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From Nadine Edwards (NE), AIMS, Edinburgh.

The issue of choice sweeps over some difficult issues, drawing on literature in the field as well as a qualitative, prospective study of women's experiences of planning home births using their own accounts - an interesting place to look at choice and ethics, because a change of venue doesn't necessarily mean a change of ideology. Both practitioners and women are doing the very best they can. Ethics might provide a good meeting place for finding a joint best.

How is choice limited by presently held belief systems? The views of Brigitte Jordan (1997), who helped generate and define the field of the anthropology of birth, and of Robbie Davis-Floyd (1992), who argues that today's obstetrical procedures are rituals that reflect a cultural belief in the superiority of science over nature, still hold: that overall, the medical model remains dominant and the social approach subordinate. The women recognised that because of the beliefs and practices in operation, even in the community, their decision-making might be restricted both theoretically in terms of information and materially in terms of practices.

In terms of information, Jo Green and colleagues (1998) suggested from their excellent survey that "Information is in many ways a prerequisite for external control since having adequate information forms part of the basis upon which decisions can be made".
But, as Carolyn McLeod and Susan Sherwin (2000) comment: ".......the information provided is restricted to that deemed relevant by the health-care provider, itself limited by the pursuit of certain sorts of research programs while ignoring others."

This is typical of observations women made on this issue:

"I have to know everything about it, because the midwives and obstetricians steered me towards their preferred outcome".        

Joseph Raz suggests that: "If having an autonomous life is an ultimate value, then having a sufficient range of acceptable options is of intrinsic value"(in Brison 2000).

But without defined alternatives, they effectively had little choice. The choice is often between shades of the same:

"I would love to see that a GP is obliged by health policy to give women impartial, unbiased information on the available options".

"You haven't really got any choice. The choice that I made was let's get this finished and over with".

"........to have a choice, just being aware of all the options, so you know what's best for you".

        Women observed their midwives bending and occasionally ignoring policies, but there was a continual tension around how far women's decisions could be supported:

"........that feeling of the midwives being very 'by the book' and not free to make their own minds up. I'm sure if I can stay at home they'll make sure I do. But I hear so many people planning home births and going in [to hospital] for what seem like very small reasons".

So women realised that inserting a rhetoric of choice where strongly held beliefs are in operation doesn't really enable decision-making. Ideology shapes birth practices and structures of care and therefore limits choices theoretically by the information it provides and withholds, and materially by the practices it develops and restricts.

"If there seems to be a problem, I don't want to hold out and have a natural childbirth and a dead or damaged baby. I'm anxious that they'll panic and want to take charge. If the baby's in danger, then of course, do anything. But if I don't know I share the same value basis as somebody, then I don't know if they're going to be making decisions on the same basis as I would."

When women's decisions challenged policies, often midwives could not engage with or support them proactively. They had to distance themselves and advise women of their rights - something women found divisive and problematic:

"I did think they stuck to their rules very rigidly. Why can't they say, 'I think you're OK?' It had to be you taking the responsibility, which is fair enough up to a point. If you know somebody's quite happy to stay there [at home], then support them and encourage them to make it as safe as possible".

There is something here about sharing and mutuality that isn't part of choice. Typically, decision-making in health care and obstetrics is based on a series of assumptions about people and how they relate. It is based on philosophical traditions that see people as equal, rational and self-contained, relating through rights.

Most women were aware that they had rights - but only one woman said she felt comfortable and able to assert herself:

"I found out that I had a legal right [to a home birth], but I didn't really want to invoke that".

" I don't like to feel I make waves".

This is a group of women who are considered to be particularly able to assert themselves, but they were reluctant to appeal to rights if it meant jeopardising their relationships with the midwives. It has been found elsewhere (Romalis 1985) that women don't usually pursue their desires if people around them are unenthusiastic or hostile. Carol Gilligan (1985) and Mary Belenky and colleagues (1986)
found that women's decision-making was much more located in an ethics of care and relating than in rights and choices.

