Autonomy in labour and delivery in a Latin American urban centre: a qualitative phenomenological analysis

Abstract

The medicalisation of childbirth has diminished the role of labouring people. We conducted an exploratory phenomenological qualitative study, using purposive sampling, and then conducted 17 semi-structured interviews between December 2016 and October 2017 with people who had recently given birth in a public hospital in the Northern Metropolitan area of Santiago, Chile. The sufficiency of the study group was determined according to saturation criteria. Triangulated content analysis was applied to explore the clinical relationship and processes of autonomy and decision-making. The predominant clinical relationship observed was paternalism. The participation of labouring people in decision-making is scarce, with no evidence of ethically valid processes of informed consent.

Résumé

La médicalisation de l’accouchement a diminué le rôle des parturientes. Nous avons réalisé une étude qualitative phénoménologique exploratoire, en utilisant un échantillonnage raisonné, puis en menant 17 entretiens semi-structurés entre décembre 2016 et octobre 2017 avec des personnes ayant récemment accouché dans un hôpital public de la zone métropolitaine septentrionale de Santiago, Chili. La suffisance du groupe d’étude a été déterminée selon des critères de saturation. Une analyse du contenu triangulée a été appliquée pour explorer la relation clinique et les processus d’autonomie et de prise de décision. La relation clinique prédominante observée était le paternalisme. La participation des parturientes à la prise de décision est faible, sans aucune preuve de processus éthiquement valables de consentement éclairé.

Resumen

La medicalización del parto ha disminuido el papel de las personas en trabajo de parto. Realizamos un estudio cualitativo fenomenológico exploratorio, utilizando el muestreo intencional y luego realizamos 17 entrevistas semiestructuradas entre diciembre de 2016 y octubre de 2017 con personas que recientemente habían dado a luz en un hospital público del área metropolitana septentrional de Santiago, Chile. Se determinó la suficiencia del grupo de estudio según los criterios de saturación. Se aplicó el análisis de contenido triangulado para explorar la relación clínica y los procesos de autonomía y toma de decisiones. La relación clínica predominante observada fue el paternalismo. La participación de las personas en trabajo de parto en la toma de decisiones es escasa y no hay evidencia de procesos de consentimiento informado éticamente válidos.

Keywords:

• clinical relationship
• autonomy
• reproductive rights
• women’s health
• birth

Introduction

Historically, childbirth was a private event with expert accompaniment by a midwife,¹ but this norm changed and was replaced with an institutionalised model that moved childbirth to the public healthcare system and designated medical professionals as the authority of this event.^2–5 As early as the eighteenth century, the objectification of the human body and the professionalisation of medical knowledge fostered a pathological view of childbirth and the female body, whose capacity to give birth without intervention was called into question.^4–6 This perspective, which can be seen even in low-risk pregnancies, is embodied in the inequitable power dynamics and gendered violence enacted by the hegemonic medical system.^7,8 Supporting this view, Bellón argues that we are embedded in patriarchal societies that justify interventionism and the control of sexual and reproductive processes.⁹

This medicalised context can perpetuate coercive and negative practices surrounding pregnancy, delivery, and postpartum health for the woman and her family. In practice, the medicalisation of childbirth is operationalised as interventionism, a series of unnecessary and unjustified actions, procedures, and interventions that many times interfere with the progress of labour and relegate the role of the woman to that of a passive participant.^5,10,11 Examples of these hegemonic and interventionist practices include the position most frequently used for labour (lithotomy), the routine use of pharmaceutical intervention, continuous intrapartum monitoring, routine episiotomies, and unjustified caesarean delivery.¹² The widespread use of these practices has contributed to a negative perception among some birthing people of their childbirth experience, in many cases including what has been identified as mistreatment on a systemic level, which includes and goes beyond interpersonal treatment by healthcare professionals.¹³

These experiences of childbirth are familiar to people living in Latin America. Of countries belonging to the Organization for Economic Cooperation and Development (OECD), Chile has the third highest rate of caesarean delivery. In the public health system, 37.7% of live births are by caesarean,¹⁴ while in the private health sector 76% of births are delivered through this mode.¹⁵ This reality is difficult to justify by either medical benefit or patient preference. The World Health Organization (WHO) conducted a systematic review and a worldwide country-level analysis and has stated, based on this available data and evidence, that at the population level, any proportion of caesarean deliveries over 10% is not associated with lower maternal or neonatal mortality and morbidity.¹⁶ A 2015 survey of nulliparous Chilean women found that about 11.2% would prefer a caesarean, assuming a healthy pregnancy,¹⁷ and a survey of women who had had a caesarean delivery, implemented in 2014 by the Center for Journalistic Research of Chile (CIPER), indicated that 80% of them would have preferred a vaginal delivery.¹⁸

