Updated: April 2020
When I facilitate workshops with midwives and students, there is always a lot of discussion and debate about professional responsibilities in the mother-midwife relationship. These debates often get heated, and the complexities of legal, professional, and ethical issues can become confusing. This post is an attempt to ‘un-confuse’ and simplify these matters a little. Please note that this post is aimed at registered midwives ie. midwives who register each year, thereby agreeing to meet professional standards. It is also about Australian midwifery and may or may not be applicable to other countries.
Midwives can get caught up in meeting the needs of the institutions they work in, and/or feeling responsible for the decisions that women make (eg. to follow or not to follow institutional recommendations). So, it can be helpful to reflect on what our core responsibilities are in the mother-midwife relationship, and how we can meet them. These core responsibilities remain regardless of the care model and/or setting.
As midwives we have guidance about our responsibilities via our professional bodies. The International Confederation of Midwives (ICM) provide a number of core documents that are reflected in national codes and standards e.g. the Nursing and Midwifery Board of Australia (NMBA). These documents are referenced when determining whether a midwife met their professional responsibilities. In this post I discuss my interpretation of these documents and the law in relation to responsibilities. I would be interested in your interpretations too so please comment.
“Midwifery care takes place in partnership with women, recognising the right to self-determination, and is respectful, personalised, continuous and non-authoritarian.” – ICM Philosophy and Model of Maternity Care
In essence midwifery care is ‘woman-centred’. This means that the midwife must primarily meet the needs of the woman – not the institution, or cultural norms, or colleagues, or a personal agenda.
In order to meet their core responsibilities, midwives need to be research literate. By that, I don’t mean they need to be able to conduct research or understand complex statistics. However, they do need to be able to find evidence, evaluate it, and apply it to practice. This is why university midwifery programs include research in the curriculum (and yes, students generally hate it!). The NMBA Midwife Standards for Practice state that:
“The midwife supports women’s wellbeing by providing safe, quality midwifery health care using the best available evidence and resources, with the principles of primary health care and cultural safety as foundations for practice.”
“The midwife identifies what is important to women as the foundation for using evidence to promote informed decision-making, participation in care, and self- determination”
“Midwives develop a partnership with individual women in which they share relevant information that leads to informed decision-making, consent to an evolving plan of care, and acceptance of responsibility for the outcomes of their choices.” – ICM International Code of Ethics for Midwives
“Midwives provide women with appropriate information and advice in a way that promotes participation and enhances informed decision-making.” – ICM Philosophy and Model of Maternity Care
It is essential that midwives provide women with adequate information. A failure to do so not only breaches professional standards, but can also result in legal action for assault and battery (due to invalid consent) or negligence (of information giving). The legal standards for ‘reasonable information’ are listed in a previous post; and there are also professional standards about information giving.
Firstly midwives need to be clear about how they practise, their responsibilities, and their boundaries. For example, a woman needs to know that a private practice midwife is guided by the National Midwifery Guidelines for Consultation and Referral and the Safety and Quality Guidelines for Privately Practising Midwives; and what this means if her situation is categorised as a ‘consult’ or ‘refer’. In Australia, private practise midwives can withdraw care if a woman declines consultation or referral. They can also continue care if the woman declines a consult or refer. A woman needs to know her midwife’s threshold for withdrawing care before engaging their services.
When a decision is required about any aspect of care – from place of birth, to vitamin K for the newborn – adequate information must be provided about the option/procedure/intervention. In the case of a procedure – the person performing the procedure needs to gain consent ie. ensure adequate information is given. For example, if a midwife is about to start an induction process for a woman – that midwife is responsible for ensuring the woman is adequately informed. It would be nice if the person arranging the induction, or the person prescribing the medication provides adequate information… but the midwife cannot rely on this. It is her/his responsibility.
If the midwife is employed by an institution she may be obliged to offer particular options eg. a 4 hourly vaginal examination during labour. However the key word is ‘offer’. In addition to this offer, the woman needs adequate information to consent or decline the offer. If the midwife is in private practice she/he needs to inform the woman of the ‘standard’ or mainstream practise, particularly if there are state, national or international guidelines/recommendations.
