From the moment a woman is pregnant she is offered an ever increasing variety of tests. I use the term ‘offered’ despite the reality that the tests are rarely presented as options. When I ask women about the tests they had, they are often unsure about the whats and whys. The GP takes some blood for the ‘pregnancy bloods’ without explaining or gaining consent (ie. explaining each and every individual test). The ultrasound is ordered without the rationale for the procedure being discussed never mind any risks.
These tests are on offer. Women can choose to have all, some or none of them. We need to stop referring to women who decide not to test as ‘refusing’ a test – I hear this all the time ‘she refused…’. This implies it is wrong to decline something that does not fit with your needs as an individual mother. It is not our responsibility as midwives, drs etc. to ensure a test is carried out (and tick the box). It is our responsibility to offer the test along with adequate information and support the woman’s choice either way.
Antenatal care has become about screening out risk to ensure perfection – an impossible task. Antenatal care should be about supporting women to build self confidence in their ability to grow, birth and nurture a child.
You can read and listen to parents’ stories about different aspects of antenatal screening here.
Excellent post as usual Rachel. You are so right in terms of what antenatal ‘care’ is supposed to be about, instead it has degenerated into a fear filled gamut of ‘tests’ that are supposed to reassure?
I was thinking about ante-natal care just yesterday – … thinking how so many women seem to have so many ‘check-ups’ and tests, which to me generally seem so unnecessary…and my conclusion was that too many healthcare professionals are in the game for the money…and more testing = MORE MONEY.
I would love to hear this presentation.
Not long ago I decided for our next one I am going to “decline” a whole heap of the “standard” tests. With DS I just did everything I was told and didn’t know what they were testing for anyway. Luckily all the results came back normal, but really, I don’t see the sense in most of them. I’ll still do some but only after it is discussed and I won’t be just doing anything for the sake of it, especially not the BP at every appt, mine was always up, white coats syndrome I think. Now with PTSD after DS birth I expect it goes up everytime I am within 20 feet of a white coat so that is definitely out next time
Great post. I find so few women realise that they can actually say no. My experience with the midwives was great (and not all of them knew that I was a midwife so no bias) but the GPs were clearly not used to people declining their tests. I moved interstate during my first trimester and saw a couple of different GPs while settling in. Both were very keen for me to have a “dating scan”, despite certain dates one of them wouldn’t even document an EDC without it! I declined and both were politely peplexed but neither of them actually asked me *why* I was declining.
Once I started going to the midwives clinic everyone was happy to discuss options and seemed comfortable with me picking and choosing.
I have had 3 babies – all at home with midwives. After each was born, I took them to a pediatrician. Each time I declined the PKU test. This time the doc decided to use the fact that my baby isn’t gaining at least 1 oz per day to try and force the PKU in order to rule out systic fibrosis. Nevermind the fact he’s gaining nearly 6 oz per week and I’m under 5 feet tall and my other babies gained slowly too!
AN OFFER YOU CAN’T REFUSE. The policing of pregnant women proceeds apace. In the UK AIMS is receiving an increasing number of complaints from women who refuse tests, scans, or hospital births, being reported to social services as a risk to the child. The is despite the fact that the woman has a legal and moral right to refuse, and the codes of conduct of both midwives and doctors say that they must obtain consent to interventions. As a former lecturer on medical ethics, I repeatedly pointed out to professional audiences that without informed refusal, informed consent does not exist.
Jean Robinson, President, Association for Improvements in the Maternity Services, Oxford, England
and may I quote you please Jean?
Carolyn
This is terrifying. Can you imagine a woman being reported to social services for choosing to have an induction at 37 weeks for social reasons? Not likely. Yet I would consider this more of a risk to a baby than declining tests and scans.
Jean, that is a very troubling situation. Similar events are happening in Australia. What do you suggest is a solution to the erosion of women’s right to bodily autonomy?
Carolyn Hastie
You are right Carolyn – we are getting similar situations here. I am also hearing of women having tests in order to access their choice of birth place ie. only being ‘allowed’ to book into the birth centre if they have had a scan.
Hi Rachel, great topic to cover, pregnancy is belonging to the medical profession these days, not the family, with so many test and so much pressure…. , love your placenta, your testing handout is great too! many blessings, Sarah
Thanks Sarah
Women need to reclaim their self knowledge, confidence and autonomy… not sure how we go about making it happen though. the medical professional as expert is so ingrained.
Rx
I was told I had to “prove” my pregnancy was “low risk” in order to give birth in a birth center here in Australia by having scans! This was despite having 2 previous uncomplicated waterbirths at a birth center in Canada where I’m from. (never had a scan for those pregnancies but managed to do fine!) I ended up hiring an independent midwife instead, but luckily my husbands’ employer covered the cost. Options are becoming fewer and fewer it seems- it scares me to think of what my daughters will face when they have their babies.