Chile has a highly paternalistic and medicalised midwifery model.¹⁹ According to the classification of the obstetric transition described by Souza et al, Chile is classified in stage 4, characterised by low maternal mortality and fertility rates. However, authors highlight the increasing role of over-medicalisation, which is becoming a threat to quality and improved health outcomes.²⁰

A study of labour and delivery care practices across Chile also documented highly prevalent use of medical interventions in the labour of low-risk pregnant people.²¹ Over half (54.6%) of labouring people in this study were subject to continuous intrapartum monitoring, half (56.4%) had an episiotomy, and 90% received some form of labour management, including administration of Pitocin, artificial rupture of membranes, or epidural analgesia. A quarter (25%) of the birthing people in the study reported dissatisfaction with the care received, including not feeling heard, not being well-informed and not feeling considered in decision-making. This last result is especially important because previous research has established the relationship between a birthing person’s perceptions of their own wellbeing and the experience of being active participants in their own care.²²

Although in Chile midwives are the principal providers of maternal and neonatal care according to the National Women’s Health Program,²³ a qualitative study of the midwifery workforce revealed that Chilean midwives report low levels of autonomy and self-efficacy, due to the highly hierarchical and medicalised care structure.²⁴ This context lends authority to obstetricians who do not practice a midwifery model of care and makes effective teamwork difficult.

This context highlights the need to protect the patient’s right to autonomy as part of the mandate of sexual and reproductive rights (SRR), a specific application of human rights. The affirmation and recognition of SRR has accelerated since 1994, when these rights were defined at the International Conference of Population and Development in Cairo.²⁵ The premise established at this conference has since been ratified at various conferences, such as the Fourth World Conference on Women, that took place in Beijing in 1995.²⁶

Ezekiel and Linda Emanuel²⁷ have studied the models of physician-patient relationships, specifically analysing the goals of this relationship, the responsibilities of the physician, the values at play and the way in which patients perceive autonomy. From this analysis, they identified four relational models. In the paternalistic model, the physician is a benefactor whose obligation to serve the patient often outweighs the autonomy of the patient beneficiary. In the informative model, the physician gives the patient information so that the patient may decide according to their values, and informed consent is used as a bureaucratic and legal mechanism. In the interpretive model, the physician is a consultant who helps the patient understand options and take a decision, and patient autonomy is based in self-knowledge. Finally, in the deliberative model, the physician accompanies the patient in determining which of her values are most relevant to the clinical moment, and both parties are active and respected participants in decision-making.

The current study uses this frame to understand the current reality of SRR in the context of Latin American birth facilities, specifically in Chile. It is necessary to understand the process from the perspective of the woman, her experience of her clinical relationship with her providers, and her conceptualisation of informed consent, as the absence of informed consent would constitute a violation of her SRR. Thus, the study centres women’s perspectives, focusing on their subjective experiences and analysing the cultural and interpersonal aspects of their experiences of health care.

Methods

Study design

This study employed a phenomenological approach^28,29 to analyse qualitative data on the experience of childbirth from the point of view of the person giving birth. We focused on the clinical relationship between health professionals and labouring people, specifically the exercise of patient autonomy and informed consent processes during labour and delivery. While autonomy and informed consent are distinct phenomena, as informed consent does not necessarily ensure the exercise of labouring people’s autonomy and the exercise of autonomy does not imply informed consent, for this study we examine the manifestation of autonomy through the informed consent process, understanding the process to be not simply the signing of a document, but as a dynamic process between the care team and the birthing person. As such, this study sought to describe the “essence and structure” of the clinical relationship using the subjective experience of the parturient.^28,29 The study was specific to people who gave birth in public birth facilities in the northern part of Chile’s capital city.

Participants and setting

This study utilised a sequential purposive convenience sample, appropriate for an exploratory phenomenological study.^29,30 People were eligible to participate in the study if they gave birth at a public hospital in the north of Santiago and spent at least four hours in labour after admission, in order to ensure that participants had established some kind of clinical relationship with the health care team and could address the objectives of the study. Birthing people were recruited within three months of giving birth to increase the probability that they could remember their experience accurately. Professional midwives who worked at the facility, but were not part of the study team, provided information to eligible birthing people about the study. Individuals who expressed interest in participating were contacted by the first author to invite them to participate. Before agreeing to participate, respondents were informed about the goals of the study, the details of their participation, the voluntary nature of their participation, and the informed consent process.

Data collection

Data were collected through semi-structured interviews, all conducted in a private and secure space (usually the participant's home). To avoid bias in the conduct of interviews by the principal investigator, given their level of involvement in the topic (as a practising midwife), all interviews were conducted by a psychologist external to the research project, with experience in conducting interviews. The interviews were audio-recorded by the first author, who was also present at the interviews as an observer and took simultaneous field notes. The interviewer provided notes and impressions of the topics that emerged from each interview, which were used by the first author and by two additional analysts who independently analysed the transcripts. Through consensus coding, the three analysts discussed contrasting interpretations and arrived at a synthesis of the results.

