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

OBJECTIVE: Informed consent is a prerequisite for caesarean section, the commonest surgical procedure in low- and middle-income settings, but not always acquired to an appropriate extent. Exploring perceptions of health care workers may aid in improving clinical practice around informed consent. We aim to explore health workers' beliefs and experiences related to principles and practice of informed consent. METHODS: Qualitative study conducted between January and June 2018 in a rural 150-bed mission hospital in Southern Malawi. Clinical observations, semi-structured interviews and a focus group discussion were used to collect data. Participants were 22 clincal officers, nurse-midwives and midwifery students involved in maternity care. Data were analysed to identify themes and construct an analytical framework. RESULTS: Definition and purpose of informed consent revolved around providing information, respecting women's autonomy and achieving legal protection. Due to fear of blame and litigation, health workers preferred written consent. Written consent requires active participation by the consenting individual and was perceived to transfer liability to that person. A woman's refusal to provide written informed consent may pose a dilemma for the health worker between doing good and respecting autonomy. To prevent such refusal, health workers said to only partially disclose surgical risks in order to minimize women's anxiety. Commonly perceived barriers to obtain a fully informed consent were labour pains, language barriers, women's lack of education and their dependency on others to make decisions. CONCLUSIONS: Health workers are familiar with the principles around informed consent and aware of its advantages, but fear of blame and litigation, partial disclosure of risks and barriers to communication hamper the process of obtaining informed consent. Findings can be used to develop interventions to improve the informed consent process.

Pre-post implementation survey of a multicomponent intervention to improve informed consent for caesarean section in Southern Malawi.

OBJECTIVE: Surgical informed consent is essential prior to caesarean section, but potentially compromised by insufficient communication. We assessed the association between a multicomponent intervention and women's recollection of information pertaining to informed consent for caesarean section in a low-resource setting, thereby contributing to respectful maternity care. DESIGN: Pre-post implementation survey, conducted from January to June 2018, surveying women prior to discharge. SETTING: Rural 150-bed mission hospital in Southern Malawi. PARTICIPANTS: A total of 160 postoperative women were included: 80 preimplementation and 80 postimplementation. INTERVENTION: Based on observed deficiencies and input from local stakeholders, a multicomponent intervention was developed, consisting of a standardised checklist, wall poster with a six-step guide and on-the-job communication training for health workers. PRIMARY AND SECONDARY OUTCOME MEASURES: Individual components of informed consent were: indication, explanation of procedure, common complications, implications for future pregnancies and verbal enquiry of consent, which were compared preintervention and postintervention using χ2 test. Generalised linear models were used to analyse incompleteness scores and recollection of the informed consent process. RESULTS: The proportion of women who recollected being informed about procedure-related risks increased from 25/80 to 47/80 (OR 3.13 (95% CI 1.64 to 6.00)). Recollection of an explanation of the procedure changed from 44/80 to 55/80 (OR 1.80 (0.94 to 3.44)), implications for future pregnancy from 25/80 to 47/80 (1.69 (0.89 to 3.20)) and of consent enquiry from 67/80 to 73/80 (OR 2.02 (0.73 to 5.37)). After controlling for other variables, incompleteness scores postintervention were 26% lower (Exp(ß)=0.74; 95% CI 0.57 to 0.96). Recollection of common complications increased with 0.25 complications (ß=0.25; 95% CI 0.01 to 0.49). Recollection of the correct indication did not differ significantly. CONCLUSION: Recollection of informed consent for caesarean section changed significantly in the postintervention group. Obtaining informed consent for caesarean section is one of the essential components of respectful maternity care.