Maternal autonomy

Understanding risks

The apparent dangers posed by certain types of food and drink are often at the forefront of discussions about risk in pregnancy. In the UK, it is recommended that pregnant women avoid various foods (NHS Choices, 2015), often despite a dearth of evidence (Gray and Gibson, 2014). There has long been a consensus that pregnant women should abstain from alcohol, based not on strong evidence that it causes harm but rather on the precautionary principle, which reverses the burden of proof and presumes there is a risk until evidence demonstrates that there is not. Dr Anna Leppo, post-doctoral researcher at the University of Helsinki, presented findings from her research on alcohol abstinence policy in four Nordic countries (Leppo et al, 2014). This study found that policy was based on precaution but—in three of the countries—did not explain this, thus giving a misleading message about the dangers of low levels of alcohol in pregnancy (the exception was Denmark, where the rationale of the precautionary principle was openly discussed). This echoed a review of UK policy, which stated that recommendations to abstain from alcohol during pregnancy demonstrated ‘a new approach to risk based on seeking to make uncertainty certain’ (Lowe and Lee, 2010: 306).

Raphaël Hammer, professor at the University of Applied Sciences of Western Switzerland, concurred that risk discourse in pregnancy is ‘an institutional strategy’. He said many women internalise this discourse, based not on medical knowledge but on social norms regarding what constitutes a ‘good mother’, and anticipation of guilt if something were to go wrong.

Hammer presented findings from his work exploring women's perceptions of the effects of drinking during pregnancy (Hammer and Inglin, 2014). Participants in the study broadly fit into two profiles: those who abstained from alcohol while pregnant, and those who reported drinking ‘once in a while’. All participants said they felt alcohol may be harmful to the fetus, but there was a general perception that the degree of risk depended on various factors:

This emphasis on context, Hammer argued, highlights the importance of the cultural and social dimension of alcohol in daily life. One delegate in the audience said that in her home country of Italy, it is common—and socially acceptable—for pregnant women to consume wine with meals. Dr Leppo added that risks are not calculated on a purely scientific basis, but are ‘socially moulded and negotiated’.

Social perceptions of risk are linked to values and morality, rooted in cultural norms. This means we are all susceptible to confirmation bias—a tendency to interpret evidence in a way that confirms our preconceptions, and reject that which contradicts them. Dr Robbie Sutton, professor of social psychology at the University of Kent, explored this idea and how it relates to ideas around drinking in pregnancy. He discussed a study by Lewis et al (2012), which found that IQ at the age of 8 years was higher in children whose mothers drank a low to moderate amount of alcohol during pregnancy than those born to women who abstained. Dr Sutton suggested that the disconnect between the evidence and consensus could be attributed to factors including media lobbying and a tendency to be risk-averse. He explained that his team have shown the findings of Lewis et al's (2012) study to different groups of people, giving some of them a falsified version—such as reversing the results for drinking/not drinking, or stating that the study had looked at pregnant women who drank milk, rather than alcohol. In all cases, those who were aware that the results showed a benefit of drinking alcohol in pregnancy were more likely to think the study was unreliable or methodologically flawed, and to believe that the correlation was spurious rather than causal. This demonstrates, Dr Sutton argued, the extent to which people will interpret scientific evidence in a way that fits their existing beliefs. He warned that the consensus on alcohol being harmful may drive the research agenda, limiting the scope for science to challenge preconceptions.

A delegate at the conference made the point that, if public health messages are ‘dumbed down’ and not based on clear evidence, there is a danger of losing credibility; this may lead people to mistrust health advice in general, or to lie to health professionals about lifestyle factors. This idea was echoed during the round-table session on obesity in pregnancy. Dr Rachel Jarvie, lecturer in sociology at the University of Plymouth, said women with raised body mass index (BMI) who participated in her study did not identify as ‘obese’ and found the term offensive. Many of them were fearful of being judged; Dr Jarvie said there is a risk that this may lead women to not engage with health services. Aston University senior lecturer in sociology, Dr Pam Lowe, concurred and added that ‘risk’ is itself an unhelpful term; it may be more appropriate to say a woman ‘may have more difficulty with…’ certain aspects of health, rather than that she is ‘at high risk’ of problems. The language around risk in pregnancy can be woman-blaming, which is counterproductive when health professionals are trying to build a relationship of trust with women. Dr Julia Keenan, senior research associate at the University of East Anglia, said women should be understood ‘not as managers of risk, but as complex human beings’.

Health policy tends to treat obesity as a lifestyle problem that can be solved through behaviour change. Dr Jarvie pointed out that this approach fails to grasp the social context; women of lower socioeconomic status are more likely to be obese. Many of the women in her study understood the public health messages around healthy eating and exercise, and wanted to do the best for their family, but could not find a way to improve their diet or lifestyle within the financial and time constraints of their daily lives.

