By Vandana Tripathi, with contributions from Sara Malakoff, Researchers from The London School of Hygiene & Tropical Medicine, EngenderHealth, Kinshasa School of Public Health, Population Council India, and NPHD, Maia Johnstone, Reshma Naik, and Lara Vaz

In maternity care, one important component of the patient’s experience is making sure those undergoing procedures receive information from providers in a way that they understand and that can improve their satisfaction with their birth experience.¹ The right to information and consent to obstetric procedures is recognized in a global charter as a key principle of respectful maternity care (RMC).²

Why Focus on Experience of Care in Obstetric Surgery?

Deliveries by cesarean section—one of the most common surgical procedures in the world—are increasing in most countries.³ Yet, little is known about the patient’s experience of cesarean delivery and how the principles of RMC are upheld in the context of emergency or planned surgical obstetric care in low- and middle-income countries (LMICs).

A recent evidence review supported by MOMENTUM Safe Surgery in Family Planning and Obstetrics suggests the existence of troubling gaps in the documented evidence of how patients experience (or don’t experience) counseling, informed consent, and debriefing before and after cesarean delivery.⁴ The review, focused on sub-Saharan Africa, found only a small number of papers discussing counseling related to consent for cesarean delivery, and just one paper that included debriefing. Findings indicate that women receive “vague, limited, or no information” on cesarean section during health care visits, including the reasons to perform the procedure, its risks, alternatives, and what to expect after the operation.

Potential barriers hindering informed consent include providers’ fear of blame and litigation, women’s dependency on others, and distrust of providers. Potential facilitators include providers giving verbal explanations to patients and including them as partners in decision-making.⁵ Notably, the review documented some promising interventions that aimed at improving informed consent for cesarean delivery; for example, simulation training, wall posters, and supportive supervision to promote improved practices such as allowing women an opportunity and time to ask questions before the procedure.

Moving the Needle: MOMENTUM Research on Counseling, Consent, and Debriefing in Cesarean Delivery

To build a more comprehensive picture of the obstetric surgery patient’s experience of care and identify ways to improve RMC within this area, MOMENTUM Safe Surgery in Family Planning and Obstetrics conducted a mixed-methods study in the Democratic Republic of the Congo (DRC), India, and Nigeria on informed consent, counseling, and debriefing. The research aimed to understand who at facilities provides counseling, to whom it is provided, and the extent to which women and those accompanying them perceive the information provided was comprehensible, addressed their concerns, and enabled informed consent.

Early results from the research showed that consent—whether verbal or written—rarely met the definition of informed consent. Observed counseling was inadequate, with patients feeling that information about the care or treatment and risks was not clearly communicated.

Despite providers being able to define what good consent practices entail, findings from the study show that knowledge does not consistently translate into good practice. Communication with patients was overwhelmingly one way, with providers often focused on convincing women and their family members to accept decisions they had made. Consent processes tended to focus on obtaining signatures rather than reaching shared understanding of expectations.

Women and their families frequently turned to non-clinical facility staff, other women, or community members to ask questions about obstetric procedures, suggesting a lack of comfort in or fear of proactively communicating with health providers. Women’s concerns about cost, impacts on fertility, fear of surgery, and the recovery period were rarely discussed during the informed consent process. Debriefing was poorly understood and rarely observed in practice. Women sometimes learned from providers or other staff about procedures done during the delivery (such as hysterectomy) or outcomes such as stillbirth in ways that were inappropriate, not confidential, and insensitive.

Sharing Findings with Clinicians at a High-Profile Conference

Providers, patient advocates, and program implementers around the world can use these findings to support improved practices and as a jumping off point for sharing ideas on how to enhance patient experience in cesarean delivery.

After communicating the findings of the mixed-methods study at a “Breakfast with the Experts” panel at the XXIV FIGO World Congress of Gynecology and Obstetrics, MOMENTUM encouraged attendees to share their own perspectives on the causes of poor counseling and consent procedures and the interventions that can make a difference. Clinicians in the audience noted structural challenges like providers being overwhelmed by the number of patients they must see. This can contribute to poor counseling and consent procedures, especially when providers face pressures like delayed salary payments.

Yet, attendees also noted that there are always exceptional providers who deliver strong counseling and consent even in overwhelmed, low-resource settings. And so, it is worth asking: What motivates and guides these providers? Another participant shared that, just as there are many causes of poor counseling and consent in surgical care, solutions must also be multi-faceted, acting at the level of individuals, health systems, and even popular culture. Such multi-faceted solutions may allow patients and their families in need of care to arrive at health facilities already equipped with concepts of consent and expectations of the care they will receive.

What More is Needed?

As the lively discussion at FIGO indicates, providers are interested in improving the experience of clients needing cesarean delivery and recognize that the importance of respectful maternity care does not end at the operating room door. Cross-cutting change requires action at the community, facility, and policy levels, and the integration of counseling, consent, and debriefing issues into quality improvement efforts across LMICs.

MOMENTUM Safe Surgery in Obstetrics and Family Planning is applying the findings of its research to improve service delivery. For example, in the Democratic Republic of the Congo, the project is working with local partners to redesign paperwork to reduce confusion among patients and family members about informed consent and payment, which are currently combined in a single document. In India, the project is developing and testing standard content for quality counseling. These strategies and others are part of the focused responses required to improve the experience of care during this common surgical procedure and support women in their right to receive appropriate, consented, and respectful labor and delivery services.