This blog post shares some of my learnings from and reflections of a seminar I attended recently, hosted by the Birthrights group at University Hospitals Coventry and Warwickshire. I have always found medical law very challenging to understand, even having studied it at Masters level…I am still largely perplexed by the complexity of it all. Yet this session seemed to simplify things for me, offering case studies and easy to understand facts…for which I am very grateful! For further learning, please see more factsheets here.

Many of the topics under discussion were drawing from the work of the White Ribbon alliance, which I am highly drawn to in their quest to promote the wellbeing of midwives for the benefit of services around the world. Below I will discuss a few of the topics highlighted which have aroused my interest in relation to my own practice.

“Women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk”. – (Lancet 2010).

This publication evoked moral discomfort within me immediately. Having previously practiced as a home birth midwife, I am used to challenging the notion that home birth is a less safe option where mothers put their babies at risk. As with many studies which examine the safety of various birth places, I often see biases where the skill of the birth attendant and other relevant factors are seemingly ignored to promote the argument that ‘It wouldn’t have happened if you had only been in hospital’…But the thought that Women are putting their babies at risk (and choosing to do this) fundamentally goes against my own clinical knowledge and beliefs.

This paper has led to some women having forced cesarean sections…surely this is a path which nobody wishes to go down.

The discussion and debate around fetal rights has also led to mothers being prosecuted for drinking alcohol during pregnancy. This is a moral pathway which sees the woman become a vessel for a means to an end, rather than being an end in her own right. Again, do we really want to take this path? Having explored ethical arguments myself, I think there is a better way..

In this same vein, the issue of when a fetus has rights or not has also been debated and contextualized. Now that the 24 week limit upon abortions has been lifted (decriminalized), it is clear that the mother has more choice in her reproductive decision making abilities. For me, this can only be a good thing.

Human rights-based approaches guided by the World Health Organisation

• Non-discrimination: The principle of non-discrimination seeks ‘…to guarantee that human rights are exercised without discrimination of any kind based on race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status such as disability, age, marital and family status, sexual orientation and gender identity, health status, place of residence, economic and social situation’.
• Availability: A sufficient quantity of functioning public health and health care facilities, goods and services, as well as programmes.
• Accessibility: Health facilities, goods and services accessible to everyone. Accessibility has 4 overlapping dimensions:
  • non-discrimination;
  • physical accessibility;
  • economical accessibility (affordability);
  • information accessibility.

Healthcare practices that violate human rights: Drawn from the Charter for Respectful Maternity Care

Physical Abuse: Episiotomy , non consensual force, restraint, unnecessary procedures, failure to provide pain relief

Disrespect: Verbal abuse, bullying, blaming, shaming and reprimanding

Non-confidential Care: Unauthorized revelations and psychical exposure

Non-consented Care: Anything performed without adequate information or dialogue to enable autonomous decision making, or with undue pressure

Misinformed Care: biased, non transparent information given, which inhibits a woman’s ability to make an informed choice

Depersonalized Care: Inflexible application of policies or guidance, which fail to take into account of a woman’s individual circumstances.

Discriminatory Care: Unequal treatment based upon personal attributes (age, race, religion).

Abandonment of Care: Refusal to provide care due to inability to pay or birth choices (or any reason)!

Check out the Birthrights info on human rights in childbirth here

Attitudes to Autonomy

Lastly, the following statement from a paper published in 2013 had me thinking about the impact of blame cultures within our maternity services.

“Both maternity care professionals demonstrated a poor understanding of their own legal accountability, and the rights of the woman and her fetus. Midwives and doctors believed the final decision should rest with the woman; however, each also believed that the needs of the woman may be overridden for the safety of the fetus. Doctors believed themselves to be ultimately legally accountable for outcomes experienced in pregnancy and birth, despite the legal position that all health care professionals are responsible only for Adverse Outcomes caused by their own negligent actions.”

The statement outlines how both midwives and doctors are happy to accept that the mother has the right to make any final decisions, yet they were under the impression that it was them a the practitioner who would be legally accountable for any adverse outcomes which occurred. This may be in part due to the nature of our regulatory and litigation systems, which can invoke a fear in practitioners that they will be ‘blamed’ in some way for any adverse outcomes.

Yet adverse outcomes occur all of the time, in any case, and sometimes cannot be controlled. This is of course very sad…yet it is also an inevitable reality of some women’s childbearing experience. Nobody’s fault.

When women have true autonomy and the power to make their own decisions around childbirth, they also have inherent accountabilities in relation to the choices they make.

That is why it is more important than ever to make sure that we are recording the conversational dialogue that we are exchanging with women. Consent forms really have no use unless the information can be recalled and maintained. The law dictates that we must be open, honest and avoid influence in open discussion with women.

I personally believe that these conversations would be best recorded in digital format. See my paper on this here.

As always, it is the relationships we build with women that will always be the key to building trust, opening dialogues and beginning advocatory conversations which support women’s ability to make truly informed decisions. We must work in partnership with women and the wider multidisciplinary team in order to ensure that women can make the right decisions for them, and in turn take accountability for the decisions they make. We can only do our best in managing any situation to the best of our abilities as midwives (and as any other clinician). That is what we are personally accountable for.

(Image via http://hakam.org.my/wp/)

Until next time – Look after yourselves and each other