The Four Questions
In the days when I was working as a childbirth educator, I always discussed with my clients the value of asking questions of clarification from healthcare providers. Though these questions were related to being pregnant and giving birth, they are questions that will serve you in life no matter what health or medical situation you might encounter. Knowing the answers to the questions can make all the difference in the outcome that you experience, and is the core of informed choice. Asking these questions means that the decisions that you make about your care are grounded in real informed consent. For more than thirty years I have been approached by women who have had difficult and/or traumatic births and were not reconciled to the birth experience they had. They were struggling with lingering doubts about what had happened and needed help. I would wish for all pregnant women that they could avoid this dilemma by asking powerful but simple questions in advance so that they can accept the situation and still feel in control. Your active participation in the decision making process is empowering. The questions are:
1) Why?
2) What are the alternatives?
3) What are the hazards and risks of this?
4) What are the side effects of this?
Let’s go into more detail about each question.
1) Why?
It is the responsibility of your healthcare provider to justify whatever they are suggesting they want to do (it could be a procedure, an intervention or a course of action). Why do they want to do it? On what basis are they making this suggestion? Where is the evidence that this is necessary? Are you feeling pressured to make a decision? It is your right to know why they have come to this conclusion, and their responsibility to explain their rationale for making it. Be like a three year old child who is perpetually asking “why?” Even if you go along with the idea, you will feel better about making the decision if you feel you completely understand why it was necessary in the first place. You are the one who will live with the consequences.
It is important to realize that so much medical care is done without any evidence base behind it. More often than not, it has to do with a habit that has become so ingrained that the professional doesn’t think twice about the decision to do it. Asking why may cause that person to pause before doing something automatically just because they are used to it. Knowing the reason(s) why something is being done, and knowing that is it genuinely necessary, helps you to make peace with whatever decision was made. Most importantly, you are part of the decision making process by asking for an explanation that you are entitled to have.
2) What are the alternatives?
Any time your healthcare provider offers up only one choice, you are not being given a full picture of the situation. There is always more than one choice. More often than not they are giving you the choice they prefer, and hoping that you will go along with it. However, when you ask what the alternatives are, they are required to present any other possibilities that might have the same effect. When you ask this question you might find out that they don’t know another way of handling the situation. Then you have to ask yourself if you are okay with this course of action just because the practitioner is unaware of any alternatives. To give you an example, I had one client who was having her baby in a hospital and another client who was giving birth in a birth center. In the same week they both had the same situation of being stuck in the pushing stage, with very different outcomes. The woman in the hospital had a large episiotomy (the cut into the perineum that make the opening larger) and a forceps delivery. The woman in the birth center was encouraged to get out of bed and squat for a couple of contractions. This was so effective that she was barely able to get back into bed for the delivery of the baby. There is always more than one way to solve a problem!
3) What are the hazards and risks of this?
Another way of asking this question is to ask for a costs/benefits ratio. All too often the healthcare provider will explain the benefits without also including the risks that are involved. If you knew what the hazards of doing something were, you might think twice before agreeing. And that is why it is often omitted from the conversation, especially if doing something will make life easier for the practitioner. Sometimes the benefits outweigh the risks, but sometimes it is the other way around and the risks outweigh the benefits. With the epidemic of cesarean sections these days (2008-9 rate in the UK is 24.6%; 31.8% in the US, 2007), there seems to be a cavalier attitude towards the risks involved in a surgical delivery. Are you aware that babies born by cesarean section are more likely to have respiratory problems than babies born vaginally? This has to do with the removal of fluids from the lungs, which is a normal function of the squeezing contractions of labor, as experienced by the baby. That is why it concerns me that women are electing to have surgical deliveries without labor, and it could be an explanation for the increased risk of babies having asthma if they were born surgically. Women who have cesareans after laboring for hours have stimulated this health giving effect for the baby’s respiratory system. There is a long list of risks to the mother, but there is not space to cover them in this post. You want to know what the risks are of any procedure when making an important decision about your health and your baby’s health. You may still agree that the benefits outweigh the risks, but just like the alternatives question, you want to know all the consequences of the options that are available. There are justifiable reasons for doing cesareans that are genuinely life-saving; you are entitled to know the full picture of benefits and risks.
4) What are the side effects of this?
We tend to think of medication when asking this question, but there can be side effects to procedures as well. Another epidemic that is occurring in maternity care is induction, a procedure that had gone out of fashion for decades and has come back with a vengeance. Induction is a package deal that always includes synthetic oxytocin, an intravenous (IV) drip, and continuous electronic monitoring at the minimum. Did you know that more cesareans are done for failed inductions than for fetal distress or cephalopelvic disproportion (CPD, or the baby’s head is too large to move through the pelvis)? Did you know that if your cervix is not ripe for labor, and you are induced, the incidence of failed inductions goes up to 90%? And the incidence of cesarean section for a failed induction can be 65%? These are serious side effects of induction that most women are not aware of when they agree to be induced, which often leads to a cascade of interventions to offset the effects of each technique that preceded it. For instance, because the use of synthetic oxytocin causes contractions that can be significantly more painful, women often opt for an epidural to manage the pain. However, there is abundant evidence that an epidural will slow down the rhythm of your contractions (among other side effects too many to mention here), requiring even more artificial oxytocin to maintain contractions. In addition, the side effects of an epidural can increase the incidence of instrumental deliveries up to 50%, because the lack of muscle tone in the pelvic floor does not enable the baby to move its head into the proper position for delivery. Just this example shows you the side effects of the side effects. Would you still agree to the induction knowing this, or would you go back to the alternatives question and explore those possibilities? Even when truly necessary, it will be good to know what the side effects are that you might anticipate so that you can be prepared in exercising you options.
As I said above, these four questions apply to anything of a medical nature, and knowing them and using them will help you to negotiate with your practitioner so that you are entirely reconciled to the need for the measure and can give your informed consent to whatever the situation requires. I’m sure with a little tweaking this probably extends to various nonmedical situations in life too.
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