Caring for women making unconventional birth choices: A meta-ethnography exploring the views, attitudes and experiences of midwives

Background: Central to respectful maternity care, is the right for women to make autonomous birthing decisions, even where those decisions are deemed ‘unconventional’ i.e. those that fall outside of recommendations and/or... [ view full abstract ]

Background: Central to respectful maternity care, is the right for women to make autonomous birthing decisions, even where those decisions are deemed ‘unconventional’ i.e. those that fall outside of recommendations and/or guidelines. However, evidence suggests women can face conflict when exerting their agency; decisions can be steered or coerced by maternity professionals in order to comply with local guidelines.  Therefore, the purpose of this unique meta-ethnography was to explore the international literature pertaining to the perspectives of midwives to reveal insights relating to caring for women making unconventional birth choices.

Method: Based upon a predetermined search strategy, relevant databases were searched for papers >1993. Additional search methods such as reference chasing, author chasing and hand searching journals were used. Inclusion and exclusion criteria were applied.  Quality assessments were carried out and the analytical technique was based upon Noblit and Hare’s meta-ethnography. 

Results: From 7237 hits, only six studies met the inclusion criteria. Three third order interpretations were developed: ‘Different lenses, different views’ expresses the conflicting and contradictory perceptions and understandings of women’s previous experiences and the mother-baby dyad; ‘Managing multiple tensions’ conveys the different sources of fears and opposing frustrations experienced by midwifery staff; ‘Ways of working with-woman’ describes the midwives’ perspectives on the central role of relationships to caregiving.  A line of argument synthesis identified that midwives can be either overtly facilitative or reluctantly accepting of women’s unconventional birth choices, in part influenced by litigious concerns. 

Discussion: Whilst the findings of the review should be treated cautiously due to the limited number of studies found, the issues raised do reflect the wider literature relating to medico-legal and medico-ethical tensions, perceptions of risk, perceptions of maternal autonomy and constructs of ‘normal birth’.  This study highlights that for midwives working within institutions, they experience difficult negotiations between real or perceived expectations of following the guidelines, whilst simultaneously working with women who are making alternative decisions. 

Conclusion: Despite strong international rhetoric in support of women’s choices, this review found the midwifery practice of facilitating choice is inconsistent, revealing diverging perspectives.  Moreover, the paucity of evidence suggests that women’s choices and the midwifery practice of facilitating choice remains structurally and functionally invisible.  Additionally, only two studies were situated within a UK NHS context, therefore, the degree to which the line of argument synthesis resulting from this review can be translated into UK practice in general is unclear.  Therefore, it is essential that further primary research is carried out to explore at greater depth, the phenomenon of midwifery practice in relation to women’s unconventional birth choices.