What is it?
We make decisions all the time. Orange juice or apple juice? Skirt or trousers? Car or walk? But when we’re pregnant, particularly if it’s our first time, it can be daunting.
Suddenly you’re being asked about many different aspects of your care, of which you have usually no prior knowledge or experience, and many of which have the potential to impact on your health and the health of your baby.
Many antenatal class facilitators and doulas recommend using the acronym BRAIN as a way to make sure you’re not missing anything you need in order to make an informed decision – whether that be informed consent, or informed refusal.
While you’re pregnant, you’ve got time to research your options and think about what you’d like to do; decisions rarely need to be made instantly. A good Health Care Professional (HCP) will listen to your concerns and be able to answer them, or undertake that they will find out and get back to you. If they feel threatened by your questioning, get a second opinion – if they can’t justify and evidence their reasoning to you then why would you agree to their recommendation?!
But when you’re at the sharp end of labour contractions, it’s easy to feel under pressure, overwhelmed by the choice, and to forget to ask the pertinent questions you need to help the decision making process. This in turn makes it difficult to evaluate your options as effectively as you would normally, potentially leading to snap decisions you may regret later. Remembering to use your BRAIN can help.
Because no matter how the procedure/test/medication is presented to you – on a continuum from “You could try this…” to “You have to do this…” the decision ultimately rests with you.
Any HCP whose reasoning starts with ‘because it’s our policy’ or ‘that’s what we usually do’ is not doing their job properly in terms of giving you the information you need to make truly informed consent. At all times you are being offered options – which are yours to accept or refuse, even if they’re not being couched in language that sounds like it.
The acronym BRAIN works as follows:
The B stands for Benefits: What are the advantages of the approach being considered? Whether it’s a test, a form of monitoring, pain management, position, it doesn’t matter – you need to know why your HCP is recommending/suggesting it. What is the evidence base for it? If you’ve got the time, is there RCOG (Royal College of Gynecologists) or NICE (National Institute of Clinical Excellence) guidance on it you could read? RCOG/NICE always state their sources and often the RCOG even rates the’ strength’ of the evidence for their recommendations, which is very helpful. Even if it’s just internal policy, there should be documentation and references to back up the reasons for it.
The R stands for Risks: What are the disadvantages of the approach being considered? Are there any side effects? Is the decision reversible? Will it restrict my choices later on? What happens if it goes wrong? How does this relate specifically to me and my circumstances? You also have to keep in mind the severity of the hazard versus the likelihood. Are we talking an almost certain likelihood of breaking a fingernail or a very very very small likelihood of fetal/maternal death? It’s tempting to ignore very unlikely risks, but if the consequence is catastrophic, it must be taken seriously. As a doctor friend of mine put it in terms of c-section – you may not want one, but how many overcautious c-sections are acceptable to prevent one fetal/maternal death?
The A stands for Alternatives: What other approaches could we try? Is this the only option to consider (aside from doing nothing – see N later)? Just because this is what most people choose/you’d recommend, doesn’t make it right for me… (you might need to BRAIN all the alternatives too!) e.g. If I’m being advised/prescribed something because there’s a ‘risk’ of getting high blood pressure, why can’t I buy a blood pressure monitor and keep a detailed eye on my blood pressure instead?
The I represents Instinct/Intuition: What does my gut say about the approach recommended/suggested? This may seem like a particularly unscientific test, but it’s actually very useful in getting to the core of what is important to us; and determining which path is right for us. After all, giving birth is not an illness, it’s a natural part of life – but we’re all different, with our own innate values, beliefs, and preferences to consider.
The N stands for Nothing: What is likely to happen if we do nothing? Can we wait an hour/2 hours/a day/a week? Does the decision have to be made now, or can we wait to see what happens next and revisit the decision later?
Medical professionals generally want what is best for their patients. On the whole we can be assured that they really do have the right motivation when caring for us. But while we mustn’t lose sight of that, there is also room for our input in the birthing process.
To make informed decisions, you need all the relevant information. Using your BRAIN is definitely one way to attempt to ensure you get that information at the right time.