Women wanted to be autonomous, but in the context of trusting relationships with their midwives. The rhetoric of choice doesn't acknowledge how the women saw themselves as capable and vulnerable:

"I wasn't in so much of a state that I didn't know what I wanted. So it worries me that people would think that I was going to become a gibbering heap, unable to say no".

"I worried that even if I said beforehand that I didn't want them [Syntometrine and vitamin K], at a vulnerable moment they might try to persuade me. I wanted my preferences to be respected".

It is often assumed that making ethical decisions means developing our abilities to be rational and objective and suppressing other influences. But women had different concerns:

"My major responsibility is to form a relationship with the baby. The more connected I am with the birth, the more connected I am with the baby".

Unless the baby's life was directly under threat, women felt that the effects of childbearing have so profound an impact on so many areas of their lives, that social, emotional, bodily, spiritual, and sexual considerations all have their places in decision making. These are not skin-deep preferences, but ethical issues that reach down into the very fibres of personhood.

We need a solid ethical framework, letting go of oppressive general rules and absolutes, pitting a woman's rights against those of her unborn baby. We need to reclaim space for the individual woman and practitioner, creating a framework for decision making that understands that decisions are ethical processes that join a person's life experiences and their social contexts with their intellectual knowledge. Such a change, creating an ethical framework in which different concerns can be acknowledged, is a major challenge.

The women identified the need for a robust alternative to medicalised birth practices, with the skills to go with it. While not suggesting that midwifery knowledge and skills are nonexistent, women implied that it isn't robust, consistent or recognised enough to provide a real or safe alternative. They suggested that ethical practices arise from trusting relationships. Self-trust and self-esteem don't easily develop between strangers, and are rarely fostered within lives affected by poverty or abuse; relationships are central in decision making.

"Health care by itself cannot correct all the evils of oppression or even cure the health-related effects of oppression. If health-care providers are to respond effectively to the problems they must understand the impact of oppression on relational autonomy and make what efforts they can to increase the autonomy of their patients and clients". (McLeod and Sherwin 2000)

Just as women who challenge attract hostility, midwives who challenge often do so too (Leap, Hadikin & O'Driscoll)
All too often women and midwives are obliged to refine their coping and manipulation strategies rather than develop their autonomy skills. Our blaming, rule-bound, risk culture systematically undermines autonomy.

Women need to know that their deeply felt concerns will be protected under all circumstances. It's about listening and being with the woman through her birthing journey, not disengaging and leaving the decision making to her.

If we want home birth to be a realistic option and to encourage decision-making and autonomy, we need more open beliefs about birth. We need a system of care in which decision making is acknowledged as being an ongoing ethical process that happens through dialogue.

Being unsupported or supported in decision making impacts on identity:

"I just want to forget about it. I'm left with a feeling that I didn't handle the situation very well. I should have been stronger. It was not a good choice I made".

"I find I still get great stuff out of it [home birth]. If I have a crisis of confidence, I think back to the birth and it's a very good anchor for me. It makes me believe in my ability to make good choices and especially on how I make decisions".

References.

Jordan, Brigitte (1997). Authoritative knowledge and its construction. In: Davis-Floyd R E and Sargent Carolyn F (Eds) (1997). Childbirth and authoritative knowledge: cross-cultural perspectives. University of California Press.

Davis-Floyd, R E (1992). Birth as an American Rite of Passage. University of California Press.

Green, Josephine et al (1998). Great expectations: A prospective study of women's expectations and experience of childbirth. Books for Midwives.

McLeod, Carolyn and Sherwin, Susan (2000). Relational autonomy, self trust and health care for patients who are oppressed. In: Catriona Mackenzie and Natalie Stoljar (Eds). Relational autonomy: feminist perspectives on autonomy, agency, and the social self. Oxford University Press.

Brison, Susan J (2000). Relational autonomy and freedom of expression. In Catriona Mackenzie and Natalie Stoljar (Eds). Relational autonomy: feminist perspectives on autonomy, agency, and the social self. Oxford University Press.

Romalis, Shelly (1985). Struggle between providers and the recipients: the case of birth practices. In: E Lewin and V Oleson (Eds). Women. health and healing: toward a new perspective. Tavistock.

