Self Referral and Informed Decision Making

Referral by health workers is often handled in a rather directive way. Instead, there should be a mutual understanding about the need for, and purpose of the referral between health worker and patient (Paine & Siem Tjam 1988). The mother baby package (WHO 1996) suggests the antenatal care should be used to help women and their families to develop an appropriate delivery plan (including place of delivery), based on the women's history and health status. The Safe Motherhood Initiative emphasises that women's choices should be respected and ensured (Inter-agency group for safe motherhood 1997). This adds another dimension to the discussion on antenatal risk assessment and referral, because it implies involving the mother in defining the need for referral and shifts the focus from predictive power of risk factors to the risk as perceived by the individual mother. There is a wide gap between these approaches as evidenced by the high rates of self-referral and the low compliance with referral advice given by health workers. Thus a mother with her first uncomplicated pregnancy may prefer to deliver in hospital for safety reasons (and many do so) while a mother with her tenth pregnancy may prefer to deliver at home, because she feels better cared for in her domestic environment. Taking informed decision making seriously would imply to move from rigid application of referral criteria to individual counselling based on professional needs assessment and women's preferences.