This is what worries me about midwives becoming part of the system. Women must prove they fit the strict criteria in order to gain access to the birth centre, medicare funded midwife care, or hospital attached homebirth service. Even declining a test can ‘risk’ you out. What about all the women who don’t fit the criteria like those who prefer not to test, or have had a previous c-section, etc. etc? I also worry about my daughter’s birth choices – although she told me she is having a waterbirth at home with me as her midwife… that will probably be illegal by the time she is pregnant (she’s 16).
Here in the US, if you don’t get the GDM screening you’re pretty much viewed as a baby-killer. sigh. I refused for weeks to show up for the test before it just got too late for it to matter and they stopped asking. I had no indications of insulin resistance, and NO family history of diabetes, and a healthy diet and exercise routine. Yet I’m told horror stories by the doctors about babies that died from undiagnosed GDM and how it often predicts if a person will go on to develop diabetes. Pretty sure if I stay healthy and exercise that I won’t get it….but thanks for the scare tactics.
Wanted to opt out of GBS test (was negative anyway), but if you don’t test negative they automatically treat the baby as if you DO have GBS with antibiotics. Why couldn’t they just take a culture then and treat accordingly? It would be a lot more accurate than the GBS test at 36 weeks.
The more I read about US birth the more I am amazed and disgusted. Routine GDM screening and GBS screening do not even have medical science to back them up. You can’t say you have a system based on medical science if you then ignore science so blatantly. Then again it is a system based on profit – more tests and intervention = more profit. How depressing : (
I put off my GDM test until the midwife said no bother since we were so close but they asked me about it every appt and tried to make me feel bad. In the end they admitted that I had zero risk factors and everything was probably great…
I also wanted to avoid the GBS but did not want the antibiotics more than I did not want the test.
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Sadly, sometimes these tests are NOT offered as an option. Some women are given little to no choice. When I was pregnant, I went to my first OB appointment and when I declined any ultrasound, was told “you don’t have a choice. I require routine ultrasound on all of my patients. I’ll just schedule yours for your next visit if you won’t do it today.”
I live in a town where getting another doctor is not an option. We have five OBs (I live on an island) and they are all friends, so it’s not like you can just up and leave one for another. They know each other. They go to lunch together.
After declining several tests, my OB sighed and said “you aren’t going to get a midwife, are you? You can’t birth with a midwife because my insurance company will not cover me if you seek outside care.”
I dumped the OB right after the appointment, hired two midwives that day and went on to have a fabulous home birth and a happy, healthy baby and we all sat around and laughed as I told stories about the doctor who told me he didn’t own a fetoscope because “they don’t work, we weren’t even trained to use them in medical school. You won’t even find one except maybe in a museum.” LOL!
If you hire a private practitioner then they have the right to insist on certain criteria. For example, I could tell women that if they don’t have an ultrasound I won’t attend their birth (I don’t by the way). In this case you have a choice to find a practitioner who will support your choices – as you did. In the public system a practitioner has a duty of care and cannot refuse to care for you.
It is sad that women’s access to practitioners and choice is limited in many areas. I’m pleased you found the right midwives for you.
I am currently between 40 and 41 week pregnant and am planning a home birth with a midwife. However, at my midwife’s encouragement as well as for my own peace of mind, I have opted to work with a CNM in an obstetrician’s office as medical backup. Everything had gone along smoothly until last week when the CNM essentially gave me an ultimatum: either submit to a bio-physical profile at 41 weeks plus 2 days or she would refuse to work with me in case of any emergency situation going forward. While I would not be against a bio-physical profile if there were a medical reason (truly prolonged pregnancy, a marked slow-down in fetal activity, etc.) I cannot in good conscious submit to 30-60 minutes of continuous ultrasound that will only tell me at this point what I already know, that everything is fine. I am simply stunned that a healthcare provider would give a patient such an absurd ultimatum based on a refusal to take a test at their proscribed point in time. I’d love to hear what you think about this.
Additionally, I need to thank you for this blog. It has been a source of comfort informed by reason throughout my pregnancy and I will continue to read it long after. It’s truly fascinating and helpful. The world needs more thinking midwives!
I’m guessing you are in the US and I’m not sure how the system works there. I’m presuming that if an emergency did take place the CNM would have a duty to provide health care to you – regardless of any tests you took or not. What does your midwife think of the situation?
Rebecca,
From http://namamaste.com/2010/06/your-right-to-refuse-a-c-section/ :
Professional ethical guidelines state that a physician may only drop you from his/her care after giving you 30 days notice. This means that if you are within 30 days of your likely delivery date, your care provider cannot terminate your care. In addition, if you are pregnant and are outside of that 30 day time frame, your provider must give you a referral and ensure you are transferred to a specific provider. Physicians who fail to meet these guidelines may be charged with patient abandonment, which is grounds for malpractice and constitutes a violation of ethical conduct that could result in loss of licensure.
Thanks for the information and link Kim.
Great post Rachel…I’ll be sending my midwifery students here to have a read. I am starting a new job as lecturer at Griffith next year so will be looking for online resources for students as my teaching will be all online 🙂
Thanks Sarah
The students are lucky to have the guru of online learning as a lecturer.
