Shared Decision Making and Informed Consent

Position Statement on Shared Decision Making and Informed Consent

The North American Registry of Midwives recognizes Shared Decision Making and Informed Consent are the cornerstones of woman centered midwifery care. Midwives want their clients to make well informed choices about their care. Shared Decision Making occurs throughout global maternity care during which the plan of care for each client is continuously explored and explained with Informed Consent obtained when appropriate.

Glossary for Informed Disclosure and Informed Consent

CPM Shared Decision Making Process: The collaborative process that engages the midwife and client in ongoing verbal and written communication about treatment options.  This dynamic process incorporates scientific evidence, clinical expertise, and the client’s preferences and values to determine the plan of care. The process of shared decision making culminates with informed consent, which can be revisited over time.

Plan of Care: A midwife provides her clients with a routine care plan that considers scientific evidence, clinical expertise, practice guidelines, community standards, legal requirements, and client values and preferences. The Plan of Care is documented in the chart and verbalized to the client and is revisited throughout the course of care as changes occur.

Community Standards: Routine maternity care, including tests and procedures, within the midwifery and obstetrical community in which the midwife practices and the client resides.

Education and Counseling: Information and discussion components of the CPM Shared Decision Making Process, provided in language understandable to the client. Verbal and written communication should free of technical jargon that the client does not comprehend. Written information should be at the client’s reading level.

Philosophy of Practice: A written document that a midwife provides as part of Informed Disclosure for Midwifery Care in which the midwife explains her personal beliefs and opinions that might impact the scope of practice offered.

Statement on Informed Consent

If a midwife supports a client’s choices that are outside of her Plan of Care, she must be prepared to give evidence of informed consent. The midwife must also be able to document the process that led to the decision and show that the client was fully informed of the potential risks and benefits of proceeding with the new care plan. It is the responsibility of the midwife to provide evidence-based information, clinical expertise, and when appropriate, consultation or referral to other providers to aid the client in the decision making process.

Information provided should be free from the personal bias of the practitioner and should be presented without coercion or intimidation. When all reasonable options have been discussed, and the client understands the possible outcomes of each option, it is the client’s right to choose her course of care. Depending on legal limitations, it is the CPM’s right to continue care with the client, or to discontinue care and provide the client with resources toward choosing other caregivers. Midwives cannot and should not knowingly put a client at harm. Continuing care with a non-compliant client must be a decision that the midwife believes is in the best interest of her client.
Documentation of informed consent in the client’s chart is the responsibility of the midwife. CPMs must obtain a client’s signature when the client’s care plan deviates from the Midwife’s Plan of Care.

Components of an Informed Consent/Informed Refusal

  1. Explanation of treatments and procedures;
  2. Explanation of both the risks and expected benefits;
  3. Discussion of possible alternative procedures, including delaying or declining of testing or treatment, and their risks and benefits;
  4. Documentation of any initial refusal by the client of any action, procedure, test or screening recommended by the midwife based on her clinical opinion or required by practice guidelines, standard of care, or law, and follow up plan;
  5. Client and midwife signatures and date of signing for informed refusal of standard of care.

Informed Disclosure for Midwifery Care

NARM requires that CPMs provide an informed disclosure to all of their clients at the onset of care that includes a comprehensive description of the midwife’s training, philosophy of birth, practice guidelines, transfer of care plan, legal status, availability of a complaint process, and relevant HIPAA disclosures.

Components of an Informed Disclosure for Midwifery Care
NARM requires the Certified Professional Midwife to have a written statement of Informed Disclosure for Midwifery Care on file for each client. An informed disclosure form should be written in language understandable to the client and there must be a place on the form for the client to attest that she understands the content by signing her full name. The form should be entitled “Informed Disclosure for Midwifery Care,” and must include, at a minimum, the following:

  1. A description of the midwife’s education, training, and experience in midwifery;
  2. The midwife’s philosophy of practice;
  3. Antepartum, intrapartum and postpartum conditions requiring consultation, transfer of care and transport to a hospital (this would reflect the midwife’s written practice guidelines) or availability of the midwife’s written guidelines as a separate document, if desired and requested by the client;
  4. A medical consultation, transfer and transport plan;
  5. The services provided to the client by the midwife;
  6. The midwife’s current credentials and legal status;
  7. NARM Accountability Process (including Community Peer Review, Complaint Review, Grievance Mechanism and how to file a complaint with NARM); and
  8. HIPAA Privacy and Security Disclosures

HIPAA Privacy and Security Rules

HIPAA Privacy and Security Rules are intended to enforce standards of ethics and confidentiality. NARM recommends that all CPMs address HIPAA compliance in their professional practice and determine their status as a “covered entity” under HIPAA. More information on whether you are “covered entity” required to comply with HIPAA can be found on the Website:

NARM requires that ALL CPMs, even those not designated as “covered entities”, address the following standards for disclosure of personal health information (PHI) in their professional documents of informed disclosure/informed consent.

CPMs must have permission from their clients to allow students to access medical records for the purpose of education or verification of documentation for their NARM application.

CPMs must disclose to their clients that they participate in regular peer review, which can sometimes necessitate confidential disclosure of health information for the purpose of reviewing the midwife’s professional conduct.

More information can be found on our HIPAA for CPMs page.

Resources for Informed Disclosure and Informed Consent:

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