Consent for interventions during childbirth: A national population-based study

Abstract

Objective: To assess the frequency and determinants of medical interventions during childbirth without women's consent at the population level.

Methods: The nationwide cross-sectional Enquête Nationale Périnatale 2021 provided a representative sample of women who delivered in metropolitan France with a 2-month postpartum follow-up (n = 7394). Rates and 95% confidence intervals (CI) of interventions during childbirth (oxytocin administration, episiotomy or emergency cesarean section) without consent were calculated. Associations with maternal, obstetric, and organizational characteristics were assessed using robust variance Poisson regressions, after multiple imputation for missing covariates, and weighted to account for 2-month attrition.

Results: Women reporting failure to seek consent were 44.7% (CI: 42.6-47.0) for oxytocin administration, 60.2% (CI: 55.4-65.0) for episiotomy, and 36.6% (CI: 33.3-40.0) for emergency cesarean birth. Lack of consent for oxytocin was associated with maternal birth abroad (adjusted prevalence ratio [aPR] 1.20; 95% CI: 1.06-1.36), low education level, and increased cervical dilation at oxytocin initiation, whereas women with a birth plan reported less frequently lack of consent (aPR 0.79; 95% CI: 0.68-0.92). Delivery assisted by an obstetrician was more often associated with lack of consent for episiotomy (aPR 1.46; 95% CI: 1.11-1.94 for spontaneous delivery and aPR 1.39; 95% CI: 1.13-1.72 for instrumental delivery, reference: spontaneous delivery with a midwife). Cesarean for fetal distress was associated with failure to ask for consent for emergency cesarean delivery (aPR 1.58; 95% CI: 1.28-1.96).

Conclusion: Women frequently reported that perinatal professionals failed to seek consent for interventions during childbirth. Reorganization of care, particularly in emergency contexts, training focusing on adequate communication and promotion of birth plans are necessary to improve women's involvement in decision making during childbirth.

Keywords: delivery; facility‐based maternity care; informed consent/statistics and numerical data; maternal health services; obstetrics and gynecology; patient‐centred care; shared decision making.

FIGURE 1

Association of women's sociodemographic characteristics, pregnancy, delivery, neonatal, and maternity characteristics with request for consent for oxytocin administration (not including prophylactic oxytocin dose at delivery of shoulder). ENP 2021, Metropolitan France, N = 2688 Poisson regression, weighted and imputed data. Other public category includes public facilities (except for teaching hospitals) and private non‐profit facilities performing public service. aPR, adjusted prevalence ratio; CI, confidence interval; ref, reference.

FIGURE 2

Association of women's sociodemographic characteristics, delivery, neonatal, and maternity characteristics with request for consent to episiotomy. ENP 2021, Metropolitan France, N = 473. Poisson regression, weighted and imputed data. Other public category includes public facilities (except for teaching hospitals) and private nonprofit facilities performing public service. aPR, adjusted prevalence ratio; CI, confidence interval; ref, reference.

FIGURE 3

Association of women's sociodemographic characteristics, delivery, neonatal, and maternity unit characteristics with request for consent to emergency cesarean birth. ENP 2021, Metropolitan France, N = 946. Poisson regression, weighted and imputed data. Other public category includes public facilities (except for teaching hospitals) and private non‐profit facilities performing public service. aPR, adjusted prevalence ratio; CI, confidence interval; ref, reference.