Maternal Decision-Making - 2013

A pregnant woman has the same rights to privacy, to bodily integrity, and to make her own informed, autonomous health care decisions as any competent individual, consistent with the legal framework of that jurisdiction.

A pregnant woman’s capacity to make an informed decision should not be confused with whether or not the doctor (medical practitioner) considers her decision to be reasonable, sensible or advisable. A doctor may not treat a competent pregnant woman who has refused consent to treatment. Recourse to the law to impose medical advice or treatment on a competent pregnant woman is inappropriate.

Most pregnant women strive to achieve the best possible health outcomes for both themselves and their unborn babies.[1] Because of the inter-dependence of the maternal-fetal relationship, both the mother and the fetus have an interest in any health care decision. In this situation, ‘interest’ refers to ‘optimal health and well-being’.

Throughout pregnancy, a woman will make health care decisions regarding lifestyle behaviours, as well as medical treatments, that impact on her own health and well-being, as well as that of the fetus. Lifestyle behaviours include, but are not limited to, diet, exercise, smoking, alcohol, licit, and illicit drug use. Medical treatments include, but are not limited to, use of medication, birthing choices, maternal surgery and fetal surgery. 

Doctors play an important role in supporting pregnant women to make fully informed health care decisions by providing advice on the risks and benefits to both the woman and the fetus of lifestyle and medical treatment options. Doctors should provide women with opportunities to ask questions and express concerns over the advice given. In many cases, these discussions may also involve the pregnant woman’s partner, other family member, or support person. 

In most circumstances, the interests of the mother and fetus converge so that a health care decision that is good for the mother is often beneficial, or at least not harmful, to the fetus. For example, a pregnant woman choosing not to smoke will not only benefit her health but that of her fetus as well. 

There are situations, however, where the interests of the mother and the fetus significantly diverge. For example, a mother may require medication or surgery to save her life that may cause serious harm to the fetus. Alternatively, the fetus may require medication or surgery to save its life that may cause serious harm to the mother. In these circumstances, the woman is faced with making a decision that may benefit herself while seriously harming her fetus or may benefit the fetus while seriously harming the mother. Again, the doctor should fully inform the pregnant woman of the risks and benefits of the recommended treatment, possible alternative treatments, and no treatment, both for herself and her fetus. The mother’s fully informed decision should be respected.  

A situation where a pregnant woman chooses not to follow advice might be distressing or challenging to a doctor. For example, where a woman chooses not to undergo a recommended Caesarean Section for either maternal or fetal indications. In these situations, the doctor should explore the woman’s reasons for acting against medical advice with her. 

The doctor must respect the woman’s informed decision, even if it is not consistent with the doctor’s advice, and continue to provide patient support. In the event that the doctor cannot in good faith continue to care for the patient, they have a duty to make timely arrangements for that patient’s ongoing care.

If a pregnant woman’s decision-making capacity is in doubt, the doctor should ensure that she is assessed as soon as possible. If a pregnant woman is considered to lack decision-making capacity, referral through the appropriate Guardianship mechanism should be initiated.