Interviews began with several socio-demographic questions including age, nationality, highest level of education, marital status, parity, number of children, and mode of birth (vaginal or caesarean). All participants agreed to audio recording of the interviews, and the recordings were later transcribed verbatim and enriched by the field notes taken by the first author. To further assure the reliability of the data collection, all participants were invited to review the verbatim transcription of their interviews and make modifications if they felt that their feelings were not expressed accurately. Of the 17 participants, eight opted to review their transcripts and five made minor changes. All participants completed an informed consent process, emphasising the voluntariness and goals of the study.

The size of the sample was determined using criteria for saturation, which was defined as the point at which there was sufficiency of both breadth and depth and no new themes were emerging from each additional interview.³⁰

Analysis

Content analysis was used to organise the data, with an emphasis on meaning.²⁸ Two analysts iteratively formulated a classification matrix of emergent categories and subcategories, using Atlas.ti version 7 software. Themes were identified both inductively and deductively (using models of clinical relationships). The second author served as an expert consultant on the development of themes in addition to the two analysts, triangulating the findings to reach the final results.

Ethical aspects

This study was conducted with the approval of the Social Sciences and Humanities Research Ethics Committee of the University of Chile, approval number 01-2017, received on October 13, 2016.

Results

Saturation was considered to have been reached after 15 interviews, but two additional interviews were completed to confirm this conclusion, for a total of 17 interviews. The ages of the participants ranged from 19 to 36, with a mean of 27.1. Parity ranged from one (primiparous) to four. Seven participants were married, seven were cohabiting, and three were single at the time of the interview (See Table 1).

Table 1. Bio-sociodemographic characteristics of participants

Participant ID	Age (years)	Nationality	Education	Marital status	Parity	Birth Mode
E1	21	Chilean	12th grade	Single	1	Vaginal
E2	23	Colombian	9th grade	Cohabiting	1	Vaginal
E3	19	Colombian	High school graduate	Cohabiting	1	Caesarean
E4	30	Chilean	College graduate	Single	1	Vaginal
E5	31	Chilean	11th grade	Cohabiting	4	Vaginal
E6	25	Chilean	Technical college graduate	Cohabiting	1	Caesarean
E7	21	Chilean	Technical college student	Single	1	Vaginal
E8	36	Peruvian	Some college	Married	1	Vaginal
E9	29	Chilean	Some college	Married	2	Caesarean
E10	31	Venezuelan	Some college	Married	1	Vaginal
E11	23	Colombian	High school graduate	Married	2	Caesarean
E12	27	Dominican	High school graduate	Cohabiting	1	Vaginal
E13	25	Chilean	Technical college graduate	Cohabiting	2	Vaginal
E14	33	Peruvian	High school graduate	Married	3	Vaginal
E15	30	Chilean	High school graduate	Married	4	Vaginal
E16	23	Chilean	High school graduate	Cohabiting	1	Vaginal
E17	34	Peruvian	High school graduate	Married	2	Caesarean

There is a growing immigrant population in Chile, with the total foreign-born population reaching almost 1.5 million in 2019, the majority of whom were of reproductive age.³¹ This reality was reflected in the study population in the north of Santiago, where eight of the 17 study participants were not born in Chile.

A summary of the major emergent themes and sub-themes is displayed in Table 2.

Table 2. Emergent themes and sub-themes of labor and delivery experiences

Category	Theme	Sub-theme
Predominant model of clinical care: Paternalistic	Manifestation of paternalistic clinical model in care processes	1. Lack of privacy
		2. Lack of continuity of care and carer
		3. Exclusion of companion of choice
	Internalization of paternalistic clinical model	1. Low expectations of treatment and agency
		2. Pain
Decision-making	Informed Consent and Exercise of Autonomy	1. Lack of information provided
		2. Exercise of autonomy

Predominant model of clinical care: paternalistic

Based on the narratives of the study participants, we observed that the characteristics of the clinical relationship are predominantly paternalistic. This is evidenced by the fact that the actions of the care team were primarily oriented toward the ease of the providers, and providers did not recognise the agency of the labouring people, ignoring their opinions and interacting with them rarely, giving them little information, and in some cases infantilising them to the point of ignoring them in clinical interaction – for example, not introducing themselves and communicating only among members of the care team:

“ … because the doctors don’t talk to you [referring to herself during labour]. They talk to the midwife, they give her the instruction and you just have to pay attention.” (E8)

“The relationship with the doctors and midwives is distant, they don’t explain things well and they don’t consider you. Consider that I had had two previous normal births. I knew that something wasn’t going well with this one. I had a bad time of it, and no one listened to me.” (E14)

