What’s Missing From the Conversation on Autonomy

According to United Nations Population Fund Executive Director Dr. Natalia Kanem:

Bodily autonomy means my body is for me; my body is my own. It’s about power, and it’s about agency. It’s about choice, and it’s about dignity. 

You are the ultimate decision-maker when it comes to your body. Obtaining informed consent prior to performing an exam or administering a medication or beginning a procedure is how your care provider honors and respects your right to bodily autonomy. This includes the right to refuse medical treatment and to say no. 

Here’s what ACOG has to say:

Pregnancy is not an exception to the principle that a decisionally capable patient has the right to refuse treatment, even treatment needed to maintain life. Therefore, a decisionally capable pregnant woman’s decision to refuse recommended medical or surgical interventions should be respected.

At least, that’s how it should be. Unfortunately, this basic human right is violated on a regular basis, all around the world, and in many different ways. In maternity care, this can look like:

• Undergoing a cervical exam without first being asked for consent
• Being told electronic fetal monitoring is a requirement
• Hearing about the risks associated with vaginal birth after cesarean (VBAC) but not the risks associated with a repeat cesarean
• Feeling pressured to schedule an elective induction at 39 weeks
• Having a care provider intentionally break your water without your consent during a cervical exam
• Being required to push in a specific position

Our maternity care system is imperfect. We need to keep having these conversations. Pregnant and birthing people need to be aware of their rights and what violations can look like. We need to continue emphasizing that individuals have the right to refuse medical treatment and to say no. As said by Birth Monopoly’s Cristen Pascucci:

The right to say “no” in any consent situation is what makes a “yes” meaningful.

But it sometimes feels like there’s something missing from this conversation on autonomy, especially when it comes to saying no or refusing medical treatment or going against medical advice. We also need to talk about responsibility and reality. It’s not just about making the decision. It’s also about:

• Understanding your “why” behind your decisions
• Informing your decisions with accurate information
• Understanding the difference between autonomy and access

We’ll talk more about all of this in this post. I also want to talk about social media, because this is where many of these conversations on autonomy are happening. And there are a lot of important conversations on this. But, sometimes, social media content is missing important details or isn’t factual, which can cause harm. So, I’ve included some examples of red flags to watch for.

Understanding Your “Why” Behind Your Decisions

When making decisions about your pregnancy, birth, and baby, I want you to understand your “why” behind them. It’s not just about saying yes or no. Why are you saying yes or no? Why are you choosing one option over the other?

Here are some examples:

• Consenting to IV antibiotics during labor, because you tested positive for Group B strep. Your care provider discussed the benefits and risks of your options with you, and this is what they recommend.
• Choosing intermittent auscultation for your low-risk birth over electronic fetal monitoring, because you learned that routine use of electronic fetal monitoring isn’t evidence-based and doesn’t improve outcomes.
• Choosing to limit cervical exams during birth, because your amniotic sac had ruptured and you know that reduces your risk of infection.
• Refusing routine use of erythromycin eye ointment for your baby after birth, because you’ve been tested for sexually transmitted infections and you haven’t been sexually active during pregnancy.

🚩 Social Media Red Flag

Please be aware that Instagram reels and TikTok videos that talk about medical interventions aren’t usually giving you the full picture. For example, I’ve seen reels that talk about induction of labor once you pass your due date and that you can just say no. There are different variations on this, but the emphasis is typically on refusing this intervention. And that’s about it.

In reality, this decision is much more complex. Yes, we should emphasize your right to refuse induction just because you’ve reached your due date or that you’re now at 41 weeks of pregnancy. But that’s not enough. We should be encouraging people to explore this decision on a deeper level. 

Hypothetically, if pregnancy just continued on, is there a point where you would consent to an induction? At what point would this be and why? What are the risks and benefits of continuing the pregnancy or inducing labor? If you’re birthing at a birth center or at home, are there any limitations in place? If so, what are they?

This is important, because, in reality, there will be a point near the end of pregnancy when this topic is going to come up. In my own pregnancies, I was asked when I’d like to schedule an induction, just in case. I could’ve just said no. But, what was more beneficial, was to have the discussion about when. We talked about the risks and benefits of induction, as well as the risks and benefits of continuing the pregnancy beyond 41-42 weeks. In each pregnancy, I settled on a date that I was comfortable with, because I knew my “why” behind my decision. I also hoped each time that I wouldn’t still be pregnant on that scheduled date. And in each case, I wasn’t.

Dig deeper to understand the “why” behind your decisions.

Informing Your Decisions With Accurate Information

Make sure you’re informing your decisions with accurate information. There is a ton of misinformation available online, so this isn’t always easy. 

📊 Resource Database: I have a resource database available on my website filled with reliable sources of information to make this easier. It’s always available in the header section, but you can also access by clicking here.

🚩 Social Media Red Flag

I saw an Instagram post today on screening for gestational diabetes.

But first, let’s look at some information on what this screening looks like, according to this article from JAMA®:

Screening for gestational diabetes is typically done with an oral glucose challenge test or oral glucose tolerance test. This involves drinking a liquid that has a set amount of glucose (sugar) (50 g or 75 g) and then having blood drawn and blood sugar level measured after a set number of hours to make sure that it is not too high. Screening is typically done in the second trimester, between 24 and 28 weeks of gestation.

This Instagram post recommends alternatives to the sugary liquid that pregnant people are given for this screening test. Some of the alternative options mentioned include:

• Organic orange juice
• Pancakes with maple syrup
• Organic jelly beans
• Organic grape juice and a banana

These options are presented as valid alternatives, but the post fails to mention that using one of these alternatives could result in a missed diagnosis.

According to an Evidence Based Birth® article on diagnosing gestational diabetes:

The research on alternatives is very limited at this time, so we do not have high-quality evidence that eating candy or taking glucose in food will correctly identify people with GDM as well as the standard screening and diagnostic tests do.

Don’t trust sources that post misinformation or present information in a misleading way.

Understanding the Difference Between Autonomy and Access

Along with autonomy, we need to also talk about access. While we should always be afforded the right to say no when it comes to our births and our bodies, we don’t always have the ability to access the things we want to say yes to. 

For example:

• You want to birth in a birth center, but there are none in your local area.
• You want a water birth, but it’s against hospital policy to deliver in the tub.
• You want to deliver your breech baby vaginally, but your care provider hasn’t been trained for this.
• You want a vaginal birth after cesarean (VBAC), but your care provider doesn’t attend this type of birth.
• You want to schedule an elective induction at 39 weeks, but your chosen hospital doesn’t have the staffing and won’t schedule you for one without a medical reason.

We don’t always have access to evidence-based options for factors beyond our control. It’s important to talk about this when we talk about autonomy. Expanded access to a wider array of options is needed, but it isn’t an easy fix in the short term.

🚩 Social Media Red Flag

Social media posts aren’t always realistic or helpful. One example I noticed recently was on vaginal breech birth. The gist of this post was to just switch providers if your baby is in a breech position, you want to deliver vaginally, and your provider will only support a cesarean birth.

While switching could be a possibility, this post didn’t mention anything about how few providers are currently trained in and support vaginal breech birth. It’s not easy for everyone to “just switch”, especially at the last minute.

Lack of access can limit our options. 

Final Thoughts

Let’s keep taking about autonomy, especially that right to informed refusal and to say no. But we also need to be aware of what is often missing from this conversation.

• Make sure you understand the “why’ behind your decisions.
• Use accurate information to inform your decisions.
• Understand why you might not have access to all of the options you want to say yes to.