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There is no such thing as complete freedom of choice
for the childbearing family
Essay by Bärbel Frodermann
Some years ago, choice in relation to maternity care became a focus of attention with the publication of the government report "Changing Childbirth" (Department of Health 1993). The fundamental idea was put forward in terms of the three C`s: Control, Choice and Continuity, and it was aimed to realise these concepts for women and their families in maternity services (Jackson 1996).
The following essay will clarify the meanings of the term of choice . Further, the concept of freedom of choice will be explained. Changing Childbirth (Department of Health 1993) recommended the concept of informed choice. However, freedom of choice and informed choice are different concepts that need to be clarified. Choice should be available for the childbearing family and it belongs to the fundamental principles of liberal thinking.
The title of the essay is a challenge to find arguments for or against this statement. In my view, there is no complete freedom of choice for the childbearing family. In realty, choice is frequently influenced by many factors and, therefore, it cannot be said that women have complete freedom of choice. As Williams (1997, pp. 241) states: "In reality, free choice does not exist".
In the context of this essay, it is necessary to analyse the factors that influence choice. These factors can be cultural influences. Choice of the childbearing family can also be influenced by the social background, like education, social class and the family's environment - to name but a few. These influences will be more clarified in this essay.
Further explanation will be provided of the concept of power, women's autonomy and empowerment. The essay will explain what can be done to support the childbearing family to make choices and how midwives can work for and with women.
Choice: A definition
Choice is defined as "the act or an instance of choosing" (Oxford Concise 1995, pp. 231). A, in my view, more valuable definition in the context of the topic is " the power or opportunity to choose" (Ibid.). The second definition is particularly relevant because of the term of "opportunity". In order to have choice, it is necessary to have an opportunity to choose something and whether or not choice has been offered to the childbearing family (Clement 2000).
The Winterton Report also states that, beyond continuity and control, not only women also desire choice but there is also a need of the childbearing family (Walton and Hamilton 1995). Changing Childbirth (Department of Health 1993) recommended that women should have choice during pregnancy, childbirth and the puerperium. The term "freedom" means "the condition of being free or unrestricted" (Oxford Concise 1995, pp. 538). Interestingly, the term is unrestricted in the context of choice for the childbearing family. In my view, there can be restrictions, such as those caused by religion, cultural beliefs and traditions. But these are not the only aspects. Other influencing factors will be explained in the main body of the essay.
The midwife needs to be aware of and informed about these aspects. It is also one of the responsibilities of midwives to provide care for every childbearing family and to treat the clients with respect. The midwife also needs to reflect this in her own practice and share information. The midwife needs to work close together with the GP and other health professionals to ensure that choices are available for all women (McClean et al 2000). To support the proposition that there is not complete freedom of choice of the childbearing family, it is necessary to clarify what the influences on choice are.
Choice and the influences
The influences on choice need to be clarified, so that midwives can draw their conclusions to practice and also reflect these ideas in their own practice, thus improving the quality of their care (Lavender, Moffat and Rixon 2000).
Religion, beliefs and traditions influence women and their families in childbirth (Schott and Henley1996) and also their choice. If people come from other cultures, they may have different opinions and impressions about childbirth, based on religious and ethnic ideas and norms. (Ibid.) Often, women from other cultural backgrounds cannot understand the English language. If women do not speak English well, they may be unable to say what their needs are, leading to unmet needs, anxieties and frustration for both the childbearing family and the midwife (Watson 1986). Stereotypes of women from ethnic minorities and women belonging to a lower social class often exist based on a lack of knowledge of their life and culture (Gerrish et al. 1996, Neile 1997). Often the stereotype exists that people from lower social classes have an unhealthy lifestyle, although there is no evidence to support this claim. The aim of midwifery care is to focus on the mother and the baby, while also considering the family context and trying to avoid stereotyping (Powell 1995).
Beyond cultural and ethnic influences, choice can also be influenced by the social background and the educational levels. Women's expectations of childbirth are formed by their life experience, family upbringing, their beliefs, and education (Powell 1995). The social class, economic circumstances and background can be cause for difficulties to access the maternity services and reduce the degree of choice (Ibid.). Women's choice can be influenced by not feeling part of the society, with women and their families thus feeling isolated and excluded.
