2
Maternal Decision-making During Pregnancy: Parental Obligations and Cultural Differences

https://doi.org/10.1016/j.bpobgyn.2017.02.002Get rights and content

Highlights

  • Decision-making and clinical counseling during pregnancy are ethically complex.

  • Pregnant women have the authority to make decisions during pregnancy.

  • Parental obligations should guide maternal decision-making.

  • Clinicians should use parental obligations to guide maternal counseling.

  • Cultural differences make maternal decision-making more challenging.

Decision-making during pregnancy can be ethically complex. This paper offers a framework for maternal decision-making and clinical counseling that can be used to approach such decisions in a systematic way. Three fundamental questions are addressed: (1) Who should make decisions? (2) How should decisions be made? and (3) What is the role of the clinician? The proposed framework emphasizes the decisional authority of the pregnant woman. It draws ethical support from the concept of a good parent and the requirements of parental obligations. It also describes appropriate counseling methods for clinicians in light of those parental obligations. Finally, the paper addresses how cultural differences may shape the framework's guidance of maternal decision-making during pregnancy.

Introduction

Pregnant women today face an array of decisions during pregnancy. Better understanding of embryonic and fetal development has offered insight into the effects of choices about nutrition, medications, and other substance use. Genomic and genetic innovation and improved imaging allow prenatal diagnosis that can be used to inform decisions about pregnancy termination or appropriate intervention. Fetal therapy is now an option for a variety of conditions that previously entailed certain morbidity and mortality. Finally, fetal monitoring and new surgical delivery options are changing the way pregnant women prepare for birth. This list excludes related questions about how and when to conceive and any medical intervention that might be appropriate after a baby is born.

New knowledge and technology hold great potential to improve the well-being of both women and fetuses and create new options that can raise challenging questions about whether, when, and how to employ such knowledge and technology. Therefore, pregnant women and their health care providers face an expanding set of decisions as a routine part of prenatal care when pregnancy progresses normally and an even more complex array of options when concerns arise. In this review, questions of who should make decisions during pregnancy and how those decisions should be made are explored. The role that a clinician should play in these decisions and ethical justifications for various counseling approaches are described. Finally, strategies for negotiating cultural differences are presented.

It is worth clarifying from the outset that the vast majority of these decisions are not governed by legislation in most countries (with some notable exceptions such as elective pregnancy termination). In contrast, many of the world’s religions do offer direct or indirect guidance about what a woman should or should not do during pregnancy. Religious beliefs and perspectives are therefore likely to have a considerable impact on the decision-making processes of some pregnant women. Although law and religion may inform or influence these decisions, the focus of this review is not on legal or religious considerations but on the ethical aspects of decision-making during pregnancy.

Section snippets

A Case to Consider

Mrs. S is 31 years old and 20 weeks into her first pregnancy. During the routine anatomy scan performed at 19 weeks, a thoracic myelomeningocele was found. Mrs. S was referred to a nearby fetal therapy center for further evaluation where MRI confirmed the ultrasound finding and revealed a Chiari II malformation of the brain. No other congenital anomalies were identified, and the baby’s karyotype was normal. Dr. Y explained the condition to Mr. and Mrs. S and described two different treatment

Who should make decisions?

In Western society, we have a well-established ethical consensus that treatment decisions during pregnancy are left solely to the pregnant woman. A woman’s right to determine what happens to her own body has such great moral weight that it overwhelms all other ethical considerations that might come into play. This position is built upon the bedrock of medical ethics: the requirement to obtain the informed consent of a patient undergoing medical intervention [1]. It is buttressed by

How should decisions be made?

Having clarity about who is the appropriate decision-maker does not offer much insight into how decisions should be made during pregnancy. What ethical considerations should Mrs. S take into account when she is choosing a treatment approach? What ethical constructs should she use to shape and guide her deliberations?

What is the role of the clinician?

In the case of Mr. and Mrs. S, it is clear that Mrs. S is the individual who should be making decisions. A framework based on parental obligations that considers a number of variables can help guide her decision-making. The narrow focus on the pregnant woman may raise questions about the role of the clinician in the decision-making process, but clinicians’ input and guidance are vital to maternal decision-making during pregnancy.

Cultural Differences

Thus far, we have looked at maternal decision-making through the lens of Western perspectives and values. We have relied on concepts of autonomy, parenthood, and well-being that are central to our culture but are not universally defined and shared. Reviewing the wide array of existing cultural beliefs that might impact decision-making in the context of pregnancy is beyond the scope of this paper. Even so, it is possible to consider how a clinician should respond to decisions that reflect the

Conflicts of Interest

None.

Practice Points

  • Pregnant women have the authority to make decisions about interventions during pregnancy

  • Decisions can be guided by reflection on parental obligations

  • Directive counseling is an appropriate part of the process of shared decision-making in some cases

  • The ethical justification for directive counseling may conflict with other ethical considerations when significant cultural differences are involved

Research Agenda

  • The perspectives of women making difficult decisions in pregnancy

  • The

References (21)

There are more references available in the full text version of this article.

Cited by (10)

  • Home births in Spain

    2021, Anales de Pediatria
  • Society for Maternal-Fetal Medicine Consult Series #55: Counseling women at increased risk of maternal morbidity and mortality

    2021, American Journal of Obstetrics and Gynecology
    Citation Excerpt :

    Healthcare practitioners should practice active listening and self-reflection to identify any differences, ensure their biases do not cloud their ability to provide neutral counseling, and speak with a judgment-free and respectful tone and language.37 Healthcare practitioners should also be aware of their patient’s cultural background and how that may impact their preferences regarding shared decision-making, including involving support individuals in this process.38 Finally, many factors contribute to the decisions women make about their pregnancies,36 including many outside their control.

  • The professional role of skilled birth attendants’ in Nepal – A phenomenographic study

    2019, Sexual and Reproductive Healthcare
    Citation Excerpt :

    Family roots are important, and how they relate to the cultural values of Nepal is difficult for an outsider to fully understand. These culture barriers have an impact on the SBAs’ moral responsibility, and can be painful and troublesome for them [31]. It could be valuable to recommend the use of a social-ecological approach when dealing with ethical problems for SBAs in Nepal it is complex to give advice during pregnancy due to cultural differences [32].

  • A case report of an unusual and rare social cause of extreme prematurity in a newborn

    2023, Journal of Datta Meghe Institute of Medical Sciences University
View all citing articles on Scopus
View full text