Informed consent in childbirth is under fire by advocates, who stress that there is a widespread absence of meaningful informed consent during birth. While informed consent in medical settings always poses challenges, informed consent in childbirth raises particular concerns. Labor unfolds in real-time, and people are heavily reliant on their provider for information during birth. Providers may not adequately seek informed consent out of a belief that they should make decisions in the fetal interest, rather than the parent. Furthermore, laboring people make choices that are more than medical: birth is a value-laden process entwined with beliefs about parenting, life-meaning, and fetal interests. A new solution is on the table that could help improve the process of informed consent in childbirth: guided decision-making apps. This year, multiple mobile apps are in the works that would assist laboring people and clinicians in real-time decision-making during labor and birth.
The National Health Service of England (NHSE) is planning to pilot its prototype app, called IDECIDE, by summer 2020. Like many countries, the UK has seen widespread outcry in recent years about the lack of consent offered for medical procedures during childbirth. In response, NHSE has been developing IDECIDE as a way to facilitate improved consent during labor, in collaboration with advocacy group Birthrights UK, as well as the Royal College of Medicine, Royal College of Obstetricians and Gynecologists, and the British Intrapartum Care Society. The bedside “consent tool” walks providers and patients through decision-making around common medical procedures in childbirth. It can be calibrated to the urgency of the given decision, offering more or less information and process depending on the time-sensitivity. The app appears to do more than just present the patient with information and signature boxes–it walks the provider and patient through a series of exchanges about the decision at hand, including discussion of the details of the current situation, the patient’s perspective, healthcare provider’s experience, and the choices available. Finally, it records the patient’s decision and offers an opportunity for evaluation a few weeks later.
Another informed consent app is in the works in the United States by a Colorado company called [M]otherboard. The app is coincidentally also called iDecide. This app is a click-through informed consent model and focuses more on delivery of evidence-based content to patients in a colorful, digestible format. As issues arise in labor, a tablet with the app can be handed to the patient, who can peruse detailed educational information on the issue at hand and the options available, as well as sample questions to ask their provider. This information is used to facilitate more meaningful conversation with the provider. [M]otherboard is preparing to begin piloting the app in the coming months.
Advertising for both [M]otherboard’s app and the UK app mention mitigating provider liability in addition to supporting patients. The tools help ensure that providers have entirely met their duty to disclose benefits, risks, and alternatives to patients and that patients make the final decisions in their births. In the case of the UK app, it creates a digital trail of the patient’s decisions throughout the process. Presumably, in the case of litigation after the fact, the use of the app would serve as evidence that the patient was fully informed and chose the procedures that were performed.
Bedside consent apps offer a number of potential benefits. In the busy practice of obstetrics, they can, at a minimum, ensure that patients get access to basic, evidence-based information. Critically, it offers consistent information–currently patients can receive vastly different information, and have very different outcomes, depending on who their provider is. Apps would also be helpful because there is evidence that “decision aids” in obstetrics, that walk patients through decision-making, reduce patient anxiety, lower decisional conflict, improve patient knowledge, improve patient satisfaction, and increase the patient’s perception of having made an informed choice.
On the provider side, the use of such tools could make providers more comfortable with patient decision-making, by structuring and depersonalizing the decisions patients make. In obstetrics riddled with electronic charting mechanisms, prompts for providers, and box-ticking, there is logic to the idea that obtaining informed consent should occur in a similarly documented and regimented manner. Studies show that structuring consent and refusal of care can make providers more comfortable with patient refusal of care in pregnancy and childbirth. The liability piece is also important–providers that feel protected from blame and liability are more likely to engage in fulsome dialogue about care and to honor patient choices.
However, there are limitations to the use of bedside consent apps in labor, which cannot overcome all of the factors that make consent in birth so complex. The provider-patient power relationship is still present–despite how empowering outside information can be for patients. Patients will still rely on providers for the critical individualized assessment of their circumstances–generic information about induction, or example, can never replace the set of particular reasons that inform a given recommendation to a patient. Providers may still control which options are made available, by directing patients to read about certain procedures, but ignoring or denying information about others. To the extent that providers use manipulation or coercion to get patients to consent to their preferred medical treatment option, apps will not prevent this behavior.
One possibility is that some providers would do less informed consent with the apps. The presence of an app that can simply deliver all the key information to the patient, and ensure the provider is covered in the case of a lawsuit, could lead providers to sit back and rely more on the apps for obtaining informed consent. Some patients could see the informed consent exercise more as a click-through form than a meaningful exchange with their provider. While the apps certainly don’t preclude a conversation with the provider, and could facilitate one, they could lead some providers to do less of the heavy-lifting when it comes to offering informed consent. This issue has potential to be solved by some of the features of the UK IDECIDE app, which structures conversation with the provider more so than offering information.
Overall, the emergence of consent apps is an exciting development for childbirth. Though not a silver bullet, apps that serve as consent tools have a lot of potential to improve the process. These apps are in their early phases, and their pilot programs should help shed more light on their strengths and weaknesses. How the apps are used by providers and patients may ultimately matter more than the apps themselves. In the bigger picture, the advent of such tools further highlights the ongoing need for–and possibility of–solutions to the lack of informed consent that permeates obstetrics.
