During their training, student midwives work alongside midwives who share their knowledge and train them to become person-centred practitioners (Nursing and Midwifery Council (NMC), 2019). A key aspect of person-centred care is choice (Royal College of Midwives (RCM), 2022), with the right to choose care long being part of the maternity agenda (Department of Health, 1993). However, despite being part of the agenda for more than a quarter of a century, it is suggested that very few service users have a genuine choice about birth (Newnham and Kirkham, 2019).
Maternity services produce systematic guidance to support clinicians to suggest care to service users (RCM, 2022). These suggestions should be based on the person's own perceived risk factors (Healy et al, 2016). However, the recommendations provided in these guidelines are not always based on what is considered to be the best quality evidence (Prusova et al, 2014; RCM, 2022); despite this, rather than being treated as recommendations, guidelines are often treated as rules that pregnant people must obey (Feeley, 2019). When service users do exercise their right to make choices outside the guidelines, tension can arise because of the perceived risks associated with these choices (Brione, 2015). Page and Mander (2014) attribute this tension to the hospital's risk management processes, which were put in place to reduce harm (NHS Resolution, 2020), but have, as Berhan and Haileamlak (2016) suggested, inadvertently impacted service users' support to make autonomous decisions about their care.
Midwives' experiences of providing care for those giving birth outside the guidelines have been explored (Wickham, 2010; Thompson, 2013; Feeley et al, 2019). Holten and Miranda (2016) describe this as ‘making choices that go against medical advice’, whereas Feeley et al (2019) characterise this as when service users' choices ‘fall outside of national clinical guidelines’. The author conducted a literature search that revealed that nothing was known about student experiences of this phenomenon. This study provides an insight into these experiences, which allows educators to ensure that they educate student midwives appropriately to care for these service users once they are practicing midwives.
Aims
The aims of this study were to explore the experiences of student midwives who care for service users choosing to birth outside guidelines, focusing specifically on service users opting to have less care than is recommended by local or national guidance.
Methods
A generic qualitative approach was used for this study, as it allowed the researcher to investigate opinions, beliefs or reflections on experiences (Percy et al, 2015). It is an approach that Caelli et al (2003) state seeks ‘to discover and understand a phenomenon, a process, or the perspectives and worldviews of the people involved’. It is defined as a standalone approach, which some refer to as basic qualitative research (Kahlke, 2014).
McLeod (2022) suggests that generic qualitative research is appropriate to use when the researcher has no expertise in a specific theoretical approach because it does not have the same explicit philosophical assumptions as other established methodologies (Caelli et al, 2003). It allows the researcher to claim no formal framework, meaning the researcher cannot be penalised for deviating from the strict theoretical rules observed in other qualitative methodologies. Nevertheless, the absence of a methodological viewpoint can be problematic, as rigour cannot be guaranteed if there is a lack of criteria to adhere to (Kahlke, 2014). Therefore, the strengths of established methodologies were considered in the study's design. To circumvent poorly completing this research, the researcher considered their theoretical position. This ensured congruence between the methods and methodology and allowed consideration of how to establish strategies for rigour (Caelli et al, 2003).
Sample
Purposeful sampling was used to recruit five participants (four in their second year and one in their third year) from a university in east England. The university offers placements at three different hospital sites and there were students from each hospital in the study. All eligible students (approximately 140) were emailed an information sheet, outlining the study and explaining that participation was voluntary. This ensured that the participant made an autonomous decision to contribute (Green and Thorogood, 2018). The plan was to recruit 10 participants but unfortunately, the data collection period coincided with the beginning of the COVID-19 pandemic which halted recruitment.
Data collection
Data were gathered using audio-recorded face-to-face semi-structured interviews, which took place at the university. The interviews commenced with an invitation for the participant to describe their experience, providing context to their interview. A semi-structured interview guide was used to aid the discussion. The five interviews, lasting up to one hour, were conducted between January and February 2020.
Data analysis
The interviews were transcribed verbatim. These transcripts were read and listened to repeatedly to allow immersion in the data (Braun and Clarke, 2013). The transcripts were uploaded to NVIVO-12 Pro, where thematic analysis was used to identify relationships or divergence between narratives (Polit and Beck, 2018). Common patterns, concepts, variations and relationships that existed were explored and then organised into nodes, which represented the themes found in the data. These were categorised and placed into clusters, if patterns existed (Vaismoradi et al, 2013). This process continued until no further clustering was plausible and the resulting clusters were defined as the final themes.
