I posted this recently inside another thread where I think it was rapidly buried.
I think it's an important piece which shows from a medical person's perspective the problems encountered when dealing with a pregnant JW woman. I sincerely hope this post is read by JWs who are planning to have children. The article is an essay which was written by my wife when studying for a BSc in Midwifery.
The event that I have chosen to reflect upon occurred on a delivery suite in a hospital in the South West. As a second year midwifery student I was working under supervision by my mentor, who in accordance with confidentiality (Nursing and Midwifery Council, 2002) I will refer to as Laura. I had worked with Laura before and we had strong trust and confidence in one another. During the previous shift together a client who we were caring for had suffered a primary postpartum haemorrhage of an estimated 1, 500mls blood loss during the delivery.
The following day the experience of the haemorrhage was still very vivid in my mind when we were allocated the care of a client who was in the first stage of labour. During the hand over, we were told that this client, who in accordance with confidentiality (Nursing and Midwifery Council, 2002) I will refer to as Anne, is a Jehovah’s Witness. For that reason, in accordance with her religious beliefs, Anne had signed a health-care advance directive form (see appendix 3) stating she refuses blood and blood products. Laura and myself introduced ourselves to Anne and her husband who was with her and they reiterated that Anne would not accept blood. During this initial discussion a doctor arrived to ask Anne to sign an additional form, “Consent to medical treatment by patient who refuses to have a blood transfusion” (see appendix 4). Anne signed the form, but once the doctor had left the room asked Laura and myself to clarify everything the doctor had just said to her.
Laura and I looked at the delivery suite guidelines for the intrapartum care of women declining blood products (see appendix 5), as we needed to be clear of a care plan and treatment should Anne haemorrhage. This included a multitude of pharmacological methods, which we needed to locate and become familiar with. Further, as a student I needed to be aware of which drugs I could and could not administer (Nursing and Midwifery Council, 2002) and that it was crucial to be aware of procedures such as how to alert other members of the obstetric and paediatric team. As with all clients, Anne was risk assessed and although she was not considered to be of high risk for a postpartum haemorrhage, I was aware that it was still a possibility as this can occur without warning (Crafter, 2002, cited in Boyle, 2002). Anne had agreed for an actively managed third stage to further reduce risk as the guidelines in the unit recommend (see appendix 5).
Laura and myself continued to care for Anne during her labour. As the strength of her contractions began to increase, Anne requested an epidural which was sited and effective. Once Anne was pain free she began to talk about accepting blood fractions. However, she was not clear what this meant, only that she had read about it in The Watchtower magazine. The Watchtower Bible and Tract Society of New York (WTS) publish the Watchtower magazine twice a month. The corporation is the governing body of Jehovah’s Witnesses, believing that it is inspired by God to be the ‘faithful and discreet slave’ as described in Matthew 24, 45-47. Jehovah’s Witnesses accept the WTS’s scriptural interpretations and directives almost without question. The primary communication is through their magazine, which is printed globally in over sixteen million copies, 600, 000 of which are for distribution in the
Anne, who is rhesus negative, also said that although she had refused anti-D gamma globulin during her pregnancy, she was considering having it postnatally. Anti-D is derived from human blood plasma containing antibody to the erythrocyte factor Rh D (, 2003), and therefore Jehovah’s Witnesses forbid it. Anne’s husband became increasingly anxious about this and stressed to Anne that due to their religious convictions she was to receive no blood or blood products in any form. It is of note that Annes husband remained with her throughout all of the labour and delivery, not leaving her for even the briefest moment. The labour and delivery progressed without any deviations from the norm and Syntometrine (0.5mg ergometrine and 5 units of Syntocinon in 1ml) was administered intramuscularly to actively manage the third stage. There was a minimal blood loss, estimated to be approximately 150mls. Fetal blood was taken from the placenta to determine the rhesus factor of the baby and Anne decided that she would have the anti-D gamma globulin injection if it were necessary. There were no postnatal complications noted.
Continuing with Gibbs (1988) reflective cycle, I explored my feelings surrounding the situation. Initially I felt concern for Anne. Having witnessed a primary postpartum haemorrhage the previous day, I was very aware how suddenly and quickly it can occur. This is an emergency situation in which it is vital to act quickly (Crafter, 2002, cited in Boyle, 2002). With the added risk of refusing blood and blood products, I was aware of feeling incredibly anxious, as was Laura, who is an extremely experienced midwife. The Confidential Enquiry into Maternal and Child Health (CEMACH), 2000-2002 states that there has been an increase in the number of deaths from primary postpartum haemorrhage. Yet four of the women who died from primary postpartum haemorrhage had declined blood transfusions, which would probably have saved their lives.