Midwifes and other health professionals should be aware of these influences and also of whether or not women wish choice and whether they know their options. When they do not know their options, it is important to know how the midwife and other health professionals present these choices including the relevant information. In this context, autonomy of women and their families needs to be mentioned. The principles of autonomy are that individuals have liberties and are able to determine for themselves (Richards 1997). Midwives assisting the childbearing family to make choices need to be aware that the woman may well have her own ideas and wishes. Further, the client-doctor relationship should be characterised by client autonomy. Yet, in practice, paternalism on the part of the doctor is often experienced and, frequently, he is seen as the decision maker (Ibid.).
Organisations like the National Childbirth Trust play a key role in supporting women and their families. They offer a variety of services to help the childbearing family, like antenatal classes. They provide guidance and encouragement to new parents. Furthermore, they offer breastfeeding counselling and postnatal support. In my view, a further key role is that they represent the interests of the childbearing family and are members of Maternity Liaisons Committees, Health Authorities and other organisations (National Childbirth Trust 2001). The aim of those initiatives is to ensure that the maternity service meets women's and families' needs.
There is also a lack of information provision, which parents need and want (Robertson 2001). Therefore, full information should be given. It also needs to be recognised that pregnancy and the preparation to parenthood is often a new experience for women and their partners. The adaptation to parenthood is a process that can be problematic for the entire family. This process involves physical and emotional changes. Here, the midwife should be supportive and provide information in an understandable way. Pregnancy and childbirth is a normal, natural process. Some women can have difficulties with physiological changes in pregnancy and these can affect the relationship with their partner. Their feelings can also be influenced by other peoples' views of pregnancy, positive and negative, intent or not.
Information and offers for choice provided by the midwife should be objective, free from her own feelings and preferences (Levy 1999). But Levy (1999, pp.616) also states that "midwives often controlled the agenda and acted as gatekeepers of information". This reflects the second dimension of how power works and influences choice. Power has been described as "control of the agenda of what may be discussed and what decisions may or may not be made" (Ibid.).
The first dimension of power (Lukes 1974) is described in terms of the idea that strong-willed groups and individuals have the power to make decision against the preferences of other people. In the past, the power of health professionals has dominated that of clients and patients (Shirley and Mander 1996).
The third kind of power is described as manipulation of people and groups into accepting policies as useful that may in fact be harmful to them (Ibid.). An example for this are 'routine' blood testing during pregnancy. In this context, "routine" means it is not necessary that women make an informed decision to have these tests (Levy 1999). In these instances, the midwife can act as an advocate for the childbearing family.
Advocacy and being an advocate is about promoting the rights of another to be self-determining and autonomous (Richard 1997). There seem to be conflicts between the midwife and the health care system, as the midwife wants to support women's rights and there are restrictions caused by policies and guidelines (Ibid.). In the context of pregnancy and childbirth, the midwife should empower and support women, their partners and families to make informed decisions about their care. Next to advocacy and autonomy for the childbearing family, empowerment is a key aspect of maternity services (Richard 1997). Empowering the childbearing family means to involve them in all aspects of there care and to offer them freedom of choice, which requires that the midwife must be develop the relevant skills for it (Siddiqui 1999).
It is also necessary that there is a partnership between the childbearing family and the midwife. Achieving empowerment is not easy and the midwife herself needs to feel self-confident and self-empowered (Fletcher and Buggins 2000). Women are only truly empowered when the communications with midwives and other health professionals are based on respect (Ibid.).
Women need clear and understandable information, self-confidence in decisions and choices, motivation and respect. Midwives need to be non-judgemental and without assertiveness to empower women (Ibid.). As Richard (1997, pp.167) states: "Professional judgement should not be perceived".
In the context of empowerment of the childbearing family, control must be discussed in more detail. A study of Green et al.(1998) investigated the issues of choice and control. There were two kinds of control defined. First, external control as the control over decision making and, second, internal control as women's control of their own behaviour. The findings of the study were that information is important for women also to feel in control. Further, feeling in control was defined as feeling confident or an absence of feeling panic (Green 1999).