These patterns of interaction between care professionals and patients have a dehumanising effect on patients:

“They didn’t treat me either badly or well, they simply didn’t treat me. I felt like just another one in the room.” (E14)

Manifestation of paternalistic clinical model in care processes

Lack of privacy

The paternalistic dynamic that takes little account of the thoughts and feelings of labouring people could be influencing the lack of concern for their modesty, failing to maintain the privacy that they and the intimate process they are experiencing requires. This phenomenon can even influence the very evolution of labour:

“ … [in the] room, there was like a lot of people. I don’t know, there were like three nurses and the doctor, that doctor that came after, plus the midwife, so like … . And you know when you push … you could poop yourself, anything can happen. So, the fact that everyone is watching you, it was like … . I was embarrassed, so I think that I probably was holding back a little, so that that didn’t happen.” (E7)

“There was no privacy. They didn’t close the curtains, they passed you the female urinal with everything open. When they did my pelvic exams there were like four people watching and they didn’t close the curtains.” (E15)

“The bad part was that when they examined you, in the hospital there is only a curtain separating us, and sometimes they didn’t close it well or there were a lot of people watching.” (E16)

Lack of continuity of care and care

To establish a clinical relationship in the context of childbirth, continuity of care, also known as personalised care, seems to be fundamental, where a professional or a stable and known care team accompanies the whole process. The narratives demonstrate that when the care providers don’t introduce themselves or explain the procedures they plan to implement, there is confusion about the profession and the role of the health care personnel treating them. This confusion is especially salient in the experiences of foreign-born labouring people who do not know the traditional colours that identify each type of provider in Chilean health care systems. Additionally, various narratives illustrate that the provider (midwife) who accompanies the labour is not necessarily the same person who attends the delivery. This discontinuity added to the confusion and uncertainty of labouring people who were treated by multiple doctors during their delivery, who were not always coordinated in the advice and instructions they give, leaving labouring people wondering who to turn to with their questions.

“Since they started assisting me? Well … . First, I arrived and in the waiting room one midwife attended to me, then the doctors. Well, they might have been midwives, and then obviously after that I went to pre-delivery, they bring me there and obviously … there a midwife attends to me, in the whole process … . And the nurses … .” (E1)

Interviewer:

So then, the midwife that was with you in pre-delivery was different from the one who attended the delivery?

Participant:

Yes, she was a different one.

Interviewer:

And when did you meet the midwife who attended the delivery?

Participant:

Um … . In that moment, in the moment that they brought me into the delivery room, in that moment I saw her. (E2)

“There were 3 doctors, and they all told me different things. One told me that I had to wait, the other that it was better to do a caesarean. Then another one came and said the opposite. The only thing I wanted was for it all to be over quickly. I didn’t know who to turn to.” (E14)

Exclusion of companion of choice

Many families desire the active participation of a significant companion throughout pregnancy, childbirth, and postpartum, and this is in line with what is encouraged by various national and international programmes and institutions. This participation implies that the person chosen by the woman to be the closest companion is also included in decision-making and is part of the clinical relationship. Nonetheless, almost all the narratives demonstrate that the presence of this companion during labour is rare, since the structural factors that would facilitate their presence during this process are absent, and information is not shared with them, relegating their participation exclusively to the moment of delivery when they are called to enter. As expressed in several narratives, this reality makes the presence of a health professional during the whole process even more significant, since they are the source of support for labouring people in the absence of their families.

“Hmmm, they can’t. Your partner can’t come in during labour, just during delivery. In any case since I worked there, my co-workers came in to see me every so often.” (E6)

“I did feel alone … like you wish someone from your family was there, your boyfriend keeping you company, because I was in pre-delivery almost seven hours, so very lonely, and as there weren’t other mothers, so … . I think that that part of accompaniment during labour is missing, because you do feel really lonely.” (E7)

Internalisation of paternalistic clinical model by birthing people: low expectations of treatment and agency

In the collective imagination of birthing people there are very low expectations regarding how they are treated. There is a generalised idea that they are treated badly especially if they complain, influencing the global perception of the experience:

“I mean, it was um … . Well, I have heard of other cases, like of girls that have gone there and well they haven’t had a good experience. They were not listened to, their process of labour went faster, they had immense pains and well they have told me that no one considered them. They made them wait and wait. Well, fortunately that wasn’t my experience. It was really good.” (E1)

“They say moms get beaten [by the health care workers], and then they ask them laughing: you didn’t like getting pregnant? Things like that. They are things that everyone says about the hospitals and I had heard about that. But the truth is no.” (E4)