For an option or intervention adequate information includes:
- The rationale for the recommendation: why guidelines suggest the option or procedure.
- A description of the option or procedure: what it is, how it is carried out, what it involves, etc.
- General benefits and risks of all options: including current research, and whether guidelines are supported by research.
- Individualised benefits and risks of all options: are there different stats/research that the woman needs to consider in regard to her individual circumstances?
Let’s take a look at some examples…
Eg. What a woman needs to know about induction of labour for post-dates pregnancy:
- That most clinical guidelines recommend induction of labour at 41 weeks + because there is an increase in perinatal mortality (baby death) for pregnancies that continue beyond 41 weeks. I can see that some of you are already cringing, but this is the truth. You also need to quantify that risk for the woman in a meaningful way eg. 30:10,000 for waiting vs 3:10,000 if labour is induced (see this post). It is not adequate to just state ‘there is increased risk’ or to say that ‘the risk is small’.
- What induction of labour involves and how it is different to physiological labour; and what would happen if she chose to wait eg. options re. monitoring.
- The general risks and benefits of induction, and of waiting (see this post).
- The individual risks for the woman i.e. factors that change her risks eg. is this her first baby? Are there other health concerns or issues (eg. VBAC)?
Eg. What a woman needs to know to consent to a routine vaginal examination during labour (as per a hospital guideline rather than in response to a situation):
- That the hospital guidelines requires the midwife to offer a vaginal examination, for example, the midwife might say “The guideline in this hospital recommends that I offer a vaginal examination to you because you have been in birth suite for 4 hours. The reason for this is to attempt to estimate the progress of your labour.” (you must do this to meet your employee requirements if there is a hospital guideline or policy)
- The evidence supporting (or not) the recommendation, and the risks and benefits of the intervention: “There is no evidence to support that a vaginal examination is an effective method of assessing labour progress because it can’t predict the future…” insert explanation about how all women have a different labour pattern… and the risks and benefits of the a VE.
- Any individual factors that alter risks or benefits eg. if her membranes are not intact there is an additional risk of infection. In some cases a VE may be helpful to support decision making with regard to necessary intervention eg. if labour seems abnormal or the baby’s heart rate is concerning.
It can also be helpful to assert that it is the woman’s decision and that you will support her in whatever she thinks is best for her (many women think they have to follow recommendations).
It is particularly important to provide clear information when a woman is making decisions outside of recommendations or the norm. There is no risk free choice – the woman must decide which risk is most significant for her. In order to do this she needs to have adequate information. For example, if a woman is choosing to birth at home she needs information about the benefits, risks and other options. She needs know the difference between home and hospital, including how the setting might alter the management of any complications.
Information sharing needs to be documented. Like any aspect of care there needs to be evidence that it happened. For example, when gaining consent for a vaginal examination – rather than writing ‘VE with consent’, list the risks discussed (bullet points will do). Some hospitals are using consent forms for common interventions eg. VE and ARM with a list of risks for the midwife to read out and get the woman to sign. If you give the woman any information resources – write down what you gave her.
It is also important to be clear about your scope and abilities by “acknowledging one’s own strengths and limitations” (NMBA 2008b). This involves being honest with women about your experience and ability to meet her needs. For example, if you have limited experience in attending breech births, and her baby is breech – she needs to know. If she is wanting a physiological placental birth and you (the midwife) have limited experience in supporting this – she needs to know.
A word about words… I realise the word ‘risk’ is used a lot in this post. However, the reality is that as midwives we are expected to talk about ‘risk’. We can change the word for ‘chance’ in many cases – but not all. Like it or not, we operate in a ‘risk’ discourse and for legal purposes need to disclose ‘risk’ information with women. However, I avoid the word ‘safe’ when talking to women about their options. Safety is in the eye of the beholder – it is up to the woman whether she thinks a 1:1000 chance of something happening is ‘safe’ or ‘unsafe’. Saying something is ‘safe’ is a judgement and can be seen as an endorsement of a particular option.
