Decision-making in critical situations during pregnancy and birth

Sammanfattning: The overall aim of this thesis was to describe the experiences of obstetricians and parents and the attitudes of midwives in relation to critical situations during pregnancy and birth. The data collection (Paper I and II) started in year 2000 with interviews with obstetricians (n=14) concerning the meaning of being in ethically difficult situations. During 2002 to 2004 interviews with parents (n=23) about handling preterm labour and birth were performed. The quantitative studies had a cross-sectional method and a descriptive (Paper III and IV) and comparative (Paper III) design. The data collection was performed during 2007 to 2008, using a structured, anonymous and self-reported questionnaire for midwives (n=259). The midwives’ attitudes about very/extremely preterm labour and birth (Paper III) and towards a woman’s refusal of emergency cesarean section (CS) or request of CS without any medical indication (Paper IV) were investigated. The tape-recorded interviews with obstetricians were analysed using the hermeneutic-phenomenological method and with the parents the Grounded theory method was used. Descriptive and analytic statistics was used to analyse the data of the quantitative studies.

The overriding theme in Paper I was “Sympathetic responsibility in decisions of critical importance for the mother and her baby” (Paper I). Together with the five subthemes this illuminated the decision-making process, which the obstetricians went through during the situations. The parents’ main concern is shown through the core category “Inter-adapting” followed by three categories; Interacting, Reorganizing and Caring. “Inter-adapting” is a new concept and was interpreted as a mutual adaptation between the actors involved in the situation (Paper II). The midwives’ attitudes in relation to very/extremely preterm labour and birth, was that midwives at university hospitals were more likely to agree on to start interventions at an earlier gestational age than midwives at general hospitals. Obstetricians seemed to be more active in management than midwives, though midwives seemed to be more willing to disclose information to the parents (Paper III). In a conflict of interest concerning a woman’s refusal of an emergency CS for fetal distress, the midwives thought that the obstetrician should try to persuade the woman to accept the recommended CS. If a woman requests a CS without medical indication, the midwives thought that the obstetrician should comply with the woman’s’ request if she had had previous maternal or fetal complications. The reason for supporting the woman’s choice was mostly out of respect for the woman’s autonomy, although midwives at university hospitals were significant less willing to do so (Paper IV). In conclusion this thesis revealed that the obstetricians respected the autonomy of the woman during the decision-making process (Paper I). Inter-adapting strategies were used to achieve the best possible outcome for the fetus/infant (Paper II). Midwives and obstetricians with experience of handling preterm births at 21 – 28 GW develop a positive attitude to interventions at an earlier gestational age as compared to midwives without such experience (Paper III). The main focus of midwives seems to be the baby’s health and a positive birth experience for the woman and therefore they do not always agree to the woman’s refusal or request of cesarean section (Paper IV).