Choice in Obstetrics

Midwifery philosophy stands upon three main pillars. They are continuity of care, choice of birthplace, and informed choice. These ideas shape the philosophy in which we aim to practice in attempts to be alternative to traditional obstetrics.

Continuity of care refers to the idea that it matters who cares for you during your pregnancy, birth, and postpartum period. We aim to have the same team of people care for you throughout this period. You will (hopefully) establish a relationship of mutual trust in your midwives and ultimately know the person at your birth.

Choice of birthplace is pretty much self-explanatory: it means that midwives believe that the hospital is not the only place appropriate for childbirth. Midwives are skilled in attending birth in hospital but also outside of hospital, such as a birth centre or at home. We give women choice in terms of where they would like to have their baby and can provide safe care in all places. (If you’re worried about the safety of homebirth, check out several studies out of McMaster. In short: it’s safe).

The third pillar is by far my favourite: informed choice. Informed choice is the idea that you are the primary decision maker in regards to your healthcare – you know what is best for you and your family. The midwife’s role is to provide information on risks, benefits, alternatives to certain testing and procedures, give you up to date, evidence-based information and recommendations so that you can make a decision. Up until now, although I saw some flaws in informed choice, I was still very proud that this philosophy was one of the main tenets upon which our practice stands. I thought it really set us apart from traditional obstetrics and in some ways I think it still does, but I’m starting to realize that informed choice is significantly more complex than I had originally thought.

Obstetrics is a particularly interesting area to talk about bioethics and choice because there is this idea of “two patients in one body.” Of course, this is true, we do maternal vital signs in labour almost as often as we check on fetal well-being. We have a duty to keep both our clients safe. Ultimately, however, and the law and literature are clear, that the client sitting in front of us in the moment is the ultimate decision maker and our feelings, even as clinicians, even the face of a bad outcome, do not trump her choices.

In one of my courses this year, a series of assigned readings on choice have really opened my mind to this idea of bioethics, the complicated nature of informed choice, and how midwives fit into this picture.

I think that clients choose midwives so that they can be a more active participant in their healthcare, and I think that this is really great. People often say that their midwives made them feel empowered and I can’t think of a greater compliment as midwives really strive to be with woman and dismantle power hierarchies that exist in a lot of traditional obstetrics. Despite this, I’m realizing that informed choice does not translate into control. This is particularly difficult to convey and even understand and so I’ll elaborate.

Childbirth is one of the very few clinical experiences in which you have little to no control. Contractions come and keep coming until the baby arrives, you can’t control how big your pelvis is and if your baby is going to fit, or if you get placenta previa or pregnancy-induced hypertension. Maybe this is a bit pessimistic, but what I’m trying to say is that you can make all the “right decisions” in regards to your pregnancy and birth and still end up with a dissatisfying birth experience. This is the major difficulty of informed choice: this idea that choice may offer the promise of an experience which in reality may or may not be met. (1)

So why offer choice at all? Because it still matters and it matters a lot. We know that just by choosing to have a homebirth you are statistically more likely to have a successful vaginal delivery, even if you are transferred to the hospital – explain how that makes any sense, but it does. (2) We know that people want to take an active role in their healthcare and that when clients know what’s going on because providers communicate well they are more satisfied with their care.

Despite all these complexities, we know that choice is crucial to obstetrics and midwifery and that having a choice matters. My next thought is how can I be the best clinician that even in the face of this reality of informed choice for my clients?

I know that making choices isn’t easy for all my clients: they are balancing their desire for a fulfilling birth experience with rational decisions about their pregnancy as a whole. (2) I know that they are making choices in the face of health care providers, partners, family, and other people who have an opinion about everything.

Informed choice is hard for midwives too. By providing informed choice, midwives can be labelled as having “bad clients” or clients that “misbehave” when they don’t follow traditional choice patterns. This puts strains on hospital relationships as midwives really do practice within two worlds and speak the language of midwifery and traditional obstetrics. But this is something that I am willing to shoulder for my clients to protect their choice as best I can but nevertheless can influence how informed choice discussions are delivered.

I am also aware that having a midwife doesn’t always remove the traditional, patriarchal approach associated with traditional obstetrics. (3) Simply educating a client about a test doesn’t translate into an informed choice. Midwives decide what goes into their informed choice discussion: we know that we tailor our discussions based on age, number of children, education level, etc. To a certain extent, it’s personalized, but I wonder what things we leave out due to bias.

Despite the difficulties and nuances of informed choice, it still remains my favourite tenet of midwifery practice. I think we as midwives have got to consistently strive to dig deeper into choice and be self-reflexive about our practice. I hope that my clients challenge my beliefs about informed choice so that I can continue to improve. I don’t think that my thoughts about this are over, but it’s a pretty good start.


(1) Jomeen J. The paradox of choice in maternity care. J Neonatal Nurs [Internet]. Elsevier Ltd; 2012;18(2):60–2.
(2) Hutton EK, Reitsma AH, Kaufman K. Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: A retrospective cohort study. Birth. 2009;36(3):180–9.
(3) Hindley C, Thomson AM. The rhetoric of informed choice: perspectives from midwives on intrapartum fetal heart rate monitoring. Heal Expect [Internet]. 2005;8(4):306–14.


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