Why Consent can not be trusted

In 2022, we saw another increase in intervention and trauma (as shown in the latest Australian Institute of Health and Welfare Mother Baby Report). We saw Obstetric Violence in the headlines, thanks to new evidence published from Western Sydney University. This is a very serious issue.

The state of our maternity system reflects society’s’ attitudes towards women. We have created a hypersexualised¹ society that has devalued physiology in favour of convenience technologies. The ‘standard’ perspective is a man’s world², in the last 100 years we have seen a shift from community based birth into centralised and medicalised birth. This has intensified as technology has replaced physiology.

This hypersexualisation has evolved into a consent-focused society, which crosses over into our medical world. The consent focus is centred on this technological ‘progression’. It creates a context where not consenting (dissent) is placed in the negative. This is strongly discouraged, and in a power imbalance often impossible to respond to in any other way but compliance. There is pressure on midwives to ‘get consent’ and pressure on women to give it. What is actually required and needed is a DECISION.

We see ‘birth plan’ templates offered by institutions, providing an illusion of choice.

Under the guise of ‘shared decision making’, we are told we are ‘involved’.

This is but a thinly veiled process of coercion.

If we find ‘how to make a birth plan’ online, we will see variations of ‘be polite’ and ‘be sure to say thank you’. This is Negative Politeness. It has nothing to do with manners or respect, and everything to do with power. This is the appeasement we use when we seek to do things ‘off script’.

This means that consent is given in one of five ways: compliance, enthusiasm, willingness, unwillingness, and coercion. Three of which are not actually consent. Overlying all of this, is a legal requirement that the consent is Informed. This is often not done (listen to this Midwives Cauldron podcast episode), which brings the validity of consent into question.

Complied Consent

Consent due to compliance might look like someone ‘handing the responsibility over’, “going with the flow’ or trusting their care provider without question. When feeling overwhelmed, ‘unqualified’, or indifferent, it can be tempting to ‘go with the flow‘. Some may believe that having no expectations means no disappointment. This is not informed consent, or even consent. It is compliance. This puts care providers at risk as well as mothers and babies. If you are a care provider concerned about the validity of the consent you are given, consider the Birth Cartographer Training to help bridge the communication gap. If you are a mother-to-be feeling uncertain, The Birth Map will provide you with an overview of birth and question prompts to start a meaningful discussion with your care provider, based on your context.

Enthusiastic Consent

If consent is ‘enthusiastic’ this means we welcome the intervention, are glad for it, understand it, and find relief with it.

Willing Consent

If consent is ‘willing’, we may recognise a situation where an intervention is warranted and understood. We might not be glad of the circumstances, but we are glad of the option.

Unwilling Consent

Unwilling consent comes about when we are worn down (counselled), or worried into compliance, or perhaps we feel unsafe. We say yes because we want things to be over, we want someone to go away, or we do not feel heard. This may also be assumed consent, where we may have consented to something previously (like an epidural) without knowing it means we must also have a catheter. This is very common in maternity, as procedures are consented to in isolation, without awareness of how it will impact our options. This is not informed consent.

Coerced Consent

Coerced consent occurs when we are bullied or told you can’t do X unless you do Y. For example – you can’t get into the bath unless you permit a cervical exam. Or you Must agree to certain conditions to remain in a public homebirth program or to have a VBAC. This disrespectful behaviour may occur if you try to assert yourself or decline a ‘standard’ procedure. Instead of respecting your no, you are harassed until you agree. This harassment may involve scare mongering, unbalanced use of statistics or over emphasis of risks if you don’t agree (whilst ignoring or underestimating risks if you do). See Timing of Birth for examples of how language can be (ab)used to encourage a particular decision. We may feel that the circumstances do not warrant consent and that the hoops we need to jump through (being ‘counselled’ by a ‘superior’, or required to fill out extra paperwork) are unethical or extreme. The pressure to consent comes with an undercurrent of danger if you do not comply (rather than the circumstances actually warranting the consent). This coercion may come about due to a care provider’s fear of liability or an adverse outcome. These fears are likely due to a system that does not support them to support women’s decisions but instead pressures the care providers to gain consent. If you are a care provider feeling this pressure, consider Birth Cartographer Training to learn how to support maternal decision making, even when it is a choice that means death or injury (which is her right).

It is for this reason that consent can not be trusted. We are processed in a system where we are an afterthought, and we are asked for consent in the moment. The system has no allowance for NO, it does not provide care providers with the support needed to facilitate this pathway. Compliance is the oil that keeps the system running.

As Bashi Kumar-Hazard says on Midwives Cauldron Season2 ep13 at 33:49 minutes:

“it comes down to the fact that we are all of us doing our best to navigate a system that was never set up with us in the first place”