Decision-making in midwifery care differs from that of many other areas of health care. Midwives work with primarily healthy women who are going through a normal physiological process, but also a life-changing journey. Throughout this journey, midwives are advocates for women (International Confederation of Midwives (ICM), 2011), responsible for providing safe, responsive and compassionate care in partnership with women, and facilitating choices (Nursing and Midwifery Council (NMC), 2009; 2012). Moreover, midwives are not caring for one person, but for a dyad: the woman and her baby (born or unborn). Respecting this dyad is crucial for the health of women and families (Association for Improvements in the Maternity Services, 2012). In this paper, the word ‘woman’ is used for ease of reading, but always acknowledges and represents the mother–baby dyad. Similarly, for ease of reading the midwife is sometimes referred to as ‘her’ rather than him/her, although it is acknowledged that some midwives are male.
Midwives as decision-makers
As autonomous practitioners, midwives need to make decisions that in turn guide their actions. They do this by using their knowledge and skills to choose between alternatives as they endeavour to make decisions in the best interests of women.
‘The midwife is considered the expert in normal pregnancy and birth, and midwife-led philosophy emphasises the natural ability of women to give birth. However, the definition of ‘normal’ can be contentious’
The quality of decision-making directly affects the quality of care (Jefford, 2012). Midwives are accountable for the decisions they make and need to be able to justify them. Thus, their decisions should be based on the best evidence (NMC, 2012; 2015). Clinical governance builds on this by emphasising professional accountability in relation to systems that underpin the quality and safety of care (Department of Health (DH), 1998). It is, therefore, critical to explore the complexity of clinical decision-making in midwifery and develop a model to guide decision-making in practice.
Midwifery-led care
Midwifery is grounded in a philosophy of normality and working with women in partnership (ICM, 2014). Midwifery-led care (as opposed to obstetric-led care) has been explored extensively and is associated with improved outcomes and reduced intervention rates with no identified adverse effects (Sutcliffe et al, 2012; Sandall et al, 2013). The midwife is considered the expert in normal pregnancy and birth, and midwife-led philosophy emphasises the natural ability of women to give birth. However, the definition of ‘normal’ can be contentious. In today's health-care system, midwife-led care usually pertains to women who have been risk-assessed and who meet strict normality criteria (Symon, 2006). Even if there were absolutely clear boundaries between what is normal and what is abnormal (such boundaries do not always exist), incorporating this concept into a usable midwifery model would be problematic. When women have complex pregnancies that require consultant care, or fall into the ‘grey zone’ between normality and risk (Dahlen and Gutteridge, 2015), midwives remain the key coordinators of care (DH, 2010). A decision-making model for midwifery should be able to adapt to this situation. Midwives work in a wide variety of settings, therefore a model's utility depends on it being applicable to all midwives who make decisions with women and babies in all settings.
How do midwives make decisions in clinical practice?
Clinical decision-making guides clinical practice. It can be argued that there is no midwifery practice without decision-making, as everything the midwife does (even if she decides to do nothing) is the result of some form of decision-making process. Barber (2012) looked at several models of decision-making and identified two key approaches: the analytical/rational approach and the intuitive/experimental approach.
Barber argued that both approaches have their strengths and weaknesses, and that midwifery reasoning involves a combination of the two. The analytical/rational approach to decision-making fits within a knowledge framework and is logical and systematic. It is focused on the analysis of all facts and the development and testing of hypotheses. It is based on the hypothetico-deductive theory, which incorporates clinical reasoning, and it benefits from being transparent, rational, robust, and the fact that it can be taught (Jefford, 2012). Clinical reasoning skills contribute to sustaining midwifery as an autonomous health profession and to providing quality care (Jefford, 2014). The analytical/rational approach is, therefore, an important decision-making model for both novices and experts. Nevertheless, midwifery will always need more than this model alone.
The role of intuition in midwifery has been well documented (Crowther, 2006; Fry, 2007; Olsson and Adolfsson, 2012) and associated with a broadening and deepening of knowledge, skills, and experience. As expertise increases, so does the role of intuitive decision-making. In this way, the development of intuition is linked to the midwife's transition from novice to expert (Benner, 2000), and to the development of authoritative knowledge (Davis-Floyd and Davis, 1996). Intuition is the process by which knowledge, skills and self-awareness are combined to make more than the sum of their parts (Barnfather, 2013). McConnell (1993) warned that the use of intuition may be risky, as it can be used in the face of incomplete information. In the absence of complete information, the level of knowledge and experience, and pattern recognition embedded in past experience, are key. Patterns are used to make judgements in response to cues or situations. This pattern-matching approach can lead to the development of rapid, ‘short-cut’ mental strategies that can be used when a decision needs to be made quickly. This process is termed heuristics. Muoni (2012) argued that heuristics have a valid place in decision-making. This quick and practical pattern-matching process is thought to be the most commonly used when making decisions in all aspects of life (Eva, 2005), as well as in midwifery (Jefford, 2014). The problem with this approach is that it is subjective and potentially dangerous in certain circumstances; it can lead to errors in decision-making and failure to recognise the error, as the analysis of all available evidence is not undertaken.