Entries into the researcher's self-reflexive diary assisted the development of exploratory comments in the transcript, aiding development of the findings. To conclude the analysis, themes were cross-checked against the interviews. This validated that they captured the meaning of the participants' experiences (Braun and Clarke, 2013).
Researcher reflexivity
To ensure personal biases did not obscure the research outcome, the process was diarised. This allowed self-analysis while analysing the data to highlight any biases or assumptions made. It allowed reflection on the researcher's influence on the process, thus ensuring that the findings were solely constructed by the participants (Moule and Goodman, 2016). This was imperative, as the researcher had experience of caring for service users birthing outside the guidelines, which Berger (2013) states can lead to researcher bias.
Ethical considerations
Written consent to participate was obtained from all participants prior to data collection. All procedures were performed in compliance with relevant laws and institutional guidelines. Ethics approval was obtained from the University Faculty Research Ethics Committee (reference: NM-SREP-19-013).
Results
Participants were able to self-define what ‘birthing outside the guidelines’ meant to them. All participants provided an example that could be defined as going against medical advice or involved care that fell outside of guidelines (based on national guidance at the time). The examples given included declining fetal monitoring, birthing in a place that was not recommended or declining certain aspects of care such as cannulation and blood products. Three themes emerged that described the participants' experiences: ‘contradictions’, ‘the actions of clinicians’ and ‘punishment and judgement’.
Contradictions
The theme ‘contradictions’ gave insight to the incongruity identified in the participants' narratives. The subtheme ‘supporting without responsibility’ explored how students vocalised supporting choices but asserted the opposite closer to completing their training and becoming a registered midwife. The subtheme ‘service users are different than expected’ illustrates students' preconceived ideas that these people would be difficult to care for, as well as the realisation that these beliefs were incorrect.
Supporting without responsibility
The participants all voiced that at the time of providing care for a service user birthing outside the guidelines, they supported the service user's informed choices.
‘They need to know why we want to do it. If they still don't want to do it, just let them do what they want to do.’
Participant 5
However, it was evident throughout four of the narratives that at the time of providing care, they had not understood the potential implications of a service user choosing to birth outside the guidelines.
‘We hadn't done emergencies yet at university, so I guess I didn't think it through like I would think it through now.’
Participant 1
Later, having more knowledge and being closer to completing training, three participants stated that their concern around these choices had increased. As a result, they felt more concern for their registration if something went wrong. This transformation saw their views becoming more aligned with midwives they described as not in support of these choices.
‘I would now feel like how my mentor felt, like, “oh, it's my pin”. I need to make sure that baby is okay.’
Participant 5
Service users are different than expected
All participants had preconceived ideas that service users choosing to give birth outside the guidelines would be difficult to care for or reckless prior to meeting them. When asked what had led to this opinion, they explained the way they had heard these service users being spoken about by other clinicians.
‘The senior midwife who handed over the care, in handover, was a bit, “this woman's obviously happy to die”.’
Participant 3
Yet all participants stated that there was a contradiction between the service user they expected to be caring for and the one they met.
‘I've been told she's this really difficult woman, and actually she was just a bit scared.’
Participant 4
After spending time with the service users, four participants realised the service users were not being difficult, but were instead driven by a personal belief, a previous experience or fear.
‘She'd had an awful caesarean last time, and she felt she wasn't cared for.’
Participant 4
The actions of clinicians
The theme ‘the actions of clinicians’ discusses how participants experienced clinicians behaving when faced with this phenomenon. The subtheme ‘how we support choice’ focused on how participants witnessed midwives' behaving defensively, even when appearing to support care outside the guidelines. The subtheme ‘without autonomy’ demonstrated actions witnessed by participants that did not respect bodily autonomy.
How we support choice
When participants were asked if they felt midwives supported the choices of those giving birth outside the guidelines, responses were varied. Some felt midwives were supportive of these choices, while others were unhappy to facilitate this care. Other midwives could be influenced by the doctors' opinion.
‘The response wasn't that great by some of the midwives because obviously we want to keep an eye on baby.’
Participant 5
‘I feel like sometimes it depends on the midwife, if they're going to just go with what the doctors want, or if they're going to say “I'd be happy to look after her”.’
