"If you treat a person as she is, she will stay that way, but if you treat her as if she were what she could be, she will become what she could be."
Sometimes we feel caught between the need to accommodate a woman's wishes and following guidelines and minimising the risk of litigation. The woman's pregnancy, labour and birth are, however, the consequence of choices she has made. And her wishes should be at the centre of the care she is given.
Unfortunately this is not often possible within the organizational cultures in which we work - we don't have the empowerment, autonomy or, very often, the confidence, with which to deliver it. And so women's wishes are frequently subordinated to organizational priorities and policies, creating great unhappiness and dissatisfaction.
Women, however, are becoming more and more vocal in demanding what they want. The consumer attitudes that have become common in many areas of our society are spreading to the maternity services, and a new generation of women increasingly want a say in the care they receive.
This may in time result in a swing the other way, towards undue deference towards what women want. But respecting women's wishes must never involve compromising standards of safety or good practice. What she says she wants may or may not be appropriate, depending on how much information she has and whether she is willing to consider the information given to her.
So woman-centred care does not mean that you should subordinate your clinical judgement to her wishes. Instead, it means that she feels you are placing her interests first and that you are hearing her point of view. For instance, if you recommend something she isn't happy with, she needs to know what the choices are and why you are suggesting that approach. This is where her confidence in your experience and judgment becomes critically important.
We need to create a culture in midwifery where women are truly at the centre of care, and this is going to mean revisiting our values and traditions and strengthening our beliefs. But it will also mean that we have to make sure that women are better informed and better prepared for labour and birth. And that the relationship they have with their midwife is a partnership of equals - not a contract between 'consumer' and 'provider'.
Tips and tricks
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Listen to her - whether or not it is possible to have the things we want, it is still of the utmost importance to feel that we have been heard. And if you understand why she wants what she is asking for, you may be able to find an appropriate alternative if it is not possible.
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Integrate a holistic model into your practice - try to see the big picture, of which her wishes form one part. What she is telling you with her voice may be different from what she is telling you with her body, and this needs to be taken into account.
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Reaffirm the founding principles on which our profession is grounded - midwives as experienced, knowledgeable and skilled experts support women through through childbirth. Just as you must respect her wishes and autonomy, she needs to respect your expertise for the relationship to work.
Further reading
Ashcroft B (1998) Choices in childbirth: myth or reality?
British Journal of Midwifery 6 (8): 502-506
Belenky M et al (1997)
Women's Ways of Knowing Basic Books, New York
Churchill H, Benbow A (2000) Informed choice in maternity care
British Journal of Midwifery 8 (1): 41-47
Hunter M. Autonomy, clinical freedom and responsibility: the paradoxes of providing intrapartum maternity care in a small maternity unit as compared with a large obstetric hospital. Kirkham M (ed) 2003 Birthcentres:
A Social Model of Maternity Care Butterworth Heinemann, Oxford