Which brings us to the issue of bias. Information sharing needs to be unbiased, and this is extremely difficult because we are all biased and have our own beliefs and opinions. However, there are some strategies to avoid transmitting your bias whilst giving information:
- Present both sides of the coin (see above) ie. risks and benefits of all options in a matter of fact manner ie. don’t share your personal opinions or experiences (with other women) about an option.
- Avoid advising or recommending particular options unless a complication or pathology is actually occurring. For example, you wouldn’t recommend induction, or waiting for an uncomplicated post-dates pregnancy; but you would recommend a medical review if a woman’s blood pressure was abnormally high.
- Ensure that the woman knows you are not invested in her decision, and that you do not want to influence her either way – say this to her.
- When asked “what would you do?” – point out that you are not her , and not in her situation, and what you would do is irrelevant to what is best for her.
- Avoid telling her what you did with your own pregnancy, birth, baby – again, this is not relevant to her.
- Don’t create unnecessary fear about other options, for example if she is choosing to homebirth, it is unprofessional to tell her how awful the local hospital is. Not only can this influence her decision, but it can also make things problematic if a transfer to that hospital is needed.
A good way to assess whether you are providing un-biased information is to look at what women in your care choose to do. If all of the women you care for choose the same option – you need to consider if you are influencing them. Women are individuals and there should be a range of decisions being made.
Woman-centred care... “enables individual decision-making and self-determination for the woman to care for herself and her family. Woman-centred care respects the woman’s ownership of her health information, rights and preferences while protecting her dignity and empowering her choices. Woman-centred care is the focus of midwifery practice in all settings.” – NMBA Midwife Standards for Practice
Once the woman has made her decision the midwife supports and advocates for her. For example, if a woman declines the offer of a vaginal examination – you simply document her decision and carry on. You may need to let colleagues know what her decision is and ensure that they respect it. In some settings, you may be questioned or pressured about her decision – but ultimately you are fulfilling your legal responsibilities regarding consent. This trumps any institutional cultural norms or expectations.
However, for a midwife in private practise responsibilities regarding support are not so clear. If a woman chooses care outside of recommendations the midwife has the choice to carry on providing support – or ‘withdraw’ care. Unfortunately this has resulted in midwives being held responsible for women’s decisions, simply by agreeing to carry on providing care.
The scope of the midwife “…includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures” – ICM International Definition of the Midwife
The midwife needs to provide competent care within the constraints of the woman’s decisions. For example, competent management of an emergency situation will be different in a home setting compared to a hospital setting.
The Mother’s Responsibilities
Unlike midwives, women are not registered and regulated. Therefore, there are no guidance documents regarding women’s responsibilities in the mother-midwife relationship (and this section is a lot smaller!). However, if midwives meet their responsibilities (above), then women become accountable for their decisions and the outcome of their decisions.
By law, women have the right to make decisions regarding what is done or not done to them. Midwifery should support women to take responsibility for their decisions.
Many factors influence decision making, and the information a midwife provides is only one piece of the puzzle. Humans are active seekers and interpreters of information. We pick and choose, using and discarding information according to internal and external constraints and considerations. Embodied knowledge, personal experiences and other people’s experiences influence the selective designation of knowledge as authoritative or not. We often start with a conclusion, then rationalise it with evidence. We surround ourselves with people who have beliefs and opinions aligned with our own. The internet has increased our access to information and people who will reinforce our beliefs and choices. Midwives cannot, and should not take responsibility for the sources information a woman chooses to engage with.
Most women will be influenced by the mainstream risk discourse and cultural norms. Women who make decisions against this discourse must seek information and people who will support their decisions. Some do this in response to previous experiences with the medical paradigm. Some choose the support of an unregistered care provider (or no care provider) to birth away from the medical paradigm and its intervention focus and inherent discourse about risk.
Outcome of Decisions
The ICM International Code of Ethics state that women should accept responsibility for the outcomes of their choices (if the midwife met her responsibilities). This is not about blame. It is about accepting that an outcome (good or bad) directly associated with a decision is the responsibility of the decision-maker.