In these examples, labouring people were expecting negative experiences based on stories they heard from other birthing people but found that their own experiences were more positive. An interesting aspect is how respondents perceive that “behaving well” conditions the treatment they receive, with some even reporting that they have been told to “behave well” as advice from other birthing people. We observe that this idea relates directly to the profile of obedience implied by the paternalistic clinical relationship; but most importantly, it reveals the fear that labouring people have of the care team, which is to say, of being mistreated:

“ … what I was saying before that I didn’t complain a lot, because I did have that mentality that I didn’t, I didn’t want to make a fuss and yell, do you know what I mean? I didn’t want to stress out the nurses, because they say that the more you complain, the worse they treat you, so because of that I wanted to avoid that.” (E2)

“ … She [the midwife] if she saw that [the other mother] was upset, she told her not to yell, that she was already helping her as much as she could … , and I was like calm, I think it was because of that, that I was treated in a different way.” (E2)

Fear of pain

The theme of fear of feeling pain emerged spontaneously from the narratives of the birthing people, present during pregnancy and increasing with the proximity of delivery. It is a central and determinant aspect of the process, reflecting the presence of preconceived ideas and stories of other birthing people’s experiences where this aspect wasn’t satisfactorily addressed.

“They told me ‘We are going to give you anesthetic, so you don’t feel pain’ so I said ‘oh, wow, they are going to give me anesthetic, ok give it to me’. I didn’t have pain yet … that was the good part, because other girls had said to me that they took a long a time to give the anesthetic, it took hours … . And that was what I was thinking, I was very scared because of that, that they would take so long with the anesthetic … but yea they gave it to me right away.” (E1)

Furthermore, in the absence of or interruption of pain, we see happiness and wellbeing expressed in the narratives:

“In the moment of the anesthetic the doctor said to me ‘you have to be very calm, because when the anesthetic is placed, you aren’t going to feel any pain,’ and yea it was like he said. In the moment they gave me the anesthetic I didn’t feel anything more. Actually, when I was pushing it was the same, I didn’t feel anything and that was the best … . I mean, the best.” (E1)

“When the doctor said that I had to have a caesarean, ooh what a relief. I know that it’s bad, but I didn’t want to feel pain.” (E17)

Informed consent and exercise of autonomy

The participants of this study were patients in a system that offers two instances of written informed consent: at the beginning of the hospitalisation, when it was explained what labour and delivery consisted of and what procedures could possibly be performed, and at the point of administration of the anaesthetic. In the narratives we see that the birthing people associate informed consent primarily with this second instance; nonetheless, it is confusing and imprecise. Even if the informed consent is not written it allows labouring people to be protagonists and active participants in decision-making alongside their care team; they experience it as an authorisation that makes them responsible for certain consequences, principally those associated with the administration of the anaesthetic. The narratives also reveal that the moment of the application of anaesthetic is not the most opportune time for informed consent because, among other things, some labouring people are in a lot of pain.

“The first time [of 3 doses of anaesthesia] they made me sign a paper where they explained the position, the injection went into the back, that it was going to calm my pain. That paper was the consent and authorisation for the anaesthetic and obviously in there they explained everything.” (E6)

“He just explained a little bit about what it was for, and they told me that I had, I mean that if I wanted them to do it that I should sign where it said that yes, I agreed with those things.” (E2)

Regarding informed consent for anaesthetic: “It’s to make you responsible, in case something happens to you, you move, if something happens. I think it’s for that” (E5).

These examples illustrate that the informed consent procedures utilised in the study setting are purely instrumental and likely would not meet minimum standards of ethically valid informed consent.

Lack of information provided

Sufficient information for a reasonable person to make a decision is considered a necessary prerequisite for informed consent to take place.³² In the narratives, we can see that the quality of information is insufficient, incomplete or confusing, which does not allow the labouring person to actively participate in the process. In many instances, they don’t understand well what is happening and this lack of information, in combination with the factors discussed above, keeps them in a position of passivity in the face of unfolding events, making them incapable of meaningfully participating in decision-making:

“Well based on what I understood [regarding a urine test to evaluate pre-eclampsia] the doctor told me it was because they wanted to see if I had any infection … that with that they would know if they needed to keep me in the hospital, and … . I don’t know, something about blood pressure, because I arrived with very high blood pressure, and with that test they realised that they had to keep me in the hospital.” (E2)

“When I was like 6 or 7 dilated a resident broke my water; she broke my water, I don’t know why, they didn’t explain it to me … . Like the midwife arrived and said to her ‘ok you have to break the waters’ and then they put, it seems like she stuck a scissors inside me and then I felt water coming out. but they didn’t explain to me why they broke it.” (E7)

Multiparous mothers or mothers that have more knowledge of the health system for whatever reason, express in their narratives that this can actually be a disadvantage, since the providers take for granted that they have knowledge about what is going on, which is detrimental to the sharing and quality of information.

