ETHICAL CONSIDERATIONS IN PRE AND PERINATAL EDUCATION

-Shivakumar Belavadi, PPNE, Bangalore, India

TOPIC – Identify and discuss at least two ethical issues facing the pre and perinatal psychology educator.  Give examples of how these issues can rise up in the process of education, and how they can be addressed.

I am outlining two issues which have come up in the context of my engagements with parents at the Prenatal Stage (in the course of Pregnancy) in India. I am considering myself ‘as a PPNE’, since I have been taking up similar engagements over the years.

  1. Where the Parent(s) seek the advice of a PPNE on a medical opinion given by the consulting Obstetrician.

It is common in India for expecting parents to seeking information and opinions from multiple sources. A typical scenario is in the case of pregnant women/parents who first consult with their regular doctor (Obstetrician) and subsequently seek the Guidance of PPNE on what action they should take.

As a PPNE, I first recognise that the area in which a PPNE operates is primarily of sharing information leading to education of the listener. A PPNE is not a therapist and does not possess medical knowledge and skills of a licensed medical practitioner or a professional Obstetrician. As a first step I recognize my limits.

At a secondary level, there is an element of trust between the consulting Obstetrician and the pregnant lady. Any words spoken by a PPNE which disturbs or shakes the trust between a doctor and patient, should be avoided.

That said the PPNE, also stands in a position of trust as the parent/pregnant lady is seeking guidance. This becomes even more relevant where the words of the obstetrician seem to be coming a notch below the expected level of knowledge of a practicing professional. A case in instance would be where the pregnant lady is routinely advised to take medication for Gestational Diabetes or Hypertension. In such situations, I as a PPNE do know that medication should not be the first recourse.

To bestow the sense of autonomy and choice to the parents, I inform them that now there is a respected and recognized body of knowledge that speaks of minimal medication, especially for Gestational Diabetes or Hypertension. I give them reference of the writings / works of senior medical professionals including obstetricians and gynaecologists. These infuse a sense of dignity for the parent & child and the parents develop a sense of respect for natural processes.

I suggest to them that they should revisit their consulting Obstetrician with this information and seek guidance from them. More often than not, I have seen that when the empowered parents revisit the obstetrician, it improves the relationship between them and irrespective of the final advice given by the doctor. In some cases , it has also avoided unnecessary medication being given to the pregnant lady. Where medically necessary, the parent is always informed that the guidance of the obstetrician should prevail.

  1. Where a pregnant lady begins to consult at a Hospital/Provider where there is a well-known predisposition for performing C section deliveries.

There are certain hospitals/providers in India where over 80% of pregnancy cases result in Caesarean deliveries. When I as  the PPNE becomes aware that the pregnant woman is going to such a provider- an ethical dilemma comes up on further course of action.

In India, in cities the concept of midwifery/doulas/birthing centres are almost non-existent. It is routine for pregnant women to begin the process of consulting at a Hospital or Nursing homes as they are called in India and finally admit themselves at the same place in the final stage of pregnancy when they are about to deliver the baby.

Again the PPNE is not the competent person to guide a pregnant woman on the choice of a doctor/provider. That is respecting the pregnant woman’s choice and autonomy. However, Integrity and responsibility would expect that the situation be considered in a wider perspective.

The system of taking ‘informed consent’ is observed more in breach than in observance by the providers/hospitals in India. This is patently unfair and unlawful, but a common practice in India. In many ways it demeans the autonomy of the parent who visits the provider.

In such a scenario, where hospitals / providers are known to perform a disproportionate number of C sections, it may be necessary for the PPNE to educate the pregnant woman/parents on the benefits of normal delivery and also mention the alternative providers they may approach.  This will obviously be easier to handle earlier in the course of pregnancy.

It may be a good point to mention of 3 or 4 alternate providers whose statistical record of C section and normal deliveries are well known. This is done to provide the parents with choice and also avoid any imputation of bias or undue favouring.

Both situations mentioned above are fairly common in India. There may be more than one course of action and multiple factors to consider. The attempt made above is to deal with the same situations in a fair, just and ethical manner.

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