Whilst midwives can be affected by outcomes – they cannot take responsibility for the outcome of a woman’s informed decision. For example, if a woman chooses an induction and the outcome is fetal distress and a c-section – this outcome is not the midwife’s responsibility. The midwife’s responsibility is providing adequate information about induction, supporting the woman’s decision to induce, and competent practice (management of the induction process, identification of the fetal distress, and alerting the medical team).
Registered midwives have a responsibility to provide information, support and competent care to women. In return, women take responsibility for making decision and for the outcome of their decisions. Whilst this appears simple, it is an incredibly complex relationship and I would be interested to read your comments about these issues.
Beautifully written Rachel. I believe this accurately captures the responsibilities of the obstetrician also.
Thanks Kirsten 🙂
Thank you for starting this conversation
This is a really helpful article to put things in perspective around feeling like you are responsible for an outcome, even though it was the woman’s fully informed choice. In our ‘blame’ and ‘risk’ culture of hospital practice it sometimes feels like you get blamed for outcomes that really had nothing to do with you. We sometimes forget that a woman has choices!
That was a pleasure to read Rachel; thank you. I wanted to make a comment about midwives withdrawing care from women. I practice as a midwife in the UK in self employed independent practice ie outside the National Health Service (NHS) which is free. I charge a fee for my services. Many of the women who employ independent midwives do so because they are looking for continuity of carer, building a relationship with a known midwife/midwives and are frequently not being supported with their choices by the NHS. Home birth after previous c-section is a common example. In the UK, ALL midwives where ever and however they work, have a duty of care to a woman and cannot therefore withdraw care, if they don’t feel comfortable with a woman’s choices. The reality of this is that for women using the NHS, many don’t know they can make an off-guideline choice, and if they do, then they are likely to be moved sideways for care from another midwife/midwives who feel comfortable with this. For an independent midwife, because the midwife and woman meet and consult before hand, discuss issues, experiences, expectations etc both the woman and the midwife are making an active choice about continuing their relationship – the woman by choosing to engage the midwife, and the midwife choosing to accept or decline the offer based on the consultation. I believe this mutual choosing bodes well for the development a strong trusting relationship. The likelihood of a midwife feeling she cannot provide care for a woman based on the woman’s choices will be low, in my opinion. However should this very unlikely situation arise (a long difficult home birth maybe?) a midwife would be expected to continue to give care, but would seek support and guidance from a supervisor of midwives which is currently a statutory part of regulation of midwives in the UK (but that’s all about to change)
I worked as a midwife in the UK and attended homebirths that were ‘high risk’. It was so much easier there – I had a duty of care and was never questioned about why I supported the woman. Here it is very different. When there is a poor outcome the midwife is scrutinised. Just agreeing to attend is seen as condoning the woman’s choice and therefore being complicit in an outcome. With increasing regulation we have having increasing freebirths… and increasing homebirth deaths.
Personally I never withdraw care once I have taken a woman on as a client. I’ll support her whatever she chooses and make sure I document everything and that she takes responsibility for her decisions. But that does makes me vulnerable.
What do you mean with
” increasing freebirths… and increasing homebirth deaths…”
There have been a few deaths involving free births in ‘high risk’ situations (eg. twins) – situations in which midwives feel unable to provide support due to regulations. Whilst I support free birth as a choice. I do not think it should be something women resort to because they are unable to find midwifery care.
Reblogged this on The Irish Baby Fairy and commented:
Really well put. Hope we eventually get to this way of thinking in Ireland.
