O&G Forum

OBSTETRICS & GYNAECOLOGY FORUM 2021 | ISSUE 2 | 8 O&G Forum 2021; 31: 06 - 09 ORIGINAL RESEARCH Figure 3. Patients’ reported knowledge of risks associated with caesarean delivery, given as choice options Discussion Mutual trust provides the foundation of a good doctor-patient relationship. Patients become progressively more informed about health and diseases therefore obtaining informed consent before subjecting a patient to any test, procedure or investigation is essential. 5,7 Obstetric patients present multiple ethical challenges to the healthcare provider at the time of the informed consent process. The literacy rate may impact on the level of understanding between the patient and doctor during the informed consent process. Although consent forms in our institution are in English some of the informed consents were taken in other South African languages such as Northern Sotho and isiZulu to further assist patients to understand and make informed decisions in a language they are comfortable in. Clinical informed consent must at minimum include four content elements namely information about the procedure, risks, benefits and alternatives (in these cases, avoidance of caesarean section) which were all included in our questionnaire. We found that whilst the majority of patients were well counselled with regards to the name of the procedure and indication for the caesarean delivery, little information was offered to the patients regarding the risks, benefits or alternatives to caesarean delivery. This may be attributed to the majority of the caesarean deliveries being emergencies. The risk most mentioned was reported as the risk of bleeding. Participants reported very little knowledge with regards to delivery options for future pregnancies. This is regarded as a major negative outcome of the analysis. Participants were well counselled regarding type of anaesthesia and the possibility of blood transfusion, this could be because a separate blood consent form needs to be completed for consent to blood products prior to surgery. Participants reported to have been adequately informed regarding their right to refuse the operation which speaks to the healthcare workers understanding of patient autonomy. The results indicated that doctors were the predominant healthcare providers involved in obtaining informed consent. This is appropriate as the surgeon should ideally obtain informed consent. Overall the findings indicate that the consenting process for caesarean deliveries was not done well enough as not all the elements of the informed consent process were seemingly discussed with the participants. Latika et al. in India (2015) and Lubansa et al. in Zambia (2010), both low-middle income countries, conducted similar studies in their respective institutions and their results were similar to our findings. The majority of their patients were adequately counselled on the name of the procedure and indication but reported poor counselling regarding the risks and complications associated with the procedure. This indicates a lack of information during the informed consent process and can have legal implications if the patient develops complications intra- or post-operatively. Latika et al. found that counselling on the right to refuse caesarean delivery was poorly delivered. Conversely, in our study and from Lubansa et al. it was noted that patients were informed of their right to refuse caesarean delivery as this forms the cornerstone of patient autonomy and should never be underestimated. 9,10 Studies conducted in developing countries including the major economies of India and Nigeria regarding the adequacy of consent for caesarean sections showed that although patients knew the indications of their operations they were not adequately counselled regarding complications and risks. In our study patients were selected irrespective of having had an elective or emergency caesarean delivery because irrespective of indication proper counselling of the patient cannot be undermined. 10,11,12 Tripathy et al. in India (2020) and Ogunbode et al. in Nigeria (2015) recognized the importance of individual autonomy but also acknowledged that decisions were made within the family. 10,13 In their studies consent practices were also influenced by level of education and urbanization. Our study utilised individual autonomy and our consent practices were influenced by multilingualism in our institutions. While in elective procedures consent discussions could include family members, that is rarely the case in emergencies. Ogundode et al. alluded to the fact that consent documents are written in English but a large proportion of their patients would have preferred to be counselled in their home language. 10 This can be extrapolated to the South African context where we have eleven official languages and a significant foreign population who speak their own native languages. With South Africa being a multilingual society information may possibly be lost in translation during the informed consent process. The National Health Act (2003) stipulates that healthcare workers obtaining informed consent must, where possible, counsel the patient in a language that he/ she understands. 8 This is a major practical difficulty as most practitioners are able to use few languages. Language forms a major challenge to the informed consent process and this should never be disregarded as it has potential to compromise patient autonomy. Patient comprehension is fundamental to valid informed consent. Current practices may often be limited by inadequate patient comprehension. A systematic review of 52 studies evaluating 60 interventions to improve patient comprehension in informed consent suggested that interactive informed consent interventions, particularly those that intentionally promote active patient involvement and bidirectional communication, may be superior to non-interactive interventions. Among interactive interventions, those that use test/feedback and teach-back techniques were most effective. 14 The field of Obstetrics and Gynaecology faces special ethical considerations in the implementation of informed consent, relating to mother and fetus as patients, and because emergencies may arise rapidly and without warning in patients that the healthcare worker does not have had a rapport with. 15 Referring specifically to caesarean deliveries, it is difficult to maintain respect for patient autonomy when serious decisions must be made in the challenging situations of labour and delivery, be it an elective or emergency procedure. The key principles for informed consent to be valid are that the patient must have capacity to make an informed decision, consent must be provided voluntarily, and the patient must be properly informed of the risks and benefits of the intended procedure, which is not always adequately achieved in women who are in active labour. 2,3, 4, 15 Obtaining informed consent has become the cornerstone of medical practice today yet it is not free of limitations and challenges. Broader limitations of informed consent include the fact that patients cannot give consent when they are young, very ill or mentally impaired. Informed consent cannot be used for setting up public health policies as there has to be of uniform standard whereas one needs to individualize the informed consent process. 16 Challenges more specific to the informed consent process, and illustrated in this study, include language barriers especially in a culturally diverse country like South Africa where the doctor and patient often speak different languages. The person translating