Shanthi Muttukrishna and Ray Noble

1. Informed Consent and Confidentiality in Reproductive Health Care views of women attending a community clinic in Andhra Pradesh, India. P. 048 Shanthi Muttukrishna and Ray Noble Centre for Reproductive Ethics and Rights UCL Institute for Women’s Health, University College London 86-96 Gower Street, London WC1E 6HX Introduction Insistence on spousal consent and lack of confidentiality is a major factor preventing access to reproductive health care for women in rural India[1]. As part of a project to develop medical ethics in the medical curriculum in India we are undertaking a study to determine the extent to which stereotypic or overly-simplistic assumptions about the needs and views of women in rural India inform medical practice. Methods In a preliminary study, the views of thirty-one women (aged 18 – 50 years) were obtained in face-to-face structured interviews in their own language (Telugu) at a community clinic in rural Andhra Pradesh in December 2007. Results The women explicitly trusted doctors (Fig. 1) as people they ‘had faith in’ or ‘trusted’ (7); ‘good people’ (13);’like parents’ (2) or like ‘god’ (5); and believed doctors always act in their best interest. 30 said they preferred the doctor to make the final choice of treatment, but liked to discuss the treatment options (27). Four women would not wish to know because they ‘were afraid’ (1) or because ‘doctor knows best’ (3). All would like the doctor to explain their condition in simple terms. 21 said they would not mind if the doctor informed relatives without their permission (Fig. 2). Family members would ‘take better care of them’; ‘pay for treatment’; ‘worry about what would happen to children’. However, a third (10), mostly younger women, wanted privacy and wished to choose whether to inform family members. The views of doctors (N=10) in a local hospital differed about whether or when a husband or other relative would be informed (Fig. 3): “Relatives may have to pay for treatment”; “would consult with husband unless patient reluctant to talk”; “always seek to preserve privacy”; “would discuss with husband”; “for major surgery would seek husband’s consent”. Discussion Reproductive health is a major factor in domestic violence against women in rural India[3], yet confidentiality in health care is often difficult to achieve or absent in clinical practice. In a recent report on sterilization services in Chennai, 80% of the women reported that consent had been obtained by the clinician from a member of the family, often the husband[2]. Our study indicates that for a significant number of women, particularly younger women, privacy and confidentiality in decision making is considered important. Conclusion A better understanding of the needs and wishes of women should be built into the medical curriculum to better inform ethical clinical practice and improve access to health care for rural women. References [1] Gupte M, Bandewar S, Pisal H. Women’s perspectives on the quality of general and reproductive health care: evidence from rural Maharashtra. In: Koenig MA, Khan ME, editors. Improving quality of care in India’s family welfare programme. New York: Population Council; 1999. p. 117-39. [2] Rajalakshmi. Informed consent in sterilisation services: evidence from public and private health care institutions in Chennai. Health and Population Innovation Fellowship Programme Working Paper No. 4. New Delhi: Population Council; 2007. [3] Rao, V. Wife-beating in rural south India: a qualitative and econometric analysis. Sot'. Sci. Met/. Vol. 44, No. 8, pp. 1169-1180, 1997. Fig. 3. View of doctors in district hospital Obstetric and Gynaecology department on whether husband/relative would be informed during consultation: Fig. 1. The perception of doctors by the women in the study group Fig. 2. Women’s views on clinicians informing other family members of their condition and treatment without their permission. Funded by British Council UKIERI. Informed consent was obtained from all participants in the study and from staff at the Community Clinic.