Better Births. Anna Brown

Ethical issues related to fulfilling the ‘with woman’ concept, which examine the impact of moral and practice dilemmas on delivery of current midwifery practice, underpin the consequences of this and related concepts. Midwives' and women's perspectives of ethical practice, embedded in shared knowledge, power and trust, have highlighted the challenges faced in making decisions to ensure safe and positive birth experiences; this is within the remit of relational autonomy and codes of professional midwifery practice. The stories that follow illustrate how midwives fulfil and deliver compassionate, empathetic and ethical ‘with woman’ care and how one woman challenged routine care and opted for an unconventional delivery to achieve the transformative and life‐changing experience of birthing her baby.

Table 2.1 Concept Analysis of the ethical perspective of being ‘with woman’.

‘With woman’ antecedents	Evidence	Attributes (A) and consequences (C)
Continuity of carer	Taylor et al. (2018) and Yoshida and Sandall (2013) raised issues practical barriers to C of C role	Confidence (A) Safety (A) Need for training (C) Adequate staffing (C) Sound leadership and Management (C)
Decision making	Katz Rothman (2013) Challenges to making decisions as a social process based on bioethics Chadwick (2015) importance of safety	Mother–midwife relationship (A) Respect for autonomy (A) Promoting professionalism and trust (A) Preserving safety (C) prioritising people (C) Effective practice (C)
Care and responsibility	MacLellan (2014) The role of care and responsibility through ethics of care Newnham and Kirkham (2019) Dodwell and Newburn (2010) explore relational support	Actions and judgement (A) Interpersonal relationship (C) Valued social relationship (C) Balance of care and responsibility (A) Compassion (C) Non‐maleficence and accountability (C) Offering choices and fulfilling women's expectations (A) Control (C) Empowerment (C)
Choices	Jefford and Jomeen (2015) impact on midwives' working practices Hastings‐Tolsma and Nolte (2014) ‘failure to rescue’ Griffiths (2011) law of negligence Smith (2016), Jefford and Fahy (2015) intuitive humanistic theory. Daemers et al. (2017) sharing decision making Newnham et al. (2017) lack of choices. Borelli et al. (2017) influencing factors on the expectations of the midwife's role	Legal and professional accountability (A) Autonomous practice (C) Professional vulnerability (C) Defensive practice (C) ‘Safe’ practice (A) Interventions in childbirth (C) Right not to be harmed (A) Midwifery evidence and logical rationale (C) Intuitive practice to include knowledge, experience and attitudes (C) Fulfilling women's wishes (C) Centres the woman (C) Organisational & resource limitations (A) Biased and not true informed consent (C) May impact their place of birth choices (C) Need for safety and fulfilling experience (C)
Relational autonomy	Christman (2015) dynamics of deliberation and reasoning Nieuwenhuijze et al. (2014) Thompson (2013) women's awareness of constraining factors Morad et al. (2013) trusting relationships. Noseworthy et al. (2013) relational autonomy Hall et al. (2018) women's dynamic experience of birth Meadow (2014) Social context of relational model and Lewis (2019) principle of respect. Dahlberg and Aune (2013) quality and content of care	Informed choices (A) Shared knowledge (C) Negotiation (C) Shifting power between woman and midwife (C) Professional self‐esteem & self‐respect(C) Women's dignity (A) Mutual trust & sympathetic understanding (C) Caring and nurturing environment (A) ‘Being with others’ (C) Women's autonomy fulfilled (A) Confidence and self‐belief in the body's ability to give birth (C) Creating a space to develop skills (A) Self‐confidence and self‐esteem for women (C) Holistic care through presence and emotional support by MWs (C) Importance of positive birth experience(A) MW as advocate & companion (C)
Ritual companion	Reed et al. (2016) ‘Rites of passage’ Pembroke and Pembroke (2008) women at centre of care Brown (2012) ‘with woman’ Moloney & Gair (2015) compassion Raynor and England (2010) transparency and therapeutic communication Dierckx de Casterlé (2015) ethical perspectives of the skilled companion	Rites of protection (A) Relationship that is enabling and empowering (C) Caring presence (C) Environment of security and trust (A) Spirituality (A) Responsiveness and availability (C) Perceptiveness (A) Responsive to needs and values (C) Empathy and intuition (A) Warmth and acceptance (C) A fulfilling birth experience (C) Empathetic presence (A) Women feel accompanied and supported (C)
‘The good midwife’	Nicholls and Webb (2006) Byrom and Downe (2010) key elements of the good midwife Overgaard et al. (2014) Dahlberg et al. (2016) attitudes and behaviour	Clinical competence (A) Well‐developed skills of compassion, kindness, knowledge and skills (C) Women provided with information and listened to (C) Fulfil women's needs (C) Feel safe and cared for (C)

      A Midwife's Story

      Anna's Story

      In 2012, I conducted a study exploring how midwives learn, develop and demonstrate communication to embrace elements of empathy, intuition and sensitivity when ‘with woman’ at the point of birth. The purpose of this study was to develop a better understanding of ‘hidden’ skills that midwives perceive they need to draw upon to truly be ‘with woman’. The findings suggest that midwives fulfil the ‘with woman’ concept in different ways and identify several attributes which describe the interplay between woman and her midwife during the time of birth.

      The perceived therapeutic relationship between women and midwives is one attribute of this concept which a midwife perceived as building ‘a relationship with them [women] and understanding what they want’. ‘Identifying their needs without them having to ask you.’ ‘Being in tune with their [women's] emotional state’ and ‘being trusted’. ‘Having a good interpersonal relationship.’ ‘If you don't have that empathy you don't build up that rapport with women … pick up cues from the women.’ Another attribute of the ‘with woman’ concept is being able to identify and support women's needs and was seen by midwives as ‘being perceptive to their needs’ and ‘responding to things that she [the woman] says, by nodding to acknowledge you've heard what she said’ and ‘it's about what her [woman's] body is doing and what your body is doing in response’, ‘… and being sensitive to when some parents don't want you with them’.

Another interesting attribute of the ‘with woman’ concept became apparent in this study (Brown 2012). This was demonstrated through compassion, by giving women time to adjust during their pregnancy and in labour played out through watching and waiting. A midwife said, ‘You can show presence, a supportive presence, its watching and waiting, it's not just doing.’ Another midwife said, ‘You just need the women to get used to their surroundings, and to me, they just need to get used to my voice.’ ‘Kindness is so hard to measure, and it is a sixth sense … and I think it's sensitivity – there is something there that you cannot explain but you have a feeling’ and ‘reading the situation’ and ‘knowing when you should shut up and when you shouldn't’, ‘the language you use because you have to adapt to their [the women's] ability to understand the language you are using’ and ‘tone of voice’; ‘recognising when it is good not to say anything’ and ‘recognising silence’.

      Findings from this study (Brown 2012) suggest a resulting consequence of the above ‘with woman’ attributes which was a positive birthing experience overall. One participant said, it is ‘not just being there, but exploring everything that