in working across maternity settings and practical barriers such as caring responsibilities, transport and proximity to work and health issues. However, the study participants did provide helpful suggestions in support of the care models to include adequate staffing, organisation of roles and good leadership and management, induction, support and training for staff, and finally a change in the midwifery profession culture to provide continuity of care of a high standard which is safe (Sandall 2017). The survey concludes that these models of providing maternity care may not suit all midwives and would only be successful if midwives were supported at a local level (RCM 2017) to change the ways in which they practise whilst maintaining their own wellbeing. The above issues will be explored in greater depth in the next chapter. However, changing practice and ways in which midwives work to fulfil the concept of being ‘with woman’ through the models described above can have ethical implications for midwives and an impact on the maternity services for women they care for.
Ethics and Standards
It is often challenging for midwives to make decisions which are appropriate and right for the childbearing women and the families they care for (Katz Rothman 2013). Childbirth is a social phenomenon and is created through the midwife and mother relationship and responsibilities through this social process (MacLellan 2014). Moral actions, underpinning the childbirth phenomenon, are guided by ethical principles in clinical situations to support safe and effective care based on principles of ethics (McCormick 2013).
One approach to ethics, in relation to midwifery practice, is the four principles approach, as identified by Beauchamp and Childress (2013). The principles of respect for autonomy, beneficence (do good), non‐maleficence (minimise harm) and justice (treat people fairly) map well onto the profession's code (NMC 2018). The Code (NMC 2018) specifically emphasises the preservation of safety through prioritising people, effective practice and promoting professionalism and trust. The ethical importance of safety (Chadwick 2015) for women is supported by the four ethical principles: respect for autonomy supports and respects autonomous decisions by both woman and midwife; an obligation not to cause harm through the principle of non‐maleficence; avoiding harm and calculating risks to ensure positive and beneficial outcomes through beneficence; and justice which ensures a fair distribution of risks, benefits and costs (Foster and Lasser 2011).
An interesting approach to ethical midwifery practice is presented by MacLellan (2014), suggesting that the role of care and responsibility may be embedded in actions and judgements through an interpersonal relationship between mother and midwife within a relational model as an ‘ethic of care’, also known as care ethics (Gallagher 2017). This approach is concerned with contextual details within a valued social relationship that is individual to the mother (Newnham and Kirkham 2019). In this model, care is balanced with responsibility of the midwife to ensure compassion and adhere to the principle of non‐maleficence and accountability. This relational support ensures that midwives seek to fulfil women's expectations of their birthing outcomes and is reinforced through the choices offered by midwives when women are in control and empowered through their experiences (Dodwell and Newburn 2010).
Choices, Autonomy and Decision Making
Childbearing women are entitled to make choices based on information and evidence provided by healthcare professionals in seeking the safest and best outcome during childbirth. On the other hand, midwives must consider relevant ethical principles that impact their autonomy in supporting childbearing women to make these choices. However, midwives as healthcare providers are held legally and professional accountable for the care they provide, not only within legal and professional regulations and frameworks, but also as primarily accountable to the woman and her birthing experience, their employing organisation and the community in which they practise (Jefford and Jomeen 2015). They are in a difficult position and must consider the consequences of their decisions, which places midwives in what is perceived to be a vulnerable position (MacLellan 2014). They may consider practising defensively, forgoing autonomous practice in the need to ensure that the accountability of midwifery practice is within the remit of ‘safe’ practice. Hastings‐Tolsma and Nolte (2014) identified this concept as ‘failure to rescue’, which has ethical implications for a midwifery philosophy that promotes normality in childbirth but results in ‘safe’ interventions during childbirth.
Women have the right not to be harmed when in the care of midwives, and care professionals will be liable in the law of negligence if harm results during childbirth (Griffiths 2011). On the other hand, midwives make decisions based on evidence and logical rationale, from a hypothetic‐deductive perspective, together with intuition resulting from experiences based on an intuitive‐humanistic approach (Smith 2016; Jefford et al. 2010; Jefford and Fahy 2015). However, ethical decision making ought to include the emotions and feelings, needs and wishes of the woman (Weltens et al. 2019), as a result of engagement in the mother–midwife relationship, to reflect cognitive beliefs of integrity and justice (Thompson 2005). Ultimately, Daemers et al. (2017) suggest that shared decision making is shaped by experience, intuition and individual circumstance and is influenced by knowledge, attitude towards the natural physiology of childbearing, centring the woman in the event and collaboration with other professionals.
The woman's sense of control and the ability to make choices is informed through their awareness of physiological processes in conjunction with organisational and resource limitations. However, more recently, authors have suggested that hospital culture and policies affect the way that information is presented (Newnham et al. 2017). In these situations, information is not truly unbiased and consequently women are unable to give true informed consent to care that affects their and their baby's outcome. Influencing factors, expectations of the midwife's role and perceived safety have an impact on choices women make – especially in first‐time mothers, as documented by Borelli et al. (2017). The authors suggest that choices such as choosing a place of birth are not influenced by women's perception of midwifery competence in different settings but by their preferences, prior knowledge and a need for a safe and fulfilling experience.
Towards a Relational Model with Confidence and Responsibility
The social context in which choices about care are made are not made in isolation but through an understanding of a professional's true autonomy. A relational model of autonomy is defined by Christman (2015) as the ‘relatedness [that] plays in both persons' self‐conceptions … and the dynamics of deliberation and reasoning’ and is relevant in relation to informed choices in decision making through the dynamics of shared knowledge and negotiation of shifting power between the woman and the midwife (Nieuwenhuijze et al. 2014). Both midwife and woman must become responsible for the consequences of choices made when engaging with and embracing their autonomy.
Relational autonomy creates a space in which women are supported to develop their skills, self‐confidence and self‐esteem to recognise the social context for their decisions (Meadow 2014). However, the principle of respect is key in enabling shared decision making in support of relational autonomy (Lewis 2019). Midwives need to recognise their capability to self‐trust (McCourt and Stevens 2009), to have self‐esteem, self‐respect and act effectively, underpinned by their values and evidence‐based professional knowledge. Women, on the other hand, must be aware of constraining factors, such as organisational resources, when making choices and decisions (Thompson 2013). However, the woman in labour needs to be free from pain and fear, unhindered by medical interventions and afforded her dignity through a relationship with midwives based on trust and sympathetic understanding of her individual needs in a caring and nurturing environment (Morad et al. 2013). Midwives must therefore seek alternative approaches to the care they provide through the value of relational autonomy in which the midwife's and the woman's autonomy is negotiated respectfully to reach an informed decision (Noseworthy et al. 2013). The resulting empowerment process is mutual within the context of midwives ‘being with others’ rather than fulfilling midwifery skills and tasks (Hermansson and Martensson 2011). Parents, once informed and made aware of available resources and possibilities,
