Better Births. Anna Brown

through beneficence; and justice which ensures a fair distribution of risks, benefits and costs (Foster and Lasser 2011).

      An interesting approach to ethical midwifery practice is presented by MacLellan (2014), suggesting that the role of care and responsibility may be embedded in actions and judgements through an interpersonal relationship between mother and midwife within a relational model as an ‘ethic of care’, also known as care ethics (Gallagher 2017). This approach is concerned with contextual details within a valued social relationship that is individual to the mother (Newnham and Kirkham 2019). In this model, care is balanced with responsibility of the midwife to ensure compassion and adhere to the principle of non‐maleficence and accountability. This relational support ensures that midwives seek to fulfil women's expectations of their birthing outcomes and is reinforced through the choices offered by midwives when women are in control and empowered through their experiences (Dodwell and Newburn 2010).

Choices, Autonomy and Decision Making

Childbearing women are entitled to make choices based on information and evidence provided by healthcare professionals in seeking the safest and best outcome during childbirth. On the other hand, midwives must consider relevant ethical principles that impact their autonomy in supporting childbearing women to make these choices. However, midwives as healthcare providers are held legally and professional accountable for the care they provide, not only within legal and professional regulations and frameworks, but also as primarily accountable to the woman and her birthing experience, their employing organisation and the community in which they practise (Jefford and Jomeen 2015). They are in a difficult position and must consider the consequences of their decisions, which places midwives in what is perceived to be a vulnerable position (MacLellan 2014). They may consider practising defensively, forgoing autonomous practice in the need to ensure that the accountability of midwifery practice is within the remit of ‘safe’ practice. Hastings‐Tolsma and Nolte (2014) identified this concept as ‘failure to rescue’, which has ethical implications for a midwifery philosophy that promotes normality in childbirth but results in ‘safe’ interventions during childbirth.

      Women have the right not to be harmed when in the care of midwives, and care professionals will be liable in the law of negligence if harm results during childbirth (Griffiths 2011). On the other hand, midwives make decisions based on evidence and logical rationale, from a hypothetic‐deductive perspective, together with intuition resulting from experiences based on an intuitive‐humanistic approach (Smith 2016; Jefford et al. 2010; Jefford and Fahy 2015). However, ethical decision making ought to include the emotions and feelings, needs and wishes of the woman (Weltens et al. 2019), as a result of engagement in the mother–midwife relationship, to reflect cognitive beliefs of integrity and justice (Thompson 2005). Ultimately, Daemers et al. (2017) suggest that shared decision making is shaped by experience, intuition and individual circumstance and is influenced by knowledge, attitude towards the natural physiology of childbearing, centring the woman in the event and collaboration with other professionals.

      The woman's sense of control and the ability to make choices is informed through their awareness of physiological processes in conjunction with organisational and resource limitations. However, more recently, authors have suggested that hospital culture and policies affect the way that information is presented (Newnham et al. 2017). In these situations, information is not truly unbiased and consequently women are unable to give true informed consent to care that affects their and their baby's outcome. Influencing factors, expectations of the midwife's role and perceived safety have an impact on choices women make – especially in first‐time mothers, as documented by Borelli et al. (2017). The authors suggest that choices such as choosing a place of birth are not influenced by women's perception of midwifery competence in different settings but by their preferences, prior knowledge and a need for a safe and fulfilling experience.

Towards a Relational Model with Confidence and Responsibility

The social context in which choices about care are made are not made in isolation but through an understanding of a professional's true autonomy. A relational model of autonomy is defined by Christman (2015) as the ‘relatedness [that] plays in both persons' self‐conceptions … and the dynamics of deliberation and reasoning’ and is relevant in relation to informed choices in decision making through the dynamics of shared knowledge and negotiation of shifting power between the woman and the midwife (Nieuwenhuijze et al. 2014). Both midwife and woman must become responsible for the consequences of choices made when engaging with and embracing their autonomy.

      Relational autonomy creates a space in which women are supported to develop their skills, self‐confidence and self‐esteem to recognise the social context for their decisions (Meadow 2014). However, the principle of respect is key in enabling shared decision making in support of relational autonomy (Lewis 2019). Midwives need to recognise their capability to self‐trust (McCourt and Stevens 2009), to have self‐esteem, self‐respect and act effectively, underpinned by their values and evidence‐based professional knowledge. Women, on the other hand, must be aware of constraining factors, such as organisational resources, when making choices and decisions (Thompson 2013). However, the woman in labour needs to be free from pain and fear, unhindered by medical interventions and afforded her dignity through a relationship with midwives based on trust and sympathetic understanding of her individual needs in a caring and nurturing environment (Morad et al. 2013). Midwives must therefore seek alternative approaches to the care they provide through the value of relational autonomy in which the midwife's and the woman's autonomy is negotiated respectfully to reach an informed decision (Noseworthy et al. 2013). The resulting empowerment process is mutual within the context of midwives ‘being with others’ rather than fulfilling midwifery skills and tasks (Hermansson and Martensson 2011). Parents, once informed and made aware of available resources and possibilities, will be able to agree on choices and willingly participate in the decision‐making process towards a safe and fulfilling birth experience (Halfdansdottir et al. 2015). In addition, Hall et al. (2018) indicate that women's dynamic experience of birth is influenced by the confidence felt in the belief that one's body is able to give birth, whilst drawing on emotional and physical support to cope with the experience and a sense of control over pain and pain relief to ensure comfort and increased relaxation.

      The relational model also considers relational continuity which enables professionals to provide holistic care through their presence whilst providing emotional support in the woman–midwife relationship. Quality and content of care is perceived by women to be important in enabling a positive birthing experience (Dahlberg and Aune 2013), aided by the nurturing presence of the midwife as her advocate and companion. The concept of the ‘ritual companion’ has been explored from an Australian perspective and concludes that two contrasting types of midwifery practice were being facilitated: that of the ‘rites of passage’ during childbirth, in which the woman–midwife relationship is enabling and empowering and, the ‘rites of protection’ in which labour is perceived to be a time of danger and requires monitoring and assessment to provide a sense of control over the childbirth process (Reed et al. 2016).

Earlier literature advocates for a ‘caring presence’ in the true sense of ‘with woman’ that involves a personal connection between woman and midwife placing the woman at the centre of the relationship and creating an environment of security and trust (Pembroke and Pembroke 2008). With this commitment by midwives to positively enhance the birth experience, the authors suggest that the spirituality of midwifery is played out through the concepts of responsiveness and availability. It is viewed sensitivity and respects the uniqueness of each woman. As identified in the study by Brown (2012), midwives are ‘with woman’ when they are perceptive enough to read the situation and are responsive to her needs and values. This requires the midwife to be available as a ready listener and include herself in the protective sphere that women retreat to when in labour. In addition, it needs the midwife to understand and be actively involved in providing the information and skills to enable the woman to make the right decisions.

      Women and midwives are generally in agreement about the need to achieve a positive outcome for every birthing experience. This agreement is based on shared values