“ … They connected me to a machine to see the heartbeat of the baby. I don’t know how dilated I was at that moment, I think not at all. The truth is they didn’t explain much to me because since I work there [as a surgical assistant], they think that I know.” (E6)

“No, I think that they don’t tell you much in the hospital. I think that you get more information outside. Also, when you have already had a baby, they pay even less attention to you.” (E9)

“Everyone said to me ‘You’re already a mom, how do you not know [how to push]? Well, I didn’t say this to them, but I didn’t go through this before, so I didn’t know.” (E13)

Because of insufficient information during the process itself, as well as a lack of previous preparation, the narratives of the mothers demonstrate unnecessary procedures which they frequently don’t realise are happening and are even less prepared to intervene:

“No, they don’t ask you anything. The truth is I don’t why they did it; they said, ‘take off your clothes, open your legs’ and they shaved me.” (E8)

“No, they never told me, you’re just not allowed to eat. The worst part was the thirst; they told me that I had an IV so there was no need for me to drink water, but I felt thirsty, so thirsty. Later they let me put a cotton ball with water on my lips.” (E13)

Due to the lack of information provided in the peri-partum clinical setting, information obtained prenatally takes on an even greater significance, whether this be through formal modes, such as prenatal visits or classes, or through informal modes like social networks or the internet. This preparation could affect why some birthing people feel a greater sense of calm knowing what they can expect during their pregnancy generally and during labour and delivery specifically. Nonetheless, this knowledge is not sufficient to equip them to be empowered in their reproductive process and to be true participants in clinical decision-making.

“And well, once I was pregnant, I started to research a lot, so obviously, there was no problem with my exercising during pregnancy … because obviously people told me that I shouldn’t exert myself too much, that I shouldn’t do such and such a thing, but I … I researched and I could keep doing it … I was doing yoga … so that … like it calmed me down during the delivery.” (E1)

“Yes, obviously before going, I searched on the internet what delivery was like, watching videos, what was an episiotomy like, all that. I searched a lot on the internet all those things.” (E2)

“It’s that I have a lot of people I know that have had babies, so like they all told me their different points of view, like with the delivery … . It’s that some of them said, something like ‘Oh! You’re not going to sleep, you’re going to suffer,’ and others said to me ‘oh no, that I shouldn’t worry,’ but always … . I also looked for videos on the internet; and my mom also has helped me a lot.” (E7)

“Yea, it [workshop on labour and delivery] was helpful for me. It helped me, like … . First to have like an idea of what I was going to see because everyone also started talking about the health center.” (E10)

Some narratives revealed the problem that some pregnant people have accessing antenatal preparation, such as workshops, mostly due to the times at which they are offered. Some pregnant people have to get permission from their jobs or educational institutions, which make it difficult for them to attend:

“I only went to one workshop about … . breastfeeding, to that one … because it was at two o’clock and I was at the institute, so I couldn’t make it on time, because I had classes in the morning, so I never could arrive in time for the other workshops; it was difficult for me that they were at two in the afternoon.” (E7)

“I went to like two workshops; they were good, but at work they gave me trouble if I left a lot, so I preferred to only ask for leave to go to my antenatal care appointments.” (E16)

They prefer to prioritise their antenatal care visits, thus making these visits the primary educational opportunity where pregnant people can ask questions, the primary point of preparation for labour and delivery, an opportunity for the establishment of a closer and more trusting connection between birthing people and their providers, and an opportunity for the meaningful engagement of chosen companions. But as we have previously discussed, these visits appear insufficient to prepare birthing people to take an active role in decision-making for their labour and delivery.

Exercise of autonomy

Inquiring into the conception of autonomy in the context of labour and delivery, participants had difficulty defining it. The question was often met with silence by the participants and those who did respond related these concepts primarily to “decision” and “one’s own voice.”

“Hmm, I don’t know, I had never asked myself that.” (E3)

“Like your own decision … hmmm … that.” (E6)

“Like being able to say ‘look, I want a natural birth, I don’t want it to be a caesarean, I want to have my own voice, like decision-making power.” (E10)

“I think that autonomous is like oneself. It’s like being aware of yourself, like your independence, like I am myself and I am important.” (E13)

“It is the ability to make decision, it is to decide, that’s what I think … .” (E14)

When asked about how these concepts or ideas, as they define them, are present in their experience of childbirth, participants were even more confused, conflating autonomy with self-discipline. We can appreciate the subjugation and fear of the system in their answers; their responses suggest a belief that if something bad happens, it is their own fault. The paternalistic erasure of their humanity increases their sensation of not being participants, to which they express resignation.

“ … I mean I was very present. I tried to be very disciplined, really, in the whole process … so that, obviously everything went well and not … so that there weren’t major complications, like … like I behaved well in that sense.” (E1)

“But what you said didn’t mean anything there, this was not me, it was a problem with the doctors [care team].” (E14).

