title: Maternity Care Plans: A retrospective review of a process aiming to support women who decline standard care.
abstract: BACKGROUND
  All competent adults have the right to refuse medical treatment. When pregnant women do so, ethical and medico-legal concerns arise and women may face difficulties accessing care. Policies guiding the provision of maternity care in these circumstances are rare and unstudied. One tertiary hospital in Australia has a process for clinicians to plan non-standard maternity care via a Maternity Care Plan (MCP).
  
  
  OBJECTIVE
  To review processes and outcomes associated with MCPs from the first three and a half years of the policy's implementation.
  
  
  METHODS
  Retrospective cohort study comprising chart audit, review of demographic data and clinical outcomes, and content analysis of MCPs.
  
  
  RESULTS
  MCPs (n=52) were most commonly created when women declined recommended caesareans, preferring vaginal birth after two caesareans (VBAC2, n=23; 44.2%) or vaginal breech birth (n=7, 13.5%) or when women declined continuous intrapartum monitoring for vaginal birth after one caesarean (n=8, 15.4%). Intrapartum care deviated from MCPs in 50% of cases, due to new or worsening clinical indications or changed maternal preferences. Clinical outcomes were reassuring. Most VBAC2 or VBAC>2 (69%) and vaginal breech births (96.3%) were attempted without MCPs, but women with MCPs appeared more likely to birth vaginally (VBAC2 success rate 66.7% with MCP, 17.5% without; vaginal breech birth success rate, 50% with MCP, 32.5% without).
  
  
  CONCLUSIONS
  MCPs enabled clinicians to provide care outside of hospital policies but were utilised for a narrow range of situations, with significant variation in their application. Further research is needed to understand the experiences of women and clinicians.
authors.affiliation: Mater Research Institute, The University of Queensland, Brisbane, Australia; School of Nursing and Midwifery, The University of Queensland, Brisbane, Australia. Electronic address: rebecca.jenkinson@mater.uq.edu.au.
authors.forename: Bec
authors.initials: B
authors.lastname: Jenkinson
authors.affiliation: School of Nursing and Midwifery, The University of Queensland, Brisbane, Australia.
authors.forename: Sue
authors.initials: S
authors.lastname: Kruske
authors.affiliation: Mater Research Institute, The University of Queensland, Brisbane, Australia; School of Nursing and Midwifery, The University of Queensland, Brisbane, Australia.
authors.forename: Helen
authors.initials: H
authors.lastname: Stapleton
authors.affiliation: Mater Research Institute, The University of Queensland, Brisbane, Australia; Mater Health Services, Brisbane, Australia.
authors.forename: Michael
authors.initials: M
authors.lastname: Beckmann
authors.affiliation: Mater Health Services, Brisbane, Australia.
authors.forename: Maree
authors.initials: M
authors.lastname: Reynolds
authors.affiliation: Mater Research Institute, The University of Queensland, Brisbane, Australia; School of Nursing and Midwifery, The University of Queensland, Brisbane, Australia.
authors.forename: Sue
authors.initials: S
authors.lastname: Kildea
mesh_terms: D000328:Adult; D001315:Australia; D017604:Cesarean Section, Repeat / Q000706:statistics & numerical data*; D015331:Cohort Studies; D019091:Critical Pathways / Q000592:standards*; D036861:Delivery, Obstetric; D019317:Evidence-Based Medicine; D005260:Female; D006291:Health Policy; D006801:Humans; D007744:Obstetric Labor Complications; D036801:Parturition; D010342:Patient Acceptance of Health Care; D011247:Pregnancy; D016079:Refusal to Treat; D012189:Retrospective Studies; D016312:Treatment Refusal; D016064:Vaginal Birth after Cesarean / Q000592:standards*
keywords: Hospitals; Maternity; Policy; Refusal to treat; Treatment refusal