All women deserve access to a safe birth. All women, however, also deserve a positive and empowering birth experience and to be autonomous in their decision making. With the move from the community to the hospital, most women in the western world now give birth in large maternity hospitals, which need to be run efficiently. For the maternity service to run efficiently, it is deemed that midwifery care must be standardised, and tasks must be preformed. Kirkham (2018) states that ‘standardisation requires care to be defined as a series of tasks to be monitored rather than a continuing supportive relationship’.
Providing midwifery care in this way leads to midwives losing their autonomy and flexibility which is essential to woman-centred care. Polices, procedures and guidelines instead of ‘guiding’ the midwife's practice become rules that must be adhered to. With this policy driven practice comes the fear of deviating from the rules and the pressure for midwives to conform to them increases (Kirkham, 2018; Feeley et al, 2020). Providing true woman-centred care and upholding women's autonomy can be extremely challenging within this fragmented system, and this is the challenge that many midwives face on a daily basis.
There are two important events in the history of midwifery: firstly, midwives lost their autonomy and control of their work to doctors; and secondly, doctors and midwives allocated patients according to the notions of appropriate territory; ‘normal’ for midwives and ‘abnormal’ for doctors (Donnison, 1977; Katz Rothman, 1984). Unlike other specialist areas of medicine, a woman is never defined as healthy in childbirth. Katz Rothman (1982) states that even if a woman has all the ‘healthy characteristics medicine can ask for, she still won't be called healthy or even normal. She will be classified as low risk’. Therefore, if women are only ever categorised as ‘low risk, medium risk or high risk’, with the emphasis always on risk, pregnancy and childbirth is never ‘normal’ and will always be pathological and ‘abnormal’, and will require medical-managed care to monitor the risks (Katz Rothman, 1982). Additionally, what is considered ‘low risk’ is constantly changing.
‘Providing midwife care in this way leads to midwives losing their autonomy and flexibility’
Midwives and other health professionals strive to provide care and information that is evidence-based and objective estimates of benefits and risks (Kotasha, 2017). However, benefits and risks are subjective, and may vary according to the individual woman's beliefs and values. Research shows that women and healthcare professionals do not assess risk in the same way (Lee et al, 2016; Jackson et al, 2020). Van Wagner (2016) conducted research into how Canadian health professionals talked to women about risk within their practice which she described as ‘risk talk’. Although her research showed that participants believed it was important to discuss evidence and risk with women, her findings also demonstrated how the process of ‘risk talk’ can lead to an exaggeration of risk.
If a health professional feels that a woman is making a choice that they deem is ‘risky’, they may be tempted to try and persuade her to change her mind. This is not persuasion; it is coercion and has no place in woman-centred maternity care. Kotasha (2017) states that coercion can take several forms in the clinical setting:
- Magnifying risk estimates to dissuade a patient from an option
- Exaggerating benefits or withholding risks of a recommended treatment
- Demeaning a woman for putting her fetus at risk
- Asserting a woman's decision makes her a ‘bad parent’ and threatening to involve child protection services
- Threatening to withdraw care if a woman refuses medical advice.
Often, coercion can be presented as the ‘well-meaning’ health professional, ‘helping’ a woman to really understand the ‘risk’ she is taking. Research demonstrates that women do not see this as helping; women report they feel coerced and pushed into decision making by maternity health professionals to comply with maternity service guidelines and policies (Kruske et al, 2013; Shallow, 2013). Risk talking or risk discourse is a powerful and coercive way of communicating in the clinical environment and is used by some health professionals to direct, persuade and control women (Plested and Kirkham, 2016). The guidelines and policies are written to ensure that safe and appropriate care is provided to women. Women are labelled and put into the categories of medically defined risks and this determines not only what type of care they receive but the place of birth and type of birth they should have.
The medical management of pregnancy and childbirth can best be understood in terms of the separation of mother and fetus, as their needs are seen to be at odds with each other. Wagner (1996) asserts that as the risk approach focuses more on the fetus than the woman, then the woman can be considered as merely a container for the fetus. This poses the risk that the midwife or doctor may feel that they, not the woman, are responsible for the health and wellbeing of the fetus. The universal declaration of human rights gives women a fundamental right to security of person (UN, 1948). Women have the right to decline any medical procedure that violates her bodily integrity, even if that refusal increases the chance of her or her fetus' risk of death (Kotasha, 2017).
If the woman is deemed to be choosing unsafe options, this may result in her being labelled selfish and irresponsible (O'Leary, 2015). Women who decline certain procedures or make choices that are judged to be risky may also be excluded, vilified and, in some cases, punished for their choices (Kruske et al, 2013; Plested and Kirkham, 2016). Research shows that rather than pushing women to comply, risk discourse may push women to disengage with care providers (Plested and Kirkham, 2016; Rigg et al, 2017; Feeley et al, 2020; Jackson et al, 2020).
Research exploring women's experiences of traumatic birth identify interactions with care providers as a more important factor than medical intervention or type of birth (Harris and Ayers, 2012; Reed et al, 2017; Vedam et al, 2019). Women report that policy and guideline-driven care practices lead to a lack of autonomy during birth, resulting in loss of control, poor communication and lack of consent, and this contributes to them describing their experience as traumatic (Harris and Ayers, 2012; Reed et al, 2017; Vedam et al, 2019). Reed et al (2017) found that women's descriptions of childbirth trauma centred on the actions and interactions of care providers. Women described how care providers prioritised their own agendas, disregarded embodied knowledge, used lies and threats to gain compliance, and violated them. Negative care interactions from care providers and lack of support for women's decisions are a significant risk factor for a woman developing PTSD (Harris and Ayers, 2012).
Wagner (1994) passionately supported woman-centred midwifery care and believed that the solution to a broken maternity system lay with women as the principal decision makers, alongside confident midwives in a community based maternity service. Yet, here we are nearly 30 years later with a steadily increasing caesarean rate and far too many women leaving their birth experience traumatised. Woman-centred midwifery care takes time and works on a relationship-based model with mutual respect and time for discussion and information sharing. If women are not allowed to make their own choices around their pregnancy and birth, rather than comply with strict policies and guidelines, they will find another way to make autonomous decisions with or without our support.