australian researchers recently published a comprehensive review of women’s experiences of maternity care across different models of care, using data from the Having a Baby in Queensland survey conducted in 2012 (Miller, et al., 2022). Tucked away in the supplementary files were some interesting bits of information that I’ll be sharing with you today.
Queensland women are not always giving consent for CTG monitoring
Responses from 2,802 women who completed the comprehensive survey were reported. 18% received standard care in a public hospital, 22% used GP shared care, 13% had public midwifery continuity care, and 47% had private obstetric care. A LOT of data was included in the paper, and I have kept a narrow focus on just the bits relating to fetal monitoring. The paper is free to access, so you may want to have a cruise around for other things that interest you.
Forty-two percent of women reported having had continuous CTG monitoring during labour. There were no significant differences in the proportion of women who used CTG monitoring according to model of care. When asked if someone discussed the pros and cons of CTG monitoring, 70% of women reporting having had this discussion. Women who received midwifery continuity of care were significantly more likely to have had such a conversation (82% of women) than women in standard hospital care (73%). Women receiving private obstetric care had the lowest rate at 65% but this was not statistically different to standard hospital care.
When asked whether CTG monitoring was used in labour without consent having been sought, 20% reported this happened to them. This was most likely in standard hospital care (22%), and significantly less likely for women in midwifery continuity (14%) or private obstetric care (19%). Compared with other procedures assessed in the survey (ultrasounds, blood tests, caesarean birth, induction of labour, vaginal examinations, epidural, episiotomy, or oxytocin for third stage management), CTG monitoring was the procedure most likely to have been used without consent.
While not specifically focussed on fetal monitoring, women were asked a question about whether their decisions during their labour and birth were respected by their care providers. Eighty percent agreed that their decisions were respected all the time. Women in midwifery continuity models (83%) or private obstetric care (85%) were significantly more likely to report having their decisions respected than those in standard hospital care. These rates are close to the inverse of the question about CTG monitoring without consent – which is interesting.
It’s not just a Queensland problem
Also published recently is a study from the USA, looking at the issue of non-consent in maternity care by racial identity (Logan, et al., 2022). Their data came from the Giving Voice to Mothers survey relating to birth experiences for women who gave birth between 2010 and 2016. 2,490 women responded to the survey. Twenty percent of white women and 31% of black, indigenous, or people of colour (BIPOC) reported feeling pressured by a midwife or doctor to have continuous CTG monitoring. When questioned about whether the doctor or midwife asked what the woman wanted to do before using CTG monitoring, 24% of white women and 30% of BIPOC women answered that this had not happened.
The study looked at other procedures used during labour and birth (induction or augmentation of labour, epidural or other analgesia use, episiotomy, caesarean section, amniotomy, and others). Forty percent of white women and 51% of BIPOC women reported some form of non-consent. This was more common when the birth was planned to happen in a hospital, when the primary practitioner was a doctor rather than a midwife, and when more than one practitioner provided antenatal care.
It’s not OK
It’s great to have up to date data about whether women had a conversation about fetal monitoring options, made a decision, and had that decision respected. It is not OK, however, that it wasn’t 100% of women. Time and time again, investigations into maternity care tell us that women want accurate and complete information, to be offered choice, to be listened to, and to have their decisions respected. When we have evidence that similar numbers of women encounter the same problem in different places, it suggests the problem is with our maternity care systems. Rather than telling maternity care providers to pull their socks up, we need better information about what is going on in our systems that results in women’s decisions not being enabled and supported, so we can tackle the “root cause”.
Models of care that offered continuity, particularly midwifery models, did better in both studies. This isn’t surprising, as it stands with a large body of research confirming that midwifery continuity of carer is the best model of care. It is time to prioritise maternity system funding so that women can access midwifery continuity models as a first step in ensuring all women receive respectful maternity care.
Logan, R. G., McLemore, M. R., Julian, Z., Stoll, K., Malhotra, N., & Vedam, S. (2022). Coercion and non‐consent during birth and newborn care in the United States. Birth, in press. https://doi.org/10.1111/birt.12641
Miller, Y. D., Tone, J., Talukdar, S., & Martin, E. (2022). A direct comparison of patient-reported outcomes and experiences in alternative models of maternity care in Queensland, Australia. PLoS ONE, 17(7), e0271105. https://doi.org/10.1371/journal.pone.0271105