Participant 1
However, congruence was noted in all interviews, that midwives' acceptance of the choice depended on the perceived risk.
‘It's just like a whole spectrum, isn't there? A woman who wants to free birth on her own and something goes wrong. Then you've got women who want to birth in hospital.’
Participant 3
In all narratives, regardless of the level of support the midwife exhibited, examples of defensive practice were noted. This included excessive documentation or repeatedly asking the service user to reconsider. One participant explained that this resulted in her acting this way as well.
‘I was really meticulous, and I felt that I might have gone on to her a little bit, because I was stressed.’
Participant 4
When asked why midwives behaved this way, participant 4 said ‘because they believed that's what's best for the woman’. In four of the participants' experiences, non-supportiveness of choice was also exhibited by senior midwives.
‘At the time we just went to the superior one and she said “no, you've got to do it” basically.’
Participant 5
One participant felt that this was because these choices increased the senior staff's workload.
‘It was just the higher band people that were a bit aggressive towards the situation, because they were managing so many people’.
Participant 4
Nevertheless, after the service user had given birth and the perceived workload had eased, the senior midwives' attitudes did not improve, according to the participants.
‘She was like, “oh, well it worked out well for her”, but it was almost a bit of bitterness towards it.’
Participant 4
Without autonomy
The behaviours and language witnessed by all participants did not always respect autonomy. Participants recalled hearing regular use of words like ‘allowed’, and ‘can't’, although this was not exclusive to scenarios where a service user chose to give birth outside the guidelines.
‘I've heard it a few times, “can't”.’
Participant 2
Four participants experienced care plans being made without consulting the service user.
‘The doctors had almost made a plan for her, before they'd even seen her.’
Participant 4
When service users went against the plan, participant 4 witnessed a midwife's annoyance and questioning the service user.
‘[Quoting another midwife]“This is ridiculous. Why can't we cannulate? Ridiculous. You've done that… why can't you do the rest?”’
Participant 4
Punishment and judgement
The theme ‘punishment and judgement’ explored the treatment of service users who went against the guidelines. The subthemes were ‘midwives' reluctance to provide care outside the guidelines’ and ‘unprofessional behaviour’, which illustrated the language and behaviours that participants witnessed being used by clinicians.
Midwives' reluctance to provide care outside guidelines
One participant reported that they witnessed midwives who refused to provide care.
‘In handover it was “oh, it's one of those women” and everyone was like “oh, I don't want her. I don't want that one”.’
Participant 4
Another participant described how a service user was treated when a midwife realised that she would be giving birth outside the guidelines.
‘I felt uncomfortable by the midwife's attitude, because you saw an instant change in the care given.’
Participant 2
When asked why they felt midwives acted in this way, two participants stated that they felt midwives did not know how to provide care in these scenarios.
‘She didn't know what to do.’
Participant 2
The participants further added that they also did not know what to do, as they did not recall giving birth outside the guidelines ever being discussed during training.
‘I can't pinpoint a specific conversation we've had where we've talked about…birthing outside the guidelines.’
Participant 1
‘I feel like there's not that much preparation for when you're off a guideline, because if that's what guides our practice, what do you do when you haven't got anything?’
Participant 4
Unprofessional behaviour
The participants spoke of service users being discussed by midwives in a derogatory way, including implying that they lacked awareness of the risk of their decisions. Some midwives were reported to cast judgement over choices, including those relating to religious beliefs. Participant 3 discussed the care of a Jehovah witness who declined blood products.
‘When you get handed over and the senior midwife's like “she's obviously happy to die” and you're like, “yes, but that's her belief”.’
Participant 3
However, this participant recognised that the chance of the service user dying because of the decision was minimal.
‘The chances of that [the service user dying] happening are slim.’
Participant 3
Despite witnessing negativity towards these choices, all participants described the service users experiencing what they felt were positive outcomes.
‘She went home a few hours after…she was happy with the way everything went.’
Participant 1
Participant 1 did not expect a good outcome, because of what she had been taught would happen if guidelines weren't followed.
‘That was completely different to what we've been taught and what we've been told we should do, but we still got a completely healthy baby, a completely healthy mum.’
Participant 1
Two participants also witnessed members of the wider multidisciplinary team demonstrating poor attitudes towards service users.
