Health workers' perspectives on informed consent for caesarean section in Southern Malawi

Counseling, informed consent, and debriefing for cesarean section in sub-Saharan Africa: A scoping review

BACKGROUND

Counseling as part of the informed consent process is a prerequisite for cesarean section (CS). Postnatal debriefing allows women to explore their CS with their healthcare providers (HCPs).

OBJECTIVES

To describe the practices and experiences of counseling and debriefing, the barriers and facilitators to informed consent for CS; and to document the effectiveness of the interventions used to improve informed consent found in the peer-reviewed literature.

SEARCH STRATEGY

The databases searched were PubMed, EMBASE, PsycINFO, Africa-wide information, African Index Medicus, IMSEAR and LILACS.

SELECTION CRITERIA

English-language papers focusing on consent for CS, published between 2011 and 2022, and assessed to be of medium to high quality were included.

DATA COLLECTION AND ANALYSIS

A narrative synthesis was conducted using Beauchamp and Childress's elements of informed consent as a framework.

MAIN RESULTS

Among the 21 included studies reporting on consent for CS, 12 papers reported on counseling for CS, while only one reported on debriefing. Barriers were identified at the service, woman, provider, and societal levels. Facilitators all operated at the provider level and interventions operated at the service or provider levels.

CONCLUSIONS

There is a paucity of research on informed consent, counseling, and debriefing for CS in sub-Saharan Africa.

Surgical informed consent practices and influencing factors in sub-Saharan Africa: a scoping review of the literature

INTRODUCTION

Current international standards in consent to surgery practices are usually derived from health systems in Western countries, while little attention has been given to other contexts such as sub-Saharan Africa (SSA), despite this region facing the highest burdens of disease amenable to surgery globally. The aim of this study was to examine how the concept of informed consent for surgery is interpreted and applied in the context of SSA, and factors affecting current practices.

METHODS

A systematic search of Medline, Embase and African Journal OnLine databases as well as grey sources was executed in May 2023 to retrieve relevant literature published since 2010 in English language against a set of given criteria. The socioecological framework for health was used for organising and summarising the identified evidence.

RESULTS

A total of 27 papers were included in the review. Findings revealed that consent to surgery practices is generally substandard across SSA and the process is not adequate. Patients' understanding of informed consent is limited, likewise awareness of their rights to decision-making. A range of factors at the individual, interpersonal, institutional and system/societal levels affect the informed consent process.

CONCLUSION

There is a need to find more culturally acceptable and ethical ways to include the participation of patients in the decision-making process for surgical treatment in the SSA and define standards more closely aligned with the local context.

Association between delayed cesarean section and severe maternal and adverse newborn outcomes in the Somaliland context: a cohort study in a national referral hospital

BACKGROUND

In a critical obstetric situation, the time interval between the decision of performing a caesarean section (CS) and delivery can influence maternal and newborn outcomes. In Somaliland, consent for surgical procedures, such as CS needs to be sought from family members.

OBJECTIVE

To determine the association between a delay in performing a CS and severe maternal and newborn outcomes in a national referral hospital in Somaliland. The type of barriers leading to delayed performance of CS after a doctor's decision were also explored.

METHODS

Women were followed from the time of decision to perform CS until discharge from the hospital between 15 April 2019 and 30 March 2020. No delay was defined as < 1 hour and delayed CS was defined as 1-3 hours and >3 hours from decision of CS to delivery. Information was collected on barriers leading to delayed CS and maternal and newborn outcomes. Data was analysed using binary and multivariate logistic regression.

RESULTS

Overall, 1255 women were recruited from a larger cohort of 6658 women. A delay in CS >3 hours was associated with higher odds of severe maternal outcomes (aOR 1.58, 95% CI [1.13-2.21]). On the contrary, delay in performing a CS >3 hours was associated with lower odds of stillbirth (aOR 0.48, 95% CI [0.32-0.71]) compared to women without delay. Further, family decision-making for consent was the most important barrier leading to delays of >3 hours as compared to financial factors and barriers related to healthcare providers (48% vs 26% and 15%, respectively, p < 0.001).

CONCLUSIONS

In this setting, delay in performing CS >3 hours was associated with higher risk of severe maternal outcomes. A standardised system of performing a CS by primarily addressing the barriers associated with family decision-making, financial aspects and healthcare providers is needed.

Health system responsiveness and associated factors for delivery care in public health facilities, Dessie City Administration, South Wollo zone, Ethiopia: Cross-sectional study design

OBJECTIVE

To assess health system responsiveness (HSR) and associated factors for delivery care in public health facilities, Northeast Ethiopia.

DESIGN

Institutional-based cross-sectional study.

SETTING

South Wollo zone, Ethiopia.

PARTICIPANTS

A total of 430 women who delivered within the study period from 1 June 2022 to 5 July 2022 were included for this analysis.

OUTCOME

HSR.

METHODS

Institutional-based cross-sectional study was conducted from 1 June 2022 to 5 July 2022 in nine public health facilities. The data were collected through semistructured interviewer administered questionnaire, reviewing delivery registration books and client charts. HSR for delivery care was assessed by eight domains based on WHO responsiveness assessment framework. Binary logistic regression analyses were employed to check the association of variables with HSR. An adjusted OR (AOR) with 95% CI was determined to show the strength of association, and a p<0.05 was taken as level of statistical significance.

RESULTS

In this study, the health system was responsive for 45.8% (95% CI 41.1% to 50.6%) of delivered mothers. The highest (74.2%) and lowest (45.8%) rated domains were dignity and basic amenity, respectively. In multivariable logistic regression analysis, caesarian delivery (AOR 3.67, 95% CI 1.91 to 7.06), obstetric complication in current pregnancy (AOR 0.45, 95% CI 0.23 to 0.85), referred during labour (AOR 0.36, 95% CI 0.18 to 0.69), birth within 17:30-8:30 hours (AOR 0.51, 95% CI 0.32 to 0.81) and good satisfaction (AOR 5.77, 95% CI 3.44 to 9.69) were statistically significant associated factors with HSR.

CONCLUSION

The overall responsiveness of delivery care was low. Basic amenities, choice of provider and social support domains were least rated responsiveness domains. If health professionals give emphasis to mothers during spontaneous vaginal delivery, able to prevent obstetric complications, and if health facilities increase the number of professionals to duty time, handover, the referred mothers appropriately; having clean and attractive delivery wards will be important interventions to improve responsiveness for delivery care.

Quality of Informed Consent Practices around the Time of Childbirth: A Cross-Sectional Study in Italy

Background: Few studies have explored consent request practices during childbirth. Objective: We explored consent request practices during childbirth in a referral hospital and research centre in Italy, capturing both women and health workers’ perspectives. Methods: Data were collected using self-administrated questionnaires between December 2016 and September 2018. Nine key maternal and newborn procedures were analysed. Associations between consent requests and women characteristics were explored by multiple logistic regression. Results: Among 1244 women, the rate of consent requests varied widely, with caesarean section (CS) showing the highest rate (89.1%) and neonatal conjunctivitis prophylaxis presenting the lowest rate (11.4%). Information provided on “risks/benefits” and “reasons” for procedures by health staff was most often not comprehensive for procedures of interest (range 18.6–87.4%). The lack of informed consent is not specifically linked to any pattern of women characteristics. According to 105 health workers, adequate protocols and standard forms for consent requests were available in 67.6% and 78.1% of cases, respectively, while less than one third (31.4%) reported having received adequate training and supportive supervision on how to deliver informed consent. Conclusions: Study findings align with previous evidence showing that consent request practices during childbirth need to be largely improved. More research is needed to investigate effective strategies for improvement.