Standards › Standard 12 › Policies
Policy · OBS-POL-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 12 (Obstetrics and Gynaecology), criterion 12.7
At a glance
- Each woman receives information on the options for place and mode of birth, with their risks.
- The information is given in a language and form the woman understands.
- Her choice is recorded on OBS-FRM-006, and changes are recorded too.
- A choice that cannot be met safely is explained, with the reason, and an alternative is offered.
- Stop and get help straight away if: a birth proceeds in a mode the woman did not choose, with no explanation or record.
1. Purpose
To make sure women know their options and take part in choices about their birth (12.7).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
A woman has the right to know her options and their risks, and to take part in choices about her own birth. Information given in time, and recorded, makes her decisions real.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Lead obstetrician | Owns the policy | Clinician |
| Midwife | Gives the information and records the choice | Midwife |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Inform.
- Explain options and risks for place and mode of birth, in a form the woman understands.
Key point: Understood.
Step 2. Record the choice.
- Record the choice on OBS-FRM-006 and any change, with the reason.
Key point: Choice and change.
Step 3. Explain.
- Where a choice cannot be met safely, explain why and offer an alternative.
Key point: Explained.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Women with a recorded birth choice | 95% | Monthly | Lead obstetrician | Escalate to medical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| OBS-FRM-006 | Birth choices record | Record |
| CON-SOP-001 | Informed consent before significant care (existing, reused) | Procedure |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO recommendations on antenatal care for a positive pregnancy experience (2016) and the WHO Standards for improving quality of maternal and newborn care in health facilities (2016). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)