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2 Ethical Perspectives of Being ‘with Woman’
Anna M. Brown; Donna Hunt (midwife); and Emily (woman)
Introduction
This chapter considers ethical issues which impact women and maternity healthcare professionals as a result of care delivery during the childbearing continuum. Women have to make informed decisions and face a myriad of choices during their journey. Equally, care providers have an obligation to provide the best available evidence and information to enable women to make choices about the model of care that is available to them, places of birth and modes of delivery. Midwives seek to deliver care that is effective, ethical and takes into consideration their professional autonomy and responsibility (NMC 2018). New professional standards for midwifery proficiencies indicate that key domains include ‘an accountable and autonomous midwife who provides safe and effective care as colleague, scholar and leader’ though models of continuity of care and carer (NMC 2018 p. 16). These expectations have ethical implications which can influence the outcomes of a woman's birthing experience and a midwife's scope of professional practice.
It is reasonable to suggest that women's experience of childbirth is influenced by the care providers and the environment in which the birth takes place. The power dynamics between the midwife's autonomy to provide care, which is embedded in knowledge, and a woman's input to the process is crucial to birth outcomes. The place of birth impacts on the woman giving birth and on the midwife's social and spatial relationship. This includes the dynamics of control in which the birth event takes place. A woman is empowered to feel in control in a ‘home’ environment where she is familiar and comfortable; whilst a midwife has knowledge of the complex settings in a hospital environment. The midwife is therefore perceived by the woman to be in control. As such, it has been argued that hospital births do not generally accommodate the midwifery construct of a belief in the competence of a woman's body to be able to birth a baby and be an active participant in the childbearing process (Davis and Walker 2010).
Midwifery Working Practices
A document published in 2011 (Birthplace in England Collaborative Group) supports evidence that considers the impact of midwife‐led intrapartum care from the user perspective (Renfew et al. 2008; Smith et al. 2008; Cheyne et al. 2013). This report suggests that this model of care offers a better birth experience. Other evidence shows how this model of care also increases women's satisfaction and reduces medical interventions during childbirth (Thompson et al. 2016, p. 67; Ross‐Davie and Cheyne 2014; Sandall et al. 2015). Walsh and Devane (2012, p. 897) suggest that the term midwife‐led care has evolved to mean ‘autonomous care by a midwife of women designated at entering the maternity services to be healthy and at low risk of complications for pregnancy and birth’. A meta synthesis of related literature identified that a midwifery‐led approach to care increased midwifery autonomy (Walsh and Devane 2012). This results in empathetic and nurturing care; a language of compassion and sensitivity which is facilitated through the midwife–woman relationship.
Previous literature, reporting the perspectives of service users, (CQC 2013; Janssen and Wiegers 2006) recognised the need for improvement in maternity care services and highlighted problems of lack of continuity of care, courtesy and professional competence. The findings from the 2013 Care Quality Commission (CQC) survey reported on missed essential elements of care as identified by women accessing maternity care services. These included lack of support and inconsistent information to women, which disempowered them when attempting to make decisions about their care. This was compounded by lack of continuity of care and carer. Unfortunately, these concerns are still relevant, as highlighted by the more recent Better Birth's report (NHS England 2016) which implies that maternity services improvements are still to be made, thus impeding optimal care in childbirth.
The publication by NHS England (2017) to implement Better Births and promote continuity of carer set out a guide to support maternity care providers to start up pilot schemes which encourage two main models of maternity care. The first, the Team Midwifery model, indicates that each woman has an individual midwife who is responsible for coordinating care whilst working in a team of four to eight midwives, with team members backing‐up their colleagues. The second suggested model was that of Total Case Loading in which each midwife is allocated a number of women to care for and then arranges her working life around the needs of the caseload (Dunkley‐Bent 2018). However, both schemes could impact on the work–life balance of midwives and have implications for health and wellbeing, resources and cost to staff and organisations. These findings are supported by Jepsen et al.'s (2016) study which suggests that midwives need to be prepared to provide a caseload service by balancing disadvantages of their work commitment and obligation, in return for appreciation and social recognition. The outcomes are a meaningful and satisfactory result for the midwife in fulfilling a woman's expectations through a positive birth experience. However, such a commitment and obligation must surely impact on the health and wellbeing of staff.
Taylor et al.'s survey (2018) and earlier literature (Yoshida and Sandall 2013) suggested that although midwives welcomed the focus on continuity of carer,
