Decision-making capacity in childbirth as a gatekeeper for self-determination? A scoping review of its conceptualisations

Legally, as any other adult person in the medical context, a person giving birth is presumed to have decision-making capacity. Yet, one reason for mistreatment in birth can be found in the apparent uncertainties and misconceptions regarding the conceptualisation, operationalisation and assessment of decision-making capacity in birth. The widespread notion of birthing people lacking decision-making capacity has detrimental effects on the way they are treated. We carried out a scoping review of international literature (N=121). The primary research question was: How is decision-making capacity in birth conceptualised? The vast majority of studies came from high-income countries (n=115) and were ethical/philosophical (n=48) or legal analyses (n=36). We inductively developed the following categories: (1) default assumptions, (2) criteria, (3) limiting and enhancing factors, (4) assessment, (5) population-specific conceptualisations, (6) meta-conceptualisations and (7) mistaken or questioned criteria. At a conceptual level, no universally shared consensus regarding decision-making capacity in birth exists, and, at a practical level, this ties in with various injustices experienced by birthing people. Since conceptualising decision-making capacity is a question of power and birthing people by virtue of their position in research and medicine are unlikely to be part of the respective knowledge-producing communities, for the time being it is crucial to insist that decision-making capacity in birth is legally presumed until proven otherwise, and to critically reflect on the prevailing (mis)conceptions about birthing people. In conclusion, establishing epistemic justice throughout the process of conceptualising decision-making capacity in birth is a prerequisite for advancing reproductive rights and improving birth experiences.