I hope women in Australia are respected in childbirth. All I can say is that this is definitely not the case in America. Legally speaking, women have these rights “on paper”, but rights and laws are rarely enforced and doctors know it. Very few women have the means to retain an attorney after the fact, on top of juggling a newborn. Doctors/hospitals and even some midwives take advantage of that (plus a very large dose of public shame, i.e. “as long as you leave with a healthy baby, you don’t get to complain!”) and sadly, they routinely bulldoze opposition to their plan and timetable for how a birth will proceed. It’s a very sad and dispiriting situation. Thank you for reminding everyone clearly what everyone’s rights, duties and responsibilities are! 🙂
Unfortunately Australia seems to be heading in the same direction as the US 🙁
Thank you Rachel for this post. I am a new graduate midwife and have struggled this year with the issue of informed consent. In my limited experience so far, the information that is provided to women is generally bias as it is presented in such a way that supports hospital policy and the recommendations of the medical teams. When a woman questions or declines a recommendation (occasionally see that) often times she is made to feel bad about that decision or scare tactics are used. For example, I remember as a student I was attending a birth of one of my follow through women, a VBAC, and she declined continuous monitoring and VE’s. She was a well informed woman and trusted her body and her labour. After being coerced by 2 different medical staff members she was finally told that if she did not consent she or her baby could die….She was strong and continued to refuse these interventions, her choice! She went on to have a normal birth of a healthy baby. I guess for me at this point I realise the importance of knowing exactly what the statistical risk is for let’s say uterine rupture, or refusing IOL for post dates. How else can we support women to make informed decisions. However it appears that this knowledge is not common place amongst my pears. I also hate to admit that my memory is not the greatest, and I tend to forget data like that quite easily. I wonder what the best way is to have quick and easy access to such data.
Your experience is the norm – that is why I wrote the post. Universally midwives are not providing adequate information. Many do not know the information or how to find it. And yes – it is very difficult to keep all the information in your head! You do end up with the common information in your head because you have the conversations a lot eg. induction, augmentation, VE, VBAC. One of the reasons I started this blog was to direct women and students to the information. I suggest making yourself a little notebook or file with key references in it. Something you can have handy in the clinical area. And for things that don’t come up often – you are not expected to have everything in your head. It is totally appropriate to say to a woman “I’m not sure about that… I’ll find out for you” – then find out. That is why you need good information literacy skills ie. an ability to search out the information you require and evaluate it quickly. That is why so much of your degree study requires you to use these skills (I hope). 🙂
yes I have started doing just that, a small note book with the most common info……. and yes the degree I did has equipped me quite well with research skills, I do know how to find the information I need but I have to say your blog is a godsend, so thanks!
We have a new generation of midwives coming through who have the knowledge about research to really make changes. It is good to know 🙂
…and as I say to my students – don’t reference my blog and don’t rely on my interpretation of the research – go to the source 😉
Of course it is important to cite original material, but this is nevertheless a great starting place and a great source for lively discussion and to gain perspectives that one otherwise may not have thought of…….
I cited key professional documents (with links) and linked to the legal standards too. You can look at the legal standards for ‘material risk’ to support the definitions of ‘adequate information’. 🙂
Please forgive my ignorance but how do you define ‘material risk’ as opposed to clinical risk or risk in general?
It is a legal term i.e. it used in court to determine if adequate information was given. Click on the link in the post to see how the law defines ‘material risk’. I have outlined which clinical risks would be considered ‘material’ in a legal case in the post in relation to specific interventions.
This legal requirement is why you have to be told about all risks associated with a medical procedure when you have one – even rare risks. It seems to be totally ignored in maternity care… but would still stand up in court. Midwives who are not meeting this legal requirement risk legal action.
You might find this article helpful: http://www.medscape.com/viewarticle/736411_2 🙂
thanks that was helpful 🙂
Thanks for the discussion. It is interesting that you begin mother responsibility with decisions rather than the pursuit of and attainment of adequate information. One of the failings of our society is the expectation of knowledge gained and the application of the wisdom that is obtained through growth and development, from pre-birth, babyhood, childhood and youth – ‘stuff’ that each woman takes into her role as mother.
I guess from a legal and professional perspective there is no obligation for a woman to obtain adequate information… the obligation is on the midwife to provide it. Many women choose not to seek information and that is their right. I have cared for women who chose to learn nothing about birth – they did not want any ‘education’ from me either (excluding that needed for consent). They birthed beautifully. In addition, some women do not have the skills (or time) required to seek adequate information. As midwives we have little power over this. However, we can ensure they make decisions buy not making them ourselves.