Crucially, all methods of decision-making should facilitate the midwife's self-awareness of her decision-making abilities, and her identification of gaps in her knowledge and skills. Knowledge of how decisions are made and the strengths and weaknesses of analytical, intuitive and heuristic methods will help midwives to make better decisions. In practice, a midwife may use different methods at different times. Decision-making with a woman in the antenatal period regarding plans for third stage of labour may use different methods compared to decision-making when caring for a woman with a sudden, massive postpartum haemorrhage. In some circumstances, a midwife may require a sophisticated sequence of checking and cross-referencing as she comes to a decision (see example in Box 1). A model of decision-making for midwifery must be compatible with the range of decision-making theories if it is to be meaningful in all midwifery care situations, and it should be able to reflect midwifery's true potential.
Partnership with women
Over the past decade, there has been a move away from prescriptive care and increased effort devoted to working in partnership with women and providing personalised care (DH, 2014). ‘No decision about me without me’ (DH, 2012) encapsulates this commitment to shared decision-making and patient choice. This approach has influenced the ability of midwives to provide woman-centred care and to become partners in decision-making (Leap, 2009). Woman-centred care provides us with a credible midwifery philosophy in which women are empowered to exercise their informed choice. This is consistent with the role of the midwife as one of being ‘with woman’. At the heart of this approach is the very essence of midwifery: the therapeutic midwife–woman relationship (Page, 2003). It is the quality of this relationship that determines the quality of the midwifery care in terms of the woman's safety, empowerment and satisfaction with care. Hunter (2006) proposed that reciprocal relationships between the woman and midwife are important for decision-making in partnership. However, despite a consensus regarding the relational nature of the decision-making process in midwifery practice (Noseworthy et al, 2013; Campling, 2015), there has been little analysis of how the relationship works when making decisions in modern maternity settings (Levy, 2006).
Midwifery theory, and maternity service policy and rhetoric all promote egalitarian relationships with women and emphasise the importance of choice. However, too often these principles fail to transfer to real clinical situations. Porter et al (2007) observed that putting ‘new professional’ decision-making in partnership into practice is a complicated undertaking, and Law et al (2009) found many obstacles to providing women with real informed choice. Any model used to make decisions about care needs to be based on women's autonomy to make informed choices (Delany, 2008), but also needs to recognise that this autonomy is entangled with other influences within modern maternity care. Organisational, professional, cultural, environmental and other factors may conflict, making decision-making in partnership with women multi-faceted and sometimes complex. There is a real need for a model to assist the midwife as she navigates her way through these factors, and to assist student midwives as they learn decision-making in practice.
Risk
The huge toll of litigation in maternity services has resulted in the emergence of a risk-averse culture in which midwives find themselves fearful of making the wrong decisions (Byrom, 2013). In this environment, midwives may slip into defensive practice. Such defensive practice has dramatically affected the ways in which maternity services are provided, with far-reaching effects, including the over-use of interventions during labour and birth (Greer, 2010). This dilemma between risk and choice is a very real problem for midwifery practice (Symon, 2006). Unfortunately, risk-management processes increasingly distract from personalised care and focus on servicing risk-management systems (Ballatt and Campling, 2011). Decisions need to be defensible, but not defensive. A model of decision-making that assists midwives in integrating risk and choice with all other information in order to make defensible decisions is long overdue.
Existing decision-making models
Jefford et al (2011) concluded that no existing decision-making theory meets the needs of midwifery. Following this, Jefford and Fahy (2015) proposed a model of clinical reasoning for midwifery. However, less than half of the midwives in their study actually used clinical reasoning to make decisions in practice. While the model does provide a focus for further exploration of the analytical steps involved in this important method of decision-making, it does not allow for midwives using a variety of decision-making methods. Crucially, it does not incorporate the key features of decision-making in practice, including the woman's role in decision-making.