Rx
@ Sara- I live in the US too. I hired an amazing group of midwives for and OOH birth. They were fabulous. Never pressed me to do anything I didn’t want to do and were always fully informative. In the end, I did end up screening for GBS just in case of a hospital transfer- I wanted to have the negative results handy. We never even discussed GDM testing, as there was nothing to indicate I should. We were blessed with wonderful midwives, and I was blessed with wonderful support (hubby, mom, midwives) for a very long labor (49 1/2 hours from broken waters {with contractions} to the birth of my daughter), and did end up having a beautiful OOH birth. I think the answer to our horrific maternity system is MORE MIDWIVES! People are so fearful of the non-MD attended birth around here though- it’s very ingrained. The media feeds the beast, and, unfortunately, it’s taken at face value. Excellent book on our system is Born in the USA… by Marsden Wagner, M.D.
I’ve spent the last two days soaking up every one of your posts. SO excited I stumbled upon your blog. I’m located in the US, 28 weeks pregnant and have been subjected to a countless number of tests. I was told my very first OB visit how extremely high risk I was because my pre-pregnancy weight of 220 lbs. I’ve had my blood drawn and tested three times (I have no idea what for), two scheduled ultrasounds and one where I was rushed to the exam room after the doctor ‘failed to find the baby heart beat’. Apparently the heart he was listening to was my own and was understandably racing a little fast as I watched both his and the nurses faces worried above me.
I don’t have a support group and this being my first pregnancy I’m really concerned with having a good birth experience. My insurance only covers hospital births and anytime I try to bring up a homebirth with any doctor I’m only presented with horror stories and the fact that I’m going to have a gigantic baby and diabetes and I would obviously be suicidal and killing my baby to attempt anything like that. Even the one CNM at the hospital told me she wouldn’t accept me as a patient. I feel like any option has been effectively taken from me by the words “you don’t want to harm your baby do you?”
I never really considered the option of just telling them no. There was no question about getting tests done. Just handed a piece of paper with different boxes checked to take to the technicians.
My next appointment my OB is in for a surprise when I finally wake up and start getting real answers to my questions and NO MORE TESTS.
Sasch,
Have you spoken to any homebirth midwives in your area? Some insurance companies will compensate a licensed midwife at an out-of-network rate. Depending upon your policy and deductible, you might even find that a homebirth midwife’s fee is comparable to what you would pay out-of-pocket with insurance. I encourage you to do some looking around and asking for recommendations for homebirth midwives in your area, and then actually meet with one. Many offer free consultations. Best wishes!
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I am 36 weeks pregnant and just had an ultrasound this morning for the doctor to check the fluid levels and size of the baby. Everything checked out okay, but the ultrasound technician was concerned that the fluid was “a little high”. I forgot to ask for the numbers but came home and read up on Polyhydramnios. The doctor I saw (not my regular doctor, who was in surgery) wanted me to do another blood test and another glucose test, which I refused because I just had all the same blood tests done two weeks previously, and the numbers came out fine. Also, I don’t have any other diabetes symptoms and my glucose tolerance test was okay when I took it at 30 weeks. I would love to read any information you have on fluid level detection in ultrasounds.
The measurement of fluid is very inaccurate (and so is the measurement of baby size). They take the measurements of 3 ‘pockets’ and use that to estimate… of course it depends on the pockets they use. With true polydyramnios you can tell on palpation as the baby will be difficult to feel and the fundal height (top of the uterus) will be higher than expected.
Thanks!
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Hi, we are having our second child in June. I tested this time round for Strep Group B mildly and was told you need to have IV antibiotics at the birth, if still present at 37 weeks as can cause lots of complications to baby when birthing. We are really not keen to use antibiotics, it sounds like there is more issues to come from a baby getting antibiotics so early on thru the blood. Let alone being hooked up to an IV for my birth would be horrible anyway. My first child I wasn’t even tested for this.
Do you have a post somewhere about this you can point me too or maybe just some insight would be amazing.
Thanks So Much.
Hi Joy
This is the danger of testing for GBS and why many countries don’t… now you have stress over something which might not be there at 37 weeks and if it is still there it is unlikely to cause a problem. You may have had it with your first child. However, now you know – so, some resources that might help you make an informed decision (and remember it is your decision) about what action or not to take:
http://summaries.cochrane.org/CD007467/intrapartum-antibiotics-for-known-maternal-group-b-streptococcal-colonization
http://evidencebasedbirth.com/groupbstrep/
http://midwifethinking.com/2014/01/15/the-human-microbiome-considerations-for-pregnancy-birth-and-early-mothering/
As usual it is all about balancing risk. The risk that your baby will be the rare baby that is effected vs the risk of health problems associated with antibiotic administration. Also bear in mind that you can change your plans ie. opt for antibiotics IF there are signs of infection rather than ‘just in case’. You may find that you run into opposition with the hospital if you opt out of their protocols… and they may want to monitor baby in the nursery ‘just in case’ if you don’t have any antibiotics. Again, you can say no. Good luck 🙂
Thank you that was a really helpful reply.