I agree that birth is an opportunity for self growth and transformation – a time for gaining knowledge about ourselves and our bodies (this is what my phd was about). But, I don’t think it is the woman’s responsibility to have this experience.
Great discussion Rachel. Working across the continuum is a challenge for many employed midwives within Australia. Particularly difficult for new graduate midwives to access let alone being able to support the decision making of informed women. I personally wish I could work and learn beside these new graduate midwives. A great start you have suggested is for midwives to start keeping the research, the hard data so that one can respectfully challenge the organisational beliefs. Through education, midwifery knowledge is strengthen which then informs the culture within the profession to support women better. You have once again inspired me to do continue doing the hard yards.
Having the research to hand can help women to challenge the system for themselves too. I have seen a few women take a cochrane review, or UK obstetric guidelines (which tend to be more evidence based) to an OB appointment to ask why the OBs recommendations don’t match the research or UK OB guidelines. It puts the onus on the OB to justify their recommendations… which generally ends up ‘well we do it this way at this hospital’. Women can feel empowered to go against ‘the hospital’ when they know the status quo is not evidence-based.
And our responsibilities are the same even in fragmented care – just more difficult to enact due to time constraints and work place culture.
Keep putting in the hard yards… it is the only way to shift the culture x
This issue is FINALLY being addressed in America!!! Here is the link to a story just published by the Atlanta Journal Constitution which addresses sexual abuse by doctors: http://doctors.ajc.com/ Included within the scope of this story is the issue of coerced cervical exams (check out Resources for Patients tab, then see on the right side “Acts of Misconduct, 3rd point down, “subject a patient to an intimate exam…without informed consent”). This is the FIRST TIME I have ever seen a major U.S. outlet even discussing this. I know it has been addressed (though not enough) in the U.K. and in Australia (thank you, Rachel), but it has been absolutely silenced in the U.S. We need more of this, more blogs, more websites, more discussion!! 🙂
Thank you for sharing the story. It always amazes me that an incredibly litigious country like the US continues to systematically abuse women. Women need to know their rights and be supported to take legal action. If they do this then it will change practise, and the companies that insure doctors will start insisting on a change.
Rachel thanks for your words, i agree with it. Nowadays midwives need to create a stronger bond with the families where they acknowledge they also are responsable. We need to know that we have a corresponsability, and is better if they know that because when theres a bad outcome sadly the midwives pay too much. Right now I think this is a theme going around between midwives, how can we make families and society understand about this corresponsability? How can we the midwives stop being prosecuted for attending homebirths? Life and death is part of life, complications can happen everywhere so why do the families turn around when they dont have an “orgasmic birth”. For me as midwife is prett. Sad to know that ccolleagues are being prosecuted for fighting for the rights of the mom and baby.
I agree… and wish I had answers 🙁
Can’t speak to what goes on in the minds of Australians and Brits but I can say that in America, attorneys don’t want to represent women who were victimized in childbirth. Look at the case of Kimberly Turbin who refused an episiotomy but was cut open against her will anyway. Eighty attorneys refused to take her case. She even had a recording of herself begging the doctor not to cut her and he just “overruled” her. Evidence doesn’t get clearer than that. So why did these attorneys refuse what seems like such a clear win? Because when the case goes to a jury there will always be that one hold out – inevitably an older female – who repeats over and over, “As long as you leave the hospital with a healthy baby, you don’t get to complain!” That juror tanks the case. Attorneys only get paid when they win. Fear of That Woman keeps them from undertaking a lengthy and expensive legal battle. The heartbreaking irony is that we women are doing this to each other.
My personal belief is that the, “as long as your baby is healthy, you don’t get to complain!” woman had that pounded into her head when she was in labor thirty, forty, fifty years ago and she clings to it. She may have suffered PTSD, trauma, outrage and if she had the nerve to speak about it, someone shamed her into silence. I believe she repeats it now because if she took the time to really think about it, she’d realize how utterly devastated she was/is and it’s just much easier not to open that. Shaming and silencing other women is her way to reinforce her decision to shove down her pain. We need to find a way to move past That Woman. Until we do, women will be underrepresented legally, shamed privately, ignored publicly and violated in labor.