“Hmmm, no nothing. I didn’t decide anything. I know that the doctors know, and they do what they have to do, but in my case, I felt that they weren’t doing the things well. I didn’t feel well, and I wanted to tell them, but I didn’t know who. It’s that they didn’t even ask me how I was.” (E15)

In relation to autonomy, birthing people express a desire to be more active in the process of childbirth and to have more information, which could contribute to a sense of self-control and tranquillity. This participation does not preclude the presence of the health care personnel, whom they value and recognise as fundamental figures in the process; but rather they are looking for an accompaniment that is manifested in shared decision-making:

“I would have liked to participate more, know more about what they were doing, what comes next in the process, what is this procedure. Knowing more makes you calmer; if you don’t know anything that produces more fear.” (E8)

“I would have liked to know a little bit more, what was going on, but I would have liked even more if my husband could have accompanied me, him to keep my spirits up and the midwife to attend to the delivery.” (E10)

Discussion

In general, Latin American countries have a highly medicalised and paternalistic model of birth, with overuse of routine practices, most of them not evidence-based – shaving, enemas, the lithotomy position, episiotomies, and unnecessary caesareans, all with scarce companionship or support^24,33,34 which is consistent with findings in this study. Furthermore, analysis from previous qualitative data from Chile showed that almost all birthing people have confidence in the health professionals, midwives, and obstetricians who care for them; birthing people trust their care, never question their prescriptions, and follow their recommendations.^24,35

In this study, one element of a paternalistic clinical model of particular concern to labouring people was lack of privacy. This is consistent with findings from another Chilean study reporting that the physical environment, especially lack of privacy, was one of the most important dimensions predicting maternal satisfaction.³⁶ Birthing people also complain about the lack of information given to them, rendering them unable to make informed decisions regarding their maternity care, as well as their dissatisfaction with having many different midwives between antenatal care, admission to the maternity wards, care in the labour ward, and finally delivery.^35,24 This fragmentation of care resulting from the absence of a person-centred model of maternity care is associated with poor quality and safety.³⁷

Another important and damaging manifestation of the paternalistic care model revealed in this study is the exclusion of the companion of choice from the birth process, despite their inclusion being a strong recommendation for intrapartum care³⁸ based on evidence from a Cochrane systematic review.³⁹ A previous Chilean study found that having a companion of choice was associated with higher satisfaction with labour and delivery care.⁴⁰ In Chile, while companions of choice are often present at delivery, they are less frequently present during labour.²⁴ A recent special report highlighted that although many Latin American countries have laws, norms, or decrees supporting the presence of a companion of choice, many hospitals and health professionals do not allow a companion, and many people who are not informed of their rights are denied the opportunity to have this important support during labour.⁴¹

In the public hospital setting in Chile, the paternalistic model of clinical care is co-created by the health care providers, health care institutions, and users of the health care system. Health care providers preserve information asymmetry by failing to share relevant information with patients, and promote the infantilisation of patients by ignoring them and treating them as objects rather than subjects of their own care. The health care system further dehumanises patients by interrupting continuity of care, failing to respect patient privacy, and excluding the labouring person’s companion of choice from the process.

Despite their expressed desires to participate more actively in their labour and delivery, the birthing people interviewed reinforced the norms of the paternalistic clinical model with their behaviour, including efforts to “behave well” to avoid mistreatment and to “submit themselves” to the health care providers. The fear of pain related in the interviews may be influencing the self-subjugation observed in our study in return for the perceived benefit of pain relief or pain avoidance.

These patterns in the clinical relationship represent barriers to patient exercise of autonomy. The informed consent procedures experienced by the birthing people in the sample fall short of fulfilling the three processes of informed consent described by Robert Levine: (1) information (2) understanding (3) exercise of autonomy,⁴² which inhibits the realisation of a “sense of control and empowerment in childbirth.”⁴³ The information provided to labouring people is often incomplete and insufficient to meet a “reasonable person” standard for information relevant to decision-making. Therefore, labouring people are consciously or subconsciously handing over the power of decision-making to their medical providers.⁴⁴ Furthermore, there is no process for assessing the understanding of the information that was provided; patients report being asked to simply sign a paper, and the interpretation they give of the consent procedures is that of legal responsibility for risks assumed, not an autonomous decision based on risks and benefits. Without these first two processes, the third process of the exercise of autonomy cannot be realised. Jefford and colleagues⁴⁵ suggest, based on a systematic review of clinical decision-making, that ideally midwives would use their clinical knowledge to support and capacitate birthing people to actively participate in decisions.

