妊娠同意——蒙哥马利案背景下的产前护理观察性研究：一切都是风险吗？
Consent in pregnancy - an observational study of ante-natal care in the context of Montgomery: all about risk?
机构信息
EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, Medical School Building, 74 Huntley Street, London, WC1E 6AU, UK.
Elizabeth Garrett Anderson Wing, University College London Hospital NHS Foundation Trust, 25 Grafton Way, London, WC1E 6DB, UK.
出版信息
BMC Pregnancy Childbirth. 2021 Feb 1;21(1):102. doi: 10.1186/s12884-021-03574-2.
BACKGROUND
How to best support pregnant women in making truly autonomous decisions which accord with current consent law is poorly understood and problematic for them and their healthcare professionals. This observational study examined a range of ante-natal consultations where consent for an intervention took place to determine key themes during the encounter.
METHODS
Qualitative research in a large urban teaching hospital in London. Sixteen consultations between pregnant women and their healthcare professionals (nine obstetricians and three midwives) where ante-natal interventions were discussed and consent was documented were directly observed. Data were collectively analysed to identify key themes characterising the consent process.
RESULTS
Four themes were identified: 1) Clinical framing - by framing the consultation in terms of the clinical decision to be made HCPs miss the opportunity to assess what really matters to a pregnant woman. For many women the opportunity to feel that their previous experiences had been 'heard' was an important but sometimes neglected prelude to the ensuing consultation; 2) Clinical risk dominated narrative - all consultations were dominated by information related to risk; discussion of reasonable alternatives was not always observed and women's understanding of information was seldom verified making compliance with current law questionable; 3) Parallel narrative - woman-centred experience - for pregnant women social factors such as the place of birth and partner influences were as or more important than considerations of clinical risk yet were often missed by HCPs; 4) Cross cutting narrative - genuine dialogue - we observed variably effective interaction between the clinical (2) and patient (3) narratives influenced by trust and empathy and explicit empowering language by HCPs.
CONCLUSION
We found that ante-natal consultations that include consent for interventions are dominated by clinical framing and risk, and explore the woman-centred narrative less well. Current UK law requires consent consultations to include explicit effort to gauge a woman's preferences and values, yet consultations seem to fail to achieve such understanding. At the very least, consultations may be improved by the addition of opening questions along the lines of 'what matters to you most?'
背景
如何最好地支持孕妇做出真正符合当前同意法的自主决策，这对她们和她们的医疗保健专业人员来说理解甚少，且存在问题。本观察性研究考察了一系列发生在产前咨询中的干预措施同意过程，以确定面谈中出现的关键主题。
方法
在伦敦一家大型城市教学医院进行定性研究。直接观察了 16 次孕妇及其医疗保健专业人员（9 名产科医生和 3 名助产士）之间的咨询，这些咨询讨论了产前干预措施并记录了同意书。对数据进行了集体分析，以确定描述同意过程的关键主题。
结果
确定了四个主题：1）临床框架-通过将咨询框架设定为要做出的临床决策，医疗保健提供者错失了评估对孕妇真正重要的事情的机会。对许多女性来说，有机会让她们之前的经历被“听到”是咨询前一个重要但有时被忽视的前提；2）临床风险主导的叙述-所有咨询都以与风险相关的信息为主；并不总是观察到对合理替代方案的讨论，并且很少验证女性对信息的理解，这使得对当前法律的遵守值得怀疑；3）平行叙述-以女性为中心的经验-对于孕妇来说，社会因素（如分娩地点和伴侣的影响）与临床风险一样重要，甚至更重要，但医疗保健提供者往往忽略了这些因素；4）交叉叙述-真正的对话-我们观察到在信任和同理心以及医疗保健提供者明确的赋权语言的影响下，临床（2）和患者（3）叙述之间存在不同程度的有效互动。
结论
我们发现，包含干预措施同意的产前咨询主要由临床框架和风险主导，并且对以女性为中心的叙述的探索较少。当前的英国法律要求同意咨询包括明确努力衡量女性的偏好和价值观，但咨询似乎未能实现这种理解。至少，通过添加类似于“对你最重要的是什么？”的开放式问题，可以改进咨询。
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