Mockingjay Midwifery

What Does Autonomy In Birth Mean?

Being able to make choices for yourself and having those choices respected is the cornerstone of autonomy and body sovereignty in birth. As a pregnant person, you are responsible for assessing your own risk tolerance and for making informed healthcare decisions that you feel will serve you and your baby’s best interests.

While midwives are highly educated and experienced with supporting pregnant people throughout the childbearing year, you alone are the expert of your own life and will carry the responsibility for making parenting decisions long after the birth of your baby.

The process of “becoming informed” about your options throughout pregnancy often includes gathering and assessing information from both internal and external sources before sitting with that information and deciding what is true for you, your pregnancy and what decisions you might like to make going forward. Autonomous birth can happen in any birth environment, with any caregiver, and can look many different ways from the outside. What matters, is that you are free to make choices that are meaningful and right for you.

Risk & Safety

The concept of “risk” and “safety” are very difficult to define, as they depend on an individual’s belief system, perception of the situation, and life experiences up to that point in time. What might be considered as “risky” by one person, may feel “safe” or acceptable by another depending on how each person weighs their own risks and benefits. There is no such thing as a “no risk” or “100% safe” situation in any aspect of life, and this carries on being true throughout pregnancy, birth and parenting. As much as we might prepare for and make choices during pregnancy and birth with the best of intentions, unexpected or unwanted birth outcomes sometimes happen. Unfortunately, when this occurs, both birthing people and caregivers have been socially conditioned to look for someone to blame, rather than focusing on how the birth team can provide optimal support for families going through difficult circumstances. 

Ethically and legally, ALL healthcare providers have a responsibility to facilitate and respect informed decision making. However, fear of being blamed for a bad outcome by parents, colleagues and healthcare authorities has led to a global obstetrical culture where caregivers often feel that they need to control parental choices in order to protect themselves and families from trauma and litigation.

While well intentioned, fear-based paternalistic models of pregnancy care promote a culture of biased information sharing, medical mistreatment, coercion and unnecessary intervention with many parents reporting experiencing post-traumatic stress disorder, postpartum depression, anxiety and ongoing physical, emotional and psychological health challenges after their birth experiences.

(Sources cited below)

Human rights in childbirth

The Canadian “Charter Of Rights and Freedoms”and policies from both The College Of Midwives Of Alberta and Alberta Health Services clearly state that pregnant and birthing people have the right to make autonomous healthcare decisions, even if their decision conflicts with hospital policies, or caregiver recommendations. 

You have the right to:

• Access respectful, non-negligent medical care during your pregnancy, labour, birth and postpartum.
• Give birth in the location of your choice, with a trained birth attendant present.
• Have support people of your choice present during your labour and birth (partner/friend/doula).
• Make your own informed decisions without fear of mistreatment or abandonment by your caregiver. You also maintain the right to change your mind as your labour unfolds and you are faced with new information, situations and considerations.
• Access information that is as unbiased and complete as possible in any given moment about your individual situation.
• Provide informed consent or refusal for caregiver recommendations, tests, procedures, and medical care.
• Revoke your consent or change your mind at any time about any aspect of your care.
• Sign waivers which acknowledge and document your decision to decline recommendations.

You have the responsibility to:

• Determine your own risk tolerance, consider all available information, ask questions and be your own best advocate.
• Communicate your decisions honestly with your caregiver so your caregiver can prepare a care plan outlining your choices. This helps your caregiver arrange for support “behind the scenes” so your caregiver can prepare to show up for you in the best way possible within their scope of practice.
• Claim ultimate responsibility for your medical decisions and the outcomes of your choices. Your caregiver cannot be held liable for supporting your right to make informed decisions in the event of an adverse birth outcome or a difficult birth experience. Having the right to informed decision making also means accepting that you may feel differently about your choices in retrospect.
• Release yourself/transfer out of care if you identify at any point prenatally, during labour, birth or the postpartum period that you are no longer in alignment with your caregiver and do not wish to remain in a therapeutic care relationship.

