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Building confident ways of working together around higher-risk birth choices.

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For a midwife to provide quality care and 'presence' at higher-risk births she needs designated support, particularly with documentation and novel clinical skills. Normalising complex births requires innovative team formation and openness to learning and sharing new skills. Unique care plans require dynamic teams with flexible, evolving, ongoing development strategies. Proactive, rather than reactive, risk management is crucial to cultural change which is maximally safe for mothers, babies and health professionals.
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... Beginning in 2010, while working as an independent midwife, I became aware that a significant number of women were feeling their National Health Service (NHS) did not meet their needs, particularly when they were seeking a vaginal breech birth (VBB). Feeling strongly breech services needed a home within the obstetric unit, to make the most of the multi-professional team, I and my managers pioneered an integrated care pathway and a new role, the Breech Specialist Midwife (Plested and Walker, 2014). This project was as complex as one expects a breech birth to be. ...
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Problem Women’s autonomous choices in pursuit of physiological childbirth are sometimes limited by the midwife’s willingness to support those choices, particularly when those choices are contrary to recommendations or outside of guidelines. Background Women’s reasons for making such choices have received some research attention, however there is a paucity of research examining this phenomenon from the perspective of caseloading midwives’ and their perception of personal/professional risk in such situations. Aim To synthesise qualitative research which includes the voices of midwives working in a continuity of carer model who perceive any kind of risk to themselves when caring for women who decline current established recommendations. Methods Systematic literature search and meta-synthesis were carried out following a pre-determined search strategy. The search was executed in April 2021 and updated in July 2021. Studies were assessed for quality using JBI Critical Appraisal Checklist for Qualitative Research. Data extraction was assisted by JBI QARI Data Extraction Tool for Qualitative Research. GRADE-CERQual was applied to the findings. Findings Eight studies qualified for inclusion. Five main themes were synthesised as third order constructs and were incorporated into a line of argument: Women’s rights to bodily autonomy and choice in childbearing are violated, and their ability to access safe midwifery care in pursuit of physiological birth is restricted, when midwives practise within a maternity system which is adversarial towards midwives who provide the care which women require. Midwives who provide such care place themselves at risk of damaged reputation, collegial conflict, intimidating disciplinary processes, tensions of ‘being torn’, and a heavy psychological load. Despite these personal and professional risks, midwives who provide this care do so because it is the ethical and moral thing to do, because they recognise that women need them to, because it can be very rewarding, and because they are able to. Conclusion Maternity systems and colleagues can be key risk factors for caseloading midwives who facilitate women’s right to decline recommendations. These identified risks can make it unsustainable for midwives to continue providing woman-centred care and contribute to workforce attrition, reducing options/choices for women which paradoxically increases risk to women and babies.
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