‘A member of the theatre team was openly annoyed at her, that she was not wanting to have blood products.’
Participant 3
When participants were asked how they addressed these behaviours, they all stated that the university taught that there was a professional obligation to safeguard service users from undignified treatment and that they must be their advocates.
‘Our lecturers are really good, like, “it's your woman, advocate for her, if that's what she wants, advocate for her”.’
Participant 5)
However, they felt powerless to do so. Three of the participants stated that this left them feeling guilty. When asked to elaborate on why they did not feel they could challenge these behaviours, four participants stated that they feared it could damage the student–supervisor relationship. Two participants further added that they feared it would affect their grades.
‘You don't want to ruffle anyone's feathers either way…she's got to do my paperwork later.’
Participant 2
Discussion
In this study, the results show that student midwives experience conflicts when caring for service users making birth choices outside the guidelines. This conflict exists between what they are taught and what they see, the judgements they hear and the service users they meet. This conflict is also internal, as they address feeling powerless to advocate for service users, despite knowing that this is their duty (RCM, 2022). Furthermore, the participants' narratives revealed that birth outside the guidelines was not discussed during their education. This lack of awareness makes these situations potentially challenging for midwives and could theoretically be why the midwives discussed by the participants did not feel they knew how to provide kind and dignified care in these circumstances (NMC, 2018a).
It was evident that a variety of attitudes towards service users who make choices outside the guidelines existed among those providing care. This concurs with Feeley et al's (2019) findings, which suggested a spectrum of attitudes exists among midwives, from ‘willingly facilitative’ to ‘reluctantly accepting’ when faced with this phenomenon. All participants experienced at least one person who behaved negatively towards the situation. This manifested in reluctance to provide care, clinicians making care plans without consulting the service user or speaking about them disrespectfully. These behaviours created preconceived ideas for student midwives as to what the service user would be like, and could be considered contradictory to the work that has been done to humanise birth by moving away from paternalistic healthcare (Dahlen et al, 2020). Furthermore, these actions fail to meet the expectations outlined by the NMC (2018a) in regards to preserving service user dignity and providing care that respects individual autonomy (RCM, 2022).
Autonomy, at its most basic level, is being able to control one's own life without regulatory and limiting interference from others (Beauchamp and Childress, 2019). The reluctance to provide care witnessed by the participants could be said to fail to acknowledge this basic human right and the individual's right ‘to timely healthcare’ (World Health Organization, 2015; White Ribbon Alliance, 2021). Although midwives have a right to conscientiously object to providing certain care (NMC, 2018a), refusing to provide care in these circumstances could be considered punitive (Jenkinson et al, 2017). It may also be a way for midwives to exhibit their moral opposition to these decisions (Feeley et al, 2019). These behaviours made the participants feel uncomfortable, as they felt that service users had specific motivations for their choices, to which midwives had a duty to be sensitive (NMC, 2018b; 2019).
Language surrounding childbirth and the impression it creates has been extensively discussed (Simkin et al, 2012; Hill, 2015). In these participants' narratives, language could be described as directive, with words such as ‘allowed’ and ‘can't’ being used as the norm. Participants felt exaggerated language was also used by midwives when describing the risk associated with the choice to give birth outside the guidelines. However, the participants felt that the articulated risk was not a definite diagnosis (Odent, 2014; Birthrights, 2017). Odent (2017) suggests that this language is used because clinicians believe individuals cannot give birth without assistance. It could be considered that in these experiences, when a choice challenged this belief, it caused tension between the service user and the clinicians, thus aligning to the experiences and tension felt by midwives in other research studies (Thompson, 2013; Jenkinson et al, 2016). This tension may be the result of a misinterpretation by midwives of where the accountability lies if something goes wrong (NMC, 2018b). This has been apportioned to the historic blame culture that has existed in midwifery practice.
Participants felt that fear of blame impacted their supervisors' actions, with evidence of defensive practice articulated in all scenarios (even when the participant stated the midwife was comfortable facilitating choice). Healy et al (2016) suggests that this fear prevents clinicians from trusting individuals to make decisions about their care, which can result in midwives practicing defensively (Weir, 2017). Defensive practice among midwives when providing care outside the guidelines is not exclusive to this research (Thompson, 2013). This is concerning, as this type of practice prevents midwives from providing personalised care, which is cited as being safer (NHS England, 2016; Brigante, 2022). Initially, this fear was less evident in the participants themselves, and although they believed that following guidelines was in service users' best interests, they also respected an individual's right to choose their care. However, the participants' narrative changed when they considered themselves qualified, when their professional responsibilities began to be realised. This manifested in participants seeming more fearful of the perceived risks associated with these choices.
