CARE-study: Controversies surrounding Autonomy and Responsibility: a care-Ethical study into the mother-midwife relation

An increasing number of stakeholders in maternity care are advocating for ‘respectful maternity care’, care that allows the voices of women to be heard and taken into account. While it may seem obvious that the care given to birthing women should be respectful, research shows that many women look back upon their childbirth experience as disrespectful, or even traumatic. They are unhappy with care practices that deprive them of their autonomy and threaten their dignity. In some cases, these practices involve the use of interventions against a woman’s wishes, procedures that are described by women as ‘obstetric violence’. Included here, among others, are coercion in the use, or refusal, of pain relief in labor, unnecessary episiotomies, depriving women of freedom of movement during labor, and unwanted internal examinations, support of the pelvic floor, stretching of the cervix, and vacuum-delivery. One of the reasons why respectful maternity care is hard to accomplish is the lack of an appropriate ethical framework. Put simply, the classic bioethical model is inadequate to take the laboring woman into account. Maternity care is unique in that there are two recipients: the mother and the baby. This can lead to a lack of clarity about the responsibility of the caregiver, who must balance respect for the autonomy of the mother with accountability for the medical outcome. This tension is further complicated for midwives who must consider the woman’s autonomy and the outcome of the birth, in the context of her place in the hospital/medical hierarchy as defined by the Verloskundige indicatielijst (Obstetric Indications List). In this research project, we focus on the way these tensions are currently framed in ethical theory: as an inevitable result of the so-called “maternal-fetal conflict”, or, in some cases, as a consequence of mother-midwife conflict. We develop a different, more useful moral framework based on a care ethical approach. Care ethics builds upon a normative theory of relationality, developing participatory methods for empirical research that give voice to those who are not often heard. Dialogue and participation by all stakeholders are used to decrease inequalities in power. This approach reframes the responsibilities that attend birth as shared relational questions – rather than oppositional questions – allowing these responsibilities to be discussed and worked out in a relational process. Midwifery practice traditionally offers opportunities for empowering women’s autonomy and sense of responsibility. The Netherlands has long been seen as a model of obstetric care that is more responsive to a woman’s needs and choices than systems found elsewhere in Europe and in the United States. However, Dutch midwifery care is becoming more medicalized, with a decrease in the number of women giving birth in primary care settings (at home or in polyclinics) and an increase in the number of midwives working as salaried employees of hospitals. In addition, the ministry of health is encouraging new models of “integrated care” that may reduce the independence of midwives and women's choice. These developments, coupled with ethical frameworks that place mothers in opposition to their babies and their caregivers, create a pressing need to develop ethical models that support respectful care of women and babies. This project meets that need, contributing to the development of a care-ethical approach that provides a moral foundation for understanding and solving the problem of disrespectful care and the obstetric violence that can result from that care. Using a combination of theoretical and qualitative empirical research, this project will facilitate a co-creative dialogue with all maternity care stakeholders in order to develop practical tools for preventing avoidable harm in childbirth. These tools include: an instrument for guiding conversations about the ethics of maternity care, education for midwives, and information for future parents. We will also publish our normative, empirical, and applied work in the peer-reviewed journals of medicine and ethics.