The Human Rights Act (1998) sets out fundamental freedoms and rights we should all be entitled to. It is based on the principles of equality, fairness, dignity and respect. Since starting as a Student Midwife in 1999 this act has underpinned all government and health policy I have worked under and it forms the basis for the NMC Code of Professional Conduct (2015), which is a professional bible. Midwives have a central role on preserving a woman’s human rights, but how?
Midwives have a legal duty to uphold the standards of the human rights act when supporting women in their birth choices, involving them in decisions about their care, in protecting the right to life and providing safe care, ensuring women are treated with dignity and privacy and respecting a woman’s autonomy and freedom of thought (BIHR, 2016).
On the surface this seems simple. Midwifery is a caring profession with midwives working ‘with woman’ to empower them and ensure they are safe during their journey to motherhood. Women are encouraged to be partners in their care, they are encouraged to attend antenatal classes and formulate birth plans. Their choice of place of birth is discussed. Before any care is given informed consent is sought. All these discussions around care are firmly based on risk assessment, underpinned by research and evidence. For the majority of the time this is simple and these exchanges between woman and midwife are seamless. However, what happens when a woman doesn’t fall in line with her ‘risk level’? What happens when a ‘low risk’ woman wants a caesarean section? Or when a ‘high risk’ woman wants a home birth? Where does the midwives role sit with unassisted or ‘free’ birth?
According to NICE guidelines a ‘low risk’ woman can request a caesarean section without a clinical indication (NICE,2014), but in practice this can be discouraged on grounds of the risks associated with caesarean section. To further complicate this, the risks of vaginal birth are rarely discussed, it is the “default option” of childbirth (Black, 2016). Home birth is usually considered ‘safe’ if a woman is ‘low risk’ and she will be supported in her choice in place of birth, but what happens if she has raised BMI or maternal age over 40 when she is otherwise well? She immediately becomes ‘high risk’ and her ‘choice’ is discouraged. When women choose to have an unassisted birth it is often because they believe that this natural and intuitive and do not want any intrapartum care from a midwife (Jo, 2016).
The classification of risk as ‘high’ or ‘low’ remains a fixed concept, which arguably it is not. Risk sits on a continuum, and until this is accepted it will continue to be difficult for health care professionals to provide truly individualised care. Every woman deserves her care to be based on her unique and individualised circumstances. This should be governed not only by her physical, but also her mental health and her belief systems. Every woman has her own narrative which will underpin her birth and motherhood choices. These are her choices which need to be respected, in alignment with the human rights act.Given these examples; Where does a Midwife’s responsibility with relation to the human rights act sit in situations where black and white merge in to varying shades of grey?
A midwife needs to develop a relationship with the woman in order to have open and honest discussion on the reasons for her choices and attempt to understand the motivations for her wishes. A woman wishing for a home birth may have a deep rooted fear of hospitals, by understanding this the midwife can assist the woman to seek help to resolve such an issue and support her to birth at home as safely as possible. A midwife can act as a support for women requesting caesarean section where there seems no physical clinical indication, discussing reasons for requesting this type of birth, managing any fears around birth and acting as an advocate in any discussions with an Obstetrician, if this is required. The midwife has a responsibility to discuss the risks around a woman’s birth choices in a non-judgemental manner and support the woman, liaising with a Consultant Obstetrician and/or a Supervisor of Midwives to put a modified birth plan in place, taking in to account the individual risks.
When a woman makes childbirth choices that are not in line with policies and protocol it may not be easy for a professional to understand given they have spent their career basing clinical decisions on best available research and evidence. However, midwives’ beliefs must be set aside in order to cater to women’s needs. If this does not happen a midwife could be in violation of the human rights act; “Failure to provide sufficient, objective and unbiased information for a woman to make an informed choice will also violate Article 8. See our factsheet, Consenting to Treatment.”(Birth Rights, 2016). Even in the case of unassisted birth a woman’s choice needs to be respected (NMC, 2012).
Ultimately the human rights act and childbirth are inextricably linked, and these are just a few of the issues which may arise. Midwives are well placed to ensure women’s voices are heard. By giving women their voices and truly respecting their choices, midwives are protecting and promoting their human rights, optimising birth experiences, encouraging positive birth and setting the foundations for positive motherhood.
Schiller, R. (2016) Why human rights in childbirth matter. Pinter and Martin.
Black, M. (2016) Vaginal birth comes with risks too – so should it really be the default option? http://theconversation.com/vaginal-birth-comes-with-risks-too-so-should-it-really-be-the-default-option-62855 (accessed 27/09/2016)
Birth Rights (2016) Human rights in maternity care. http://www.birthrights.org.uk/library/factsheets/Human-Rights-in-Maternity-Care.pdf (accessed 27/09/2016)
BIHR (2016) Midwifery and Human Rights; a practitioner’s guide. https://www.bihr.org.uk/Handlers/Download.ashx?IDMF=844b6bc8-c85e-4386-adb9-6ef9d88ef1ab (accessed 27/07/2016)
Jo (2016) Unassisted or freebirth. http://homebirthersandhopefuls.com/other-common-questions/unassisted-free-birth/ (accessed 27/09/2016)
HMSO (1998) The Human Rights Act. http://www.legislation.gov.uk/ukpga/1998/42/contents (accessed 27/06/2016)
NMC (2015) The Code. https://www.nmc.org.uk/standards/code/read-the-code-online/ (accessed 27/09/2016)
NMC (2012) Freebirthing. http://mydoula.co/wp-content/uploads/2012/08/NMC-Freebirth.pdf (accessed 27/07/2016)