Two participants felt that the midwives did not know how to manage care outside the guidelines. Robotham (2000) suggests this is to be expected, as to practice autonomously, clinicians must have the expertise to do so. Midwives may struggle with this proficiency because of reliance on technology, guidelines and the risk management processes to which they are accustomed (Benoit et al, 2005; Wickham, 2011). Nevertheless, when service users opt to give birth outside the guidelines, midwives are not expected to act alone. Instead, they should work alongside a consultant obstetrician or midwife, referring the service user to them so that they can discuss their plans. This ensures individuals are supported to make informed decisions about their care (National Institute for Health and Care Excellence, 2017).
Participants spoke passionately about autonomy and knew it was their professional obligation to safeguard individuals against undignified treatment (NMC, 2018a). Nonetheless, the participants felt that this was difficult as a student, as doing so could impact their relationship with supervisors and potentially their grades. This parallels Davies and Coldridge's (2018) findings, who also reported students felt powerless to advocate for service users. This is not unreasonable when considering Gillen et al's (2009) and Steen's (2011) work, which suggests students can be bullied in practice. This need for self-preservation distressed participants, who struggled with the guilt associated with failing to advocate for the service users in their care. Hunter and Fenwick (2018) suggest that these feelings can negatively affect a student's psyche, which can potentially lead to anxiety and burnout (Beaumont et al, 2016). With many midwives leaving the register (NMC, 2022), it is important to look for ways to reduce burnout early in a midwife's career. This is essential to preserving the future of midwifery practice (RCM, 2017).
Limitations
Although the small sample for this study could be a limitation, qualitative research is not intended to be generalisable but instead used to construct meaning. Thus, the modest sample size may not be a limitation of this research, especially as three themes emerged (Holloway and Galvin, 2017). It was also evident during analysis that the same themes emerged in the narratives, suggesting that data saturation had been met (Faulkner and Trotter, 2017). This supports the belief that it is possible to achievable a homogeneous qualitative sample with just 5–8 participants (Holloway and Galvin, 2017).
The Hawthorn effect may have meant that the participants changed their responses to the questions because of the presence of the interviewer, impacting the validity of these findings (Sedgwick and Greenwood, 2016). Although qualitative methodologies support researchers undertaking interviews to enhance reflexivity, a third party could have conducted the interviews. This would have ensured that the researcher did not impact the findings, especially as the researcher had experience of the phenomenon (Berger, 2013). A further limitation was that as this was an unfunded piece of research, a second researcher to analyse data could not be employed, potentially affecting the research's credibility (Polit and Beck, 2018).
Conclusions
Students were exposed to clinicians' behaviours that were, at times, inapt, with a failure to protect and advocate for service users giving birth outside of the guidelines, leaving them feeling distressed and anxious. This feeling of anxiety can lead to burnout, and all midwives should serve as role models, supporting choice and working with consultant obstetricians and midwives to ensure safer personalised care. This will teach future midwives to provide a standard of care that is person-led. It is apparent that some midwives may not know how to provide care outside guidelines, which could be a potential catalysis for poor behaviours. Training on how to provide choice should be a part of midwifery education and midwives' mandatory training.
Key points
- Choice in childbirth is not a new concept; however, it has been suggested that few service users have a genuine choice about how they give birth.
- In practice, when service users choose to give birth outside the guidelines, there can be tension with caregivers because of the medico-legal and medico ethical issues associated with these choices.
- For student midwives, the experience of caring for these women educates them on the potential challenges that they may face when service users exert their right to bodily autonomy.
- Prior to this research, nothing was known about student midwives' experiences of caring for these service users; this research aimed to bridge that gap.
CPD reflective questions
- As a midwife, what is your viewpoint on service users who choose to give birth outside the guidelines?
- Do you feel comfortable providing care outside the guidelines? What has made you feel this way?
- What additional training would assist you to feel confident in delivering care outside the guidelines?
- Do you ever use language to discuss service users that could be considered inappropriate or punishing?
- Do you consistently act as a role model for student midwives?