Further, I was aware the other midwives in the delivery suite were feeling somewhat uneasy. This was largely due to the fact that the previous year a Jehovah’s Witness woman had died following a primary postpartum haemorrhage in the unit. With such a traumatic event having occurred there were still some feelings of apprehension. This is not necessarily negative, as it can give a greater insight, awareness and preparation.
When reading Anne’s hand held antenatal notes I found that she had changed her mind numerous times concerning whether to accept the anti-D gamma globulin. In addition, Anne had not signed the health-care advance directive form (see appendix 3) until she was 39 weeks and 3 days pregnant. This was despite her community midwife discussing it with her, as documented, on three separate occasions. I questioned that perhaps she felt under pressure by her religion, or members of her religious community or perhaps by her husband. On reflection, when asked to sign the form (see appendix 4) by the doctor, it was her husband who read it and told Anne to sign. Although it must be said that she did not appear anxious or concerned about signing or her husband making decisions on her behalf. However, once the doctor had left the room, and Anne asked Laura and myself to clarify what he had said, I began to feel increasingly frustrated as well as concerned. Laura also said that she felt uneasy when this occurred. Overall, my feelings were of anxiety for the well being of Anne in the event of a haemorrhage and also for the protection of future pregnancies without the anti-D gamma globulin. To continue with the process of reflection, I next evaluated the situation, considering what was good and bad about it.
Firstly, there are issues surrounding the confusion concerning the ‘fractions’ of blood. Although Anne clearly refused blood and blood products, during her labour she did state that she had read in the Watchtower magazine that fractions of blood were acceptable. However, as previously mentioned, both Anne and her husband were confused by the term ‘fractions of blood’. My reaction to this was feeling that the couple were irresponsible for not knowing exactly what the constrains of their religion are especially with what can ultimately be a life or death situation. Singla et al, (2001) undertook an eleven-year retrospective cohort study to determine the difference between risks of maternal death for Jehovah’s Witness clients compared to the general obstetric population. A total of 332 women who were Jehovah’s Witnesses had 391 deliveries. A primary postpartum haemorrhage was experienced in six per cent of this population and this had resulted in 2 maternal deaths. This piece of research concluded that clients who are Jehovah’s Witnesses are at a 44-fold risk of maternal death. This degree of risk elevation has not been seen with other procedures, such as vascular or cardiac surgery. This may be, in part, due to the rapidity in which a life-threatening postpartum haemorrhage occurs and the potential for underestimating the full extent of the blood loss. This was a significant piece of research and therefore it appears possible to argue that all women who are Jehovah’s Witnesses should therefore be categorised as high risk during intrapartum care.
The Watchtower Society’s decision to tweak its transfusion policy has clearly created some confusion. The Associated Jehovah’s Witnesses for Reform on Blood (AJWRB) has emerged as a strong lobby group who seek to educate other Jehovah’s Witnesses, their family members, friends and healthcare providers regarding what they believe to be irrational aspects of the WTS’s policy. The group are particularly determined that Jehovah’s Witnesses can have a free and informed choice regarding their healthcare, without the fear of control or sanctions. The AJWRB also argue that biblical directives relate to the consumption of blood and that no nourishment occurs when blood is transfused, it is the same as an organ transplant, which is not forbidden by the WTS. With this confusion, it could be argued that, in the case of Anne, ignorance was her approach and she was satisfied for her husband to make the decisions on her behalf. That is to say that his actions could be seen as being protective of her in conjunction with beliefs that they held and he described as ‘the truth’. Although it could be argued that her husband and members of her religious community could be deemed as controlling and therefore Anne should have been counselled individually, as is suggested in the unit guidelines (see appendix 5).
There are always issues surrounding informed consent during labour. Anne had signed consent forms, when told to do so by her husband without fully understanding the implications. It must be noted that at the time of making decisions she was in labour and it was pre-epidural. Draper, 1998 (cited in Firth, 1998) suggests that consent must be understood in terms of thorough information and competence before reaching a decision. Jones (1996) discusses consent from an ethical perspective and describes it as a voluntary, unforced decision. Similarly, withholding consent is a womans choice and, must be respected regardless of professional opinion. To determine the womans position on the value of consent, it is necessary to determine the extent to which she values her autonomy. Clearly in the case of this client, her autonomy was vital and nothing should override decisions she has made. However, her autonomy must be questionable in this instance because Anne was frequently wavering and eventually decided to accept anti-D in the case of her neonate being rhesus positive. It is of note that legally the consent, and conversely the withholding of consent by a husband of a client is not recognised in law (Jenkins, 1995).