Gilligan, Carol (1985). In a different voice: psychological theory and women's development. Harvard University Press

Belenky, Mary et al (1986). Women's ways of knowing: the development of self, voice and mind. Basic Books

Leap, Nicky (1997). Making sense of 'horizontal violence' in midwifery. British Journal of Midwifery 5 (11)

Hadikin, Ruth and O'Driscoll, Muriel (2000). The bullying culture: cause, effect, harm reduction. Books for Midwives


Home birth: legal and ethical issues.

From Rick Porter (RP), Consultant Obstetrician, Bath.

In the locality in which he works Rick Porter can report 1500 births annually in free-standing midwife-led Community Maternity Units (CMUs) staffed exclusively by midwives, and a 10% home birth rate for the past 7 years, and he expects that similar results will soon be achieved in other areas.

Are we obliged to provide a home birth service? Yes, because of the legal obligation on the local authority to provide a midwife, who has no choice but to work in the place of birth chosen by a mother. In exactly the same way as applies throughout the medical services, we will be required to provide the same standard of care expected of a reasonable body of similar professionals. It will be found to be negligent if a lower standard than this can be proved.

The ethical duties are clear: to provide care, not to harm, and to have the informed consent of the mother. It would be negligent in terms of a lack of essential information for decision making to guarantee that the birth will eventually take place in any particular place (home, CMU); the circumstances which may require transfer to an obstetric unit have to be explained. While there is no easy answer to the issues of death or injury as possible outcomes, each of us must think hard about the wisdom of omitting to mention them; in the event of disaster we must be sure that there was a shared understanding with the client. At least it should be made clear that these risks exist in theory, however unlikely such outcomes may be, and that resources to prevent them exist in specialist units and not at home or in CMUs. Risk assessment for birth in these settings is effectively impossible; most exclusions are relative, not absolute, and supporters of home birth, if they lean toward these, risk crossing the line beyond which negligence may be charged and possibly found.

Sadly discussion of the wisdom of home birth is still a fertile place for the power game to flourish, underpinned by the fear of consequences for ourselves and the organisations in which we work, and a long way third, fear for the safety of the women wishing for the service.

Whatever the adult choice made, good records must be kept, along with well written guidelines and protocols which are adhered to, points which cannot be overemphasised when medicolegal issues are at stake. The degree of vigilance in labour needs to be higher than in hospital, because of the unavoidable delay in transfer; it is a job for the skilled. As providers of this service we are at a disadvantage in court, facing as we do prejudices which may be extreme; on the other hand the intellectual defence for supporting home birth is strengthening, both numerically and from evidence.

Discussion.

What about getting informed consent from a woman advised to transfer from home to the risky environment of the hospital? [Author: The responsibility becomes the hospital's once they have assumed the care]

NE: Some women raised the matter of death as a risk of a home birth; many midwives did not.

The importance that guidelines and protocols are evidence based, and that any ambiguity between the two should be clarified. RP insisted that these should never be imposed, but should be written by midwives for midwives, enlisting the help and support of an obstetrician, and ratified by the Maternity Services Liaison Committee.

The Medical Defence Union (MDU) has stated that practice by an obstetrician which falls outside guidelines and protocols is not legally binding on other practitioners. Many of these are written for registrars in training.

An antenatal teacher made a plea for the young and impressionable practitioners of the future to be given accurate information on pregnancy and birth, rather than mindless drama, in the media and television soap operas.

An independent midwife prefers to follow midwifery rules for medicolegal security rather than follow differing sets of guidelines.

A former independent, now NHS employed midwife makes a plea for the profession to stand firm as autonomous practitioners, taking responsibility for their own actions.

Any diversion from agreed protocols must have its rationale documented in the notes to guarantee security.

Luke Zander recorded his own practice of discussing the possibility of mortal outcomes in home births at an early stage, so that couples can reach their decisions fully informed and prepared, and so that if the decisions need to be examined later they do not lead to feelings of guilt.

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