Reflection on practice has shown that choices of the childbearing family are often not implemented. This can be the result of various reasons, such as, for example, hospital policies. Midwives need to listen what women want and what they are seeking to explain to the carer. Too often the practice is more focused on policies and guidelines (Richens 1999). For example, if the woman decided to use the pool during childbirth but then needed an induction of labour, she would not be able to use the pool. So, it is the midwifes' responsibility to inform the woman beforehand about what could happen if she needs any interventions. In my view, it is very difficult to offer choices and to tell women that there are restrictions if she needs an induction of labour. One aspect here is to offer choices and, at the same time, to provide all information of what can happen if the woman does not " fulfil the criteria" to use a birthing pool. Women can get very anxious and, therefore, it is important how the midwife provides all this information. It is important to support the childbearing family despite restrictions and policies. In practice, it is often very difficult to provide the family with all this information, not only because of time limitations.
The development of a birth plan during pregnancy can support choices of the childbearing family. It means not that this is the single solution but it can be very helpful for the childbearing family as well as midwives and other health professionals.
The antenatal clinic is an ideal area to discuss the birth plan. A study undertaken by Too (1996) has shown that birth plans can empower women to be an active part in childbirth and to explain their wishes. Another study by Jones (1998) has shown that birth plans may affect the outcome of labour. But future research in this field needs to be undertaken (Ibid.). Too (1996) concluded that the childbearing family should be encouraged to participate in planning rather than accepting those choices which midwives think are appropriate. The discussion of birth plans should also be an opportunity to address unrealistic expectations and, thus, to avoid mothers' disappointment (Jones et al. 1998).
The development of a birth plan is an opportunity to discuss whether or not a woman would refuse any intervention or treatment. If so, the midwife needs to treat her with respect and has to accept her decision. Only if she is supported and respected, women feel able to make choice.
Informed Choice and Changing Childbirth
The Changing Childbirth Report (Department of Health 1993) recommended that women should be given choice in the type of care and support they receive from the health service, and that these needs be based on unbiased information (Ibid.). The report also identified where women would appreciate to have more choice: the place of antenatal care, the place of birth, choice of carer and modes of treatment (Ibid.). It was also demanded to undertake more research to find out what particular choices are important for women and their families.
To support the childbearing family in the best way, the requirements of informed choice and informed consent need to be realised. "Maximising choice should be a priority" (Department of Health 1993, pp.101) but this is not always the case. Interestingly, Changing Childbirth (Department of Health 1993) received comments to be "a policy for affluent, white, middle class women" (English National Board for Nursing and Midwifery & Health Visiting 1998). This indicates that every midwife should reflect her/his own practice and improve the quality of care for the childbearing family.
Some midwives are better informed and up-to-date than others, some can put information into an understandable form better than others. In my experience, women are very interested and ready to make choices during pregnancy and the puerperium.
The analysis and discussion was very useful to the author, as it clarified the aims and the transfer into midwifery practice. In this context, the concept of informed choice was examined. The investigation has also shown that there is no complete freedom of choice for the childbearing family. Choice for women and their families is frequently influenced by several factors and aspects.
These influences were stated and discussed. The author explained how the midwife could support the childbearing family in making informed choices, how she could offer options for choice, and what she should avoid. In this context, the aspect of stereotyping was clarified. Midwives and other health professionals play a key role in providing the childbearing family with all necessary information. Research undertaken by Churchill and Benbow (2000) has shown that midwives play a key role in informing women. Further, the study has shown that midwives in midwife-led antenatal clinics are more successful in imparting information and enabling women to have a sense of participation in the decision making process.
Midwives also need to recognise that women and their partners can have different priorities, needs and opinions. As practitioner, the midwife needs to be open for those alternatives and be objective in giving information to them. She needs to be prepared and up to date. The essay has also clarified the meaning of autonomy in childbirth, concepts of power and advocacy, a process which offered a very valuable learning opportunity. Examining midwifery care from these perspectives was very helpful and, in my view, a good preparation for future practice. It will empower myself to support the family during pregnancy, in childbirth and during the postnatal period and help to reflect my own practice.