Creating optimal alignment with your midwife

Alignment with your midwife is essential in building relationship and trust during pregnancy and in creating an environment that feels safe and supported throughout the birth process. As some pregnant people’s choices may fall outside of clinical recommendations or standards of care, your midwife must be prepared to navigate support for “off menu choices” while being forthcoming and honest about their scope of practice, personal experience, comfort level and what can and can not be provided or facilitated in any given scenario. Your midwife, as a human being, cannot guarantee any particular birth experience or outcome as birth may be unpredictable and present with unexpected challenges.

“Unique Care Plans” can be created as a form of “harm reduction” (within a medical-ethical-legal framework) that preserves the relationship between the birthing person and their midwife, improves communication and care planning between birthing people, midwives and members of the collaborative care obstetrical team should the birthing person decide to utilize OB collaborative care services at any point, while upholding and affirming the birthing person’s autonomy and right to informed decision making.

Citation Sources

Alberta Health Services (AHS) (2011). Consent to treatment/procedure(s): Adults with capacity. Procedure Level 1. Retrieved from https://extranet.ahsnet.ca/teams/policydocuments/1/clp-consent-to-treatment-prr-01-01-procedure.pdf#search=consent

Canadian Association Of Midwives (CAM) (2015). The Canadian midwifery model of care position statement. Position Statement. Retrieved from https://canadianmidwives.org/wp- content/uploads/2018/10/FINALMoCPS_O09102018.pdf

College of Midwives of Alberta (CMA) (2013). Client requests for care outside midwifery standards of practice policy. Policy. Retrieved from https://www.albertamidwives.org/document/4998/P10-Request-for-Care-Outside-Standards-of-Practice.pdf

College of Midwives of Alberta (CMA) (2016). Informed choice policy. Policy Statement.Retrieved from https://www.albertamidwives.org/document/5006/P18-Informed-Choice-Policy.pdf

Dannaway, J., Dietz, H.P. (2014). Unassisted childbirth: Why mothers are leaving the system. Journal of Medical Ethics 40(12), 817-820. https://dx.doi.org/10.1136/ medethics-2012-101258

Feeley, C., Thomson, G. & Downe, S. (2019). Caring for women making unconventional birth choices: A meta-ethnography exploring the views, attitudes and experiences of midwives. Midwifery 72(2019), 50-59. https://dx.doi.org/10.1016/j.midw.2019.02.009 

Kotaska, A. (2017). Informed consent and refusal in obstetrics: A practical ethical guide. Birth 44(3), 195-199. https://dx.doi.org/10.1111/birt.12281

Hollander, M., van Dillen, J., Lagro-Janssen, T., van Leeuwen, E., Duist, W. & Vandenbussche, F. (2016). Women refusing standard obstetric care: Maternal-fetal conflict or doctor- patient conflict: Legal and ethical considerations. Journal of Pregnancy and Child Health 3(2). https://dx.doi.org/10.4172/2376-127X.1000251

Hollander, M., de Miranda, E. van Dillen, J., de Graaf, I., Vandenbussche, F. & Holten, L. (2017). Women’s motivations for choosing a high risk birth setting against medical advice in the Netherlands: A qualitative analysis. BMC Pregnancy & Childbirth 17(423). https://dx.doi.org/10.1186/s12884-017-1621-0  

Holten, L., Hollander, M. & de Miranda, E. (2018). When the hospital is no longer an option: A multiple case study of defining moments for women choosing home birth in high-risk pregnancies in the Netherlands. Qualitative Health Research 28(12), 1883-1896. https:// dx.doi.org/10.1177/1049732318791535

Reed, R., Sharman, R. & Inglis, C. (2017). Women’s descriptions of childbirth trauma relating to care provider actions and interactions. BMC Pregnancy and Childbirth 17(21), 1-10. https:// dx.doi.org/10.1186/s12884-016-1197-0

van der Garde, M., Hollander, M., Olthuis, G., Vandenbussche, F. & van Dillen, J. (2019). Women desiring less care than recommend during childbirth: Three years of dedicated clinic. Birth 46(2019), 262-269. https://dx.doi.org/10.1111/birt.12419