Kitson-Reynolds and Rogers' (2011) project with senior student midwives, which aimed to develop decision-making skills, provides some insight into the problem. The authors encouraged students to consider a range of well-established decision-making models to guide practice. Several of these models were based on nursing and all were at least 20 years old. A separate session dealt with the difficulties of making real decisions with women and the complexities to be considered in practice. This theory and practice gap reflects the need for a midwifery model of decision-making which can be used in current practice situations. In the absence of a suitable model that is appropriate for the woman–midwife partnership, decision-making skills are unlikely to be developed, thus threatening the autonomy and professionalism of midwifery. Midwives who lack the ability to make decisions with women may resort to formulaic care and fail to provide women with personalised care, informed choice and advocacy.
Guidelines
In an effort to reduce risk and improve the safety and quality of care, maternity care is increasingly directed by protocols, guidelines, and care pathways. Best practice guidelines have become an important part of maternity care. Guidelines can be nationally or locally produced, at the Trust or unit level. If based on best evidence, guidelines can contribute to improved health outcomes and promote consistency of care (Kirkpatrick and Burkman, 2010). However, not all recommendations in guidelines are appropriately tested through robust research (Woolf et al, 1999); some use opinion or value judgements (Rawlins and Culyer, 2004). In addition, guidelines may not be updated frequently enough to take into account the latest evidence. While guidelines may be best-practice ‘recipes’ for most women, it is entirely possible that they may not be best for an individual woman. They do not replace clinical judgement in partnership with women. As NICE (2012) stated:
‘Healthcare… professionals are expected to take our clinical guidelines fully into account when exercising their professional judgement. However, the guidance does not override the responsibility of healthcare professionals… to make decisions appropriate to the circumstances of each patient.’
There is growing evidence that midwives feel under pressure to demonstrate their compliance with guidelines, and this can have detrimental effects on individualised care (Birthrights, 2013). In this environment, midwives can feel anxious and vulnerable when women request care that contradicts guidelines (Thompson, 2013), and they are unable to support women's informed choices. This systems-focused care is formulaic rather than responsive to the needs of mothers and babies (Kirkham, 2011). Rycroft-Malone et al (2008) concluded that the successful use of guidelines is dependent on balancing them with practitioner decision-making. A model of decision-making that identifies the clinical guidelines as important evidence-based resources in the process, rather than ‘the rule’, would do much to facilitate informed choice and professional autonomy.
Evidence-based care for midwifery: time for a broader definition
The Midwives rules and standards dictate that practice should be evidence-based (NMC, 2012). Evidence is frequently misunderstood as meaning that which has come from research trials. Moreover, the terms ‘evidence-based practice’ and ‘research-based practice’ have been used interchangeably, causing confusion (Carnwell, 2001; Newhouse, 2007). The best known definition of evidence-based care is (Sackett et al, 1996: 71):
‘The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patient/clients.’
This begs the question: what is meant by evidence? Relevant research findings provide only one piece of the puzzle. It is useful to consider evidence to be all valid and relevant available information that impacts the person and the situation (Hicks, 1997). In this way, evidence-based practice is complementary to knowledge gained from research, in that it ensures that this knowledge is placed in context with all other evidence influencing clinical decision-making (Carnwell, 2001).
To make decisions in partnership with women, a broad definition of evidence reflects the reality of the decision-making process. Conclusions and recommendations from research trials should be considered. Clinical guidelines should be understood and taken into account. Evidence includes not only the clinical picture, but also the beliefs, values and preferences of the woman; the skills, ability and judgement of the midwife; and the resources available. Evidence about resources is vital as it has an impact on choice. For example, a woman may want to birth in a midwife-led unit, but there may not be one in her locality. In addition, decisions are not made in a void. Both women and midwives are subject to the influences of the environment in which they live and work. This includes the actual physical environment, as well as the political and cultural environment. In effect, the law of the land and the norms and values of society are the background against which all evidence is dealt with. Professional rules and standards guide and influence the midwife throughout.
A new model
This paper has argued that evidence-based decision-making is a multi-faceted and complex process (Higuchi and Donald, 2002; Tanner, 2006; Barber, 2012). To manage the complexity, midwives need a model for decision-making that helps them to make sense of all available facts and to make robust, appropriate, defensible decisions that are grounded in woman-centred care philosophy. Such a model needs to organise the evidence in a usable way.
The second part of this paper will discuss a new model, which brings together evidence from the woman and the practitioner, along with the appropriate research findings, and in light of all available resources, enabling midwives to make decisions in partnership with women in the real world. Part 2 will detail the factors that comprise the evidence from woman, midwife, resources and research, and a worked example will be used to demonstrate the use of the model in practice. BJM