4.2.c Differing Agendas: Attend to Power Imbalances

Power Imbalances

Optimal management of pregnancy and birth means that both clients and care providers feel that they used strategies to minimize risk while maximizing integrity (12). Care providers and clients may approach risk and integrity in birth differently. For pregnant people, maximizing integrity means preserving their ideals and values about birth, whereas for care providers it may mean upholding their beliefs and principles. Minimizing risk also includes attending to feelings of psychological risk. Concepts of risk and integrity are influenced by complex relationships between personal experiences, research evidence, and local health care cultures. A mutual understanding of these variables can improve communication, experience, and outcomes. 

Although person-centred care and shared decision making have become standard goals in health care, care providers are reluctant to put it into practice, as they feel ultimately responsible and accountable for decisions made in labour. There is a perceived fear of negative professional consequences if the decisions made lead to adverse outcomes. Some people put complete trust in their care providers to make decisions, resulting in more anger and litigation when the outcomes turn out differently than expected. This imbalance in decision making needs to be addressed to ensure people are truly involved in their care (13).

An example of the tensions that exist surrounding birth and choice can be seen in the standard use of electronic fetal monitoring (EFM) in hospital births with normal pregnancies. EFM remains a standard practice despite robust evidence that it does not lead to benefit in healthy people. Routine use of EFM highlights the tensions between best practice, provider interests in protecting themselves from litigation, the client’s ability to make informed choices, ethical principles of beneficence and autonomy, and the health and safety of parent and newborn. Some providers practice within a context of  “defensive medicine”, but this motive is not often communicated with people when obtaining informed consent (17).

Effective collaboration is contingent upon various cultural and organizational factors (14). The individuals who are collaborating together need a mutual understanding that each one remains autonomous to make independent decisions (18). Collaboration can be undermined when the responsibility of leadership at any point in the case is not clearly designated (19). Interprofessional miscommunication and  lack of role clarification are challenges that affect collaboration (20). Traditional hierarchies and gender disparities in health care organizational structure also influence the nature of collaboration (21).

 

Journal_Icon.pngPersonal Reflection

Think of a time when you were concerned about a health issue for yourself or a family member and sought more information about you or your family member’s choices for care. 

Use the evaluation tool below to complete this exercise. The leading questions are intended for people who have had a baby but you can replace the question with your reflection about you or your family member's health issue.


After you complete the survey the total score indicates your overall level of respect for that interaction. Reflect on how the scores might differ for newcomers to Canada, homeless, or historically marginalized populations.