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".
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.
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.
MOVE TO SECTION   
Click here to return to the front page
Click here for THE ROYAL SOCIETY OF MEDICINE
This page last updated 2nd December 2010
Site maintained by Basil Lee, Forum Member.