Before an analysis, it is necessary to understand why Jehovah’s Witnesses refuse blood. Jehovah’s Witnesses are Christian fundamentalists who strongly adhere to all Biblical directives. On the issue of blood, they point to the following scriptures, Leviticus 17:12-14, “…No soul of you shall eat blood…whosoever eateth it shall be cut off”. Acts 15:29, “Thay ye abstain from blood” and Acts 21:25, “Keep themselves from things offered to idols and from blood”. Essentially all other Christian and Jewish faith groups interpret these passages as referring to dietary laws, but Jehovah’s Witnesses believe that these extend to any use of blood, and certainly a blood transfusion. However, The Watchtower does seem to be altering the view concerning blood transfusion. In June, 2000 the magazine stated, “When it comes to fractions of any of the primary components, each Christian, after careful and powerful meditation, must conscientiously decide for himself” (The Watchtower 2000; June 15:29-31)
When caring for clients with such religious beliefs it is imperative to remain professional and non-judgemental at all times. The essence of giving individualised care is to ensure that the woman receives the care, which is appropriate and correct for her, despite the beliefs and principles of the midwife and obstetric team. Perhaps Anne’s strong belief in her faith was a comfort to her during labour and delivery, a time when women can feel particularly vulnerable and frightened. Nevertheless, I would question her autonomy and faith in her religious convictions if she was prepared to accept anti-D and in addition by continually deferring to her husband. When analysing my feelings, it could be argued that I would have felt very different if I had not had the experience of a postpartum haemorrhage the previous day. We learn from our experiences, and future practice will reflect that, even if in the short term. Experiencing and being involved in managing the postpartum haemorrhage has certainly made me more aware and more astute in recognising indications of this and how quickly and accurately it must be managed.
Midwifery is a profession in which ethical and moral dilemmas are commonplace. It is valuable within clinical practice to use ethical frameworks and theories such as Edwards (1996) in which judgements, rules, principles and ethics are adhered to in order to assist the midwife when facing difficult dilemmas. Clearly there are ethical dimensions in all clinical decisions and ethical and clinical soundness could be described as inseparable, as ethics are essential to good clinical practice. Firth (1998) proposes that if the midwife is the lead professional in the majority of ‘low-risk’ births, then she is responsible for decisions made in relation to her client, including moral and ethical responsibility. When considering the client, Anne had made her decisions surrounding blood based upon her religious convictions rather than on the basis clinical information. In such a situation, the midwife providing the care must respect her clients decision (Fremgen, 2002) knowing that otherwise the treatment will impact upon the whole of the clients life (Schwartz, et al 2002).
I feel that given my training and experiences to date as a second year student that I acted in an appropriate manner caring for Anne, respecting her beliefs at all times. I ensured that I knew where the drugs were, and who to call and how to call them in the event of an emergency. Yet, if a similar situation occurred again I would perhaps ask a senior member of staff to discuss things with Anne without the presence of her husband, as stated in the delivery suite guidelines (see appendix 4) to ensure that she is not under pressure from another person. However, this can be difficult when the woman insists she wants her partner with her throughout the labour and delivery, as many women do. Although I was feeling anxious, I am certain that this was not apparent to Anne or her husband at any time during the labour and delivery. Certainly, in future I will do my utmost to ensure that a woman fully understands what is being explained to her by a doctor, or any other member of staff. A positive aspect of the situation was the way in which the health care professionals involved communicated effectively within the team, remaining professional at all times. This was clearly an emotive situation and could have resulted in a high-risk obstetric emergency. I feel certain that should this have occurred, the team would have respected her religious beliefs and she would have received the best possible care.
In conclusion, the process of reflection within midwifery brings with it a deeper understanding of what can often be multifaceted and challenging situations. If midwives are to deliver a holistic and personal pattern of care, then individuality must be accounted for and respected. Given such an emotive experience, it is necessary to critically evaluate understanding through reflection. Midwifery is not based on feelings; it is a science with an evidence base, which practitioners must adhere to. Using models of reflection means appreciating and accepting each experience, which often leads to a different perspective. On a personal level, this experience was incredibly valuable. It demonstrated the importance of tailoring and delivering individualised care despite my own beliefs. I feel it was a significant learning curve and that my future practice will show the benefit of undertaking the process of reflection.