Adams and Bromley (1998) Lecture notes - module 01111
Churchill, H. and Benbow, A. (2000) A informed choice in maternity services.
British Journal of Midwifery, 8 (1) pp. 41-47
Clement, S., ed., (1998) Psychological perspectives on pregnancy and childbirth.
London: Churchill Livingstone
Department of Health (1993) Changing Childbirth.
(The Report of the Expert Maternity Group) London: HMSO
English National Board for Nursing, Midwifery & Health Visiting (1998) In McCourt, C.
and Pearce, A. (2000) Does continuity of carer matter to women from minority ethnic groups?, Midwifery, 16, pp.145-154
Fletcher, G. and Buggins, E. (2000) Empowerment - a gift bestowed or withheld?
In Alexander, J. Midwifery Practice Core topics 3. Basingstoke: McMillan Press
Gerrish et al (1996) In McCourt, C. and Pearce, A. (2000) Does continuity of carer matter to women from minority ethnic groups?, Midwifery, 16, pp.145-154
Green, J. (1999) Commentary: What is this thing called control?.
MIDIRS, 9 (3) pp.383-384
Green et al (1998) In Fletcher, G. and Buggins, E. (2000) Empowerment - a gift bestowed or withheld? In Alexander, J. Midwifery Practice Core topics 3. Basingstoke: McMillan Press
Jackson, K. (1996) The History of Changing Childbirth. In Dodds, R., Goodman, M.
and Tyler, S., eds., Listen with Mothers. Hale: Books for Midwives Press
Jones et al (1998) Do birth plans adversely affect the outcome of labour?
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Lavender, T., Moffat, H. and Rixon, S. (2000) Do we provide information to
women in the best way? British Journal of Midwifery, 7 (12) pp. 769-775
Levy, A. (1999) Midwives, informed choice and power: part 2, British Journal of Midwifery, 7 (10) pp. 613-617
Levy, A. (1999) Midwives, informed choice and power: part 3, British Journal of Midwifery, 7 (11) pp. 694-699
Lukes, S. (1974) In Levy, A. (1999) Midwives, informed choice and power:
part 1, British Journal of Midwifery, 7 (9) pp. 583-587
McClean et al (2000) Can childbirth be changed? Offering women choice,
MIDIRS, 10 (1) pp.110-111
National Childbirth Trust (2001) URL:http://www.nctpregnancyandbabycare.com/, 7.06.2001
Neile, E. (1997) In McCourt, C. and Pearce, A. (2000) Does continuity of carer
matter to women from minority ethnic groups?, Midwifery, 16,pp.145-154
Oxford Concise Dictionary English (1995) 9th edition. Oxford:Clarendon Press
Powell, A. (1995) Class and Ethnicity. British Journal of Midwifery, 3 (3) pp. 162-167
Richards, J. (1997) Too choosy about choice: The responsibility of the midwife,
British Journal of Midwifery, 5 (3) pp. 163-168
Richens, Y. (1999) Listening to mothers: improving evidence-based practice.
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Robertson, A. (2001) Birth International - Education for "Informed Choice"
URL: http:// www.acegraphics.com.au/resource/papers/andrea10html, 4.06.2001
Schott , J. and Henley, A. (1996) Culture, religion and childbearing in a Multiracial Society. Oxford: Butterworth-Heinemann
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Siddiqui, J. (1999) The therapeutic relationship in midwifery,
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Too, SK. (1996) Do birthplans empower women? A study of their views
Walton, I. and Hamilton, M. (1995) Midwives and Changing Childbirth.
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Watson, P. (1986) in Class and Ethnicity, Powell, A., British Journal of Midwifery,
3 (3), pp.162-167
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and Rafferty, AM., eds., Midwives, Society and Childbirth, London: Routledge
United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1998) Midwives rules and code of practice. London
Bärbel Frodermann is a midwife in UK.