Moreover, the timing of consent procedures may be highly relevant to the patient’s capacity for autonomous decision-making. Consent procedures implemented on hospital admission may be unduly influenced by a patient’s perception of their care being contingent on their signing a consent form. Similarly, consent procedures implemented during active labour may be rushed and patients may not have the opportunity to ask questions or process the information provided. The timing of consent procedures merits further study to explore these issues.

Binfa and colleagues³⁵ have argued that prenatal education represents an important opportunity for preparing pregnant people to exercise autonomy during labour and delivery. Data reported from the Chilean Ministry of Health reported that rate of attendance at antenatal workshops in 2012 was 89% at national level, decreasing to 50.5% in 2017.⁴⁶ In the present study, the birthing people interviewed demonstrated resourcefulness in their prenatal search for information; however, their sources of information (friends, websites) do not replace the quality information that should be offered by their health care providers, and many report barriers to accessing formal education opportunities, such as limited ability to miss work. Therefore, maternity hospitals cannot depend on antenatal education to meet their ethical obligation to provide information relevant to consent. However, antenatal education on reproductive rights may begin to dismantle social expectations of mistreatment and a passive patient role.

However, there are other factors that determine the ability of a person to exercise their autonomy in reproductive health care, including social pressures and cultural meanings that surround childbearing, beneficence toward their unborn child, and their own personal history. In light of this reality, Kukla and colleagues⁴⁷ argue that individuals may need different kinds of support to practice their autonomy in health care. The results of the current study indicate that many birthing people are not sufficiently empowered to recognise their own autonomy, and those that do may not be able to relate the concept of autonomy to their birth experience. This finding is quite alarming, because it suggests that birthing people do not recognise themselves as autonomous beings in their birth experience, nor do they identify their own rights in this context and may therefore be incapable of demanding their rights be respected.

Moreover, we also documented certain routine practices that impede the exercise of labouring people’s autonomy, such as authoritarian treatment, standardised treatment protocols, and the practice of impersonal treatment that borders on abandonment.⁴⁸ The birthing people in our study reported that the experience would have been better if they had been able to participate more in the process, playing a more active role in decision-making, and that a stable and continuous care team would have facilitated this. This report is consistent with the conceptualisation of autonomy and satisfaction in the context of labour and delivery documented by other researchers, in which the bi-directional sharing of information and respectful treatment of the patient endow a sense of shared decision-making and trust in the process.^47,49,50 Today this constitutes a very important dimension of quality of care for maternal and newborn care⁵¹ and it was included in a recent guide for labour care launched by the WHO.⁵²

Nevertheless, patients should not be held solely responsible for their role in the clinical relationship. While structural constraints may take time to change, some institutional practice changes could go a long way to promote the humanisation of labouring people. For example, patients’ privacy should be respected as much as possible. A woman does not forfeit her right to privacy when she accesses the healthcare system; therefore, hospitals should implement procedures to minimise violations of privacy with consistent use of privacy curtains and minimisation of the number of health care professionals present when a woman is exposed. Relatedly, disruptions to continuity of care should be avoided to the extent possible. If it is not possible for a woman to have a consistent care team during her first- and second-stage labour, then “warm handoffs” between providers should be implemented, and each new provider should introduce themselves to the woman. Furthermore, labouring people should be directly asked regarding their preference for the involvement of a companion of choice, and this companion should be allowed to accompany the woman as much as possible (according to her preference), during both labour and delivery.

Informed consent procedures should be designed with patient autonomy at the centre. At a minimum, labouring people should receive information about the purpose and risks of all procedures conducted on their bodies, including shaving and the placement of intravenous fluids. Moreover, they should be informed that they have the right to refuse these interventions. This information would ideally be provided prenatally as well as at the time of intervention. Providing education on benefits, risks, and patient rights across the continuum of care has benefits for both the patient and the system: the patient is better able to process, understand, and form a preference regarding the procedures, and the labour and delivery care team has a reduced burden of education if they are simply reinforcing information that was previously provided. Importantly, when the health care team caring for a woman denies her access to the information and opportunity she needs to make decisions and provide informed consent, it constitutes a failure to not only provide respectful maternity care, but also to preserve the woman’s SRR.

Finally, how birthing people internalise this paternalistic social and clinical model adds complexity to the challenge of creating respectful health systems and promoting patient autonomy. Gender, ethnic, and class divisions are multiple forms of discrimination against birthing people, engendering complex intersectional power dynamics; ultimately, the result is that birthing people are not considered and engaged in their care, not informed nor respected during childbirth, fearful of pain, and not empowered or aware of their rights, making them unable to exercise their autonomy.⁵³

Acknowledgements

The authors would like to thank all the people who shared their birth experiences for this study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Chilean National Commission for Scientific and Technological Investigation (CONICYT) [grant number 22141748]; Chilean National Agency for Research and Development (ANID) Scholarship Program, under Grant 2014 Chile National Masters.