One delegate suggested that maternity services are currently not rooted in reality but designed around an ‘ideal’ woman. Using the example of advanced maternal age, she pointed out that the trend towards having children later in life should mean that we design services appropriate for coping with the needs of older mothers; instead, there is a prevailing message that women should have babies earlier. This promotes the idea that conceiving and giving birth later in life is inherently more risky than at a younger age, and implies that women who do so are acting irresponsibly.

Central to the debate around risk is this idea of responsibility and obligation. Parents feel an obligation to their children, and this is compounded by societal expectations. Dr Sutton said: ‘We have an ideological idea that women should be willing to sacrifice anything and everything for the sake of their unborn child.’ Health professionals also feel an obligation, but there is confusion around this, as Birthrights director Rebecca Schiller pointed out: ‘It seems there is a lack of clarity among health professionals regarding what their obligations are to the fetus.’ She added that litigation is a huge burden to both the NHS, financially, and individual professionals personally. Keynote speaker Farah Diaz-Tello, of American organisation National Advocates for Pregnant Women, agreed that ‘there is a need to lift the burden of malpractice fears on front-line health-care providers’. She was speaking from a US perspective and presented some alarming examples of women being denied choice regarding their care in pregnancy and birth—and in some cases punished by law—on the grounds of perceived risks posed to the fetus.

Consultant midwife Simon Mehigan echoed Schiller's point, saying that many health professionals do not understand what their role is in discussing risk and allowing women to be autonomous. He said: ‘Sometimes, as a professional, we have to be quite brave, and tell women, “Actually, the evidence is weak but national or local policy says I have to tell you this…”’ He reflected on his 20 years in midwifery and noted a shift in how pregnancy is viewed, saying that today's pregnant women tend to be identified by their so-called risk factors—‘the obese woman, the VBAC woman, the older woman’—rather than as individuals. Health professionals have a responsibility to present women with information and evidence, he said, but whether or not something can be considered a ‘risk’ will depend on the individual woman.

Prioritising choice

A crucial principle is allowing women to make their own choices. Diaz-Tello discussed how the debate over women's choice has historically focused on abortion, but that the issue of reproductive choice is broader and more complex, encompassing the choice to have children or not, how to have children and how to parent one's children. Clare Murphy, director of external affairs at BPAS, said: ‘We really need to think about reproductive choice in its entirety… The women who have abortions are the same women who have babies.’

There is a cultural perception that pregnant women are in need of additional protection, but it is unclear whether this is to protect the woman herself or her unborn child. Diaz-Tello pointed out that in the USA, there are 21 states that have laws protecting the fetus, but only 11 with laws specifically protecting pregnant women. Referring to choice around birth, Schiller said that the phrase ‘a healthy baby is all that matters’ is often used to coerce women to do things they may not want to do, because there is an expectation that they should put the perceived needs of the fetus above their own. Pregnant women are held to a higher standard of risk management than other people (Kukla, 2010); Dr Leppo suggested we question to what extent (if at all) it is reasonable to expect women to take long-term action to maximise potential fetal health. As Hammer pointed out, pregnancy is not an illness, and there is a strong argument that women should listen to their own bodies and make the choices that are right for them.

Dr Jarvie raised the idea of the ‘teachable moment’ of pregnancy—the notion that pregnant women are the most appropriate audience for many public health messages because they are more receptive during pregnancy than at other times in their lives. Speakers and delegates at the conference broadly agreed that this is often true; the maternal desire to do the best for the child is the driving force behind most choices pregnant women make, so they are likely to follow health advice if they believe it will benefit their baby. This, however, is the problem with paternalistic health policy based on the precautionary principle; Dr Leppo warned that withholding evidence-based information from women reduces their chances to make informed decisions. Dr Sutton added that prescriptive health advice is based on the idea that ordinary people will not understand the evidence so there is a need to dilute or adapt it into recommendations. Schiller was positive about some of the choice-focused content of the National Institute for Health and Care Excellence (2014) intrapartum guidelines and the recently published National Maternity Review (2016), but added that even these documents make prescriptive recommendations; for example, suggesting more women ‘should’ give birth at home—while positive for advocates of homebirth—implies that birthplace choice does not lie with the woman herself.

Birthrights founder Elizabeth Prochaska highlighted many examples of women being denied choice in childbirth. Beginning with the issue of obesity, she said women with high BMI ‘face sanctioned, legitimised discrimination and stigmatisation’ in hospital policies, along with limited access to services and restrictions to choices in labour. Such restrictions, along with distortion of potential risks, also apply to women seeking elective caesarean section or vaginal breech birth. Pregnant women with mental health issues may face compulsory referral to specialist clinics and sometimes even court-ordered caesarean section. While policies are ostensibly designed to give women the best possible care, following generalised guidelines rather than treating each woman as an individual will inevitably lead to women being denied autonomy in decisions around their birth experience. An additional problem is that services available across the UK do not necessarily reflect the recommendations of national policy. Jennie Bristow, senior lecturer in sociology at Canterbury Christ Church University, suggested there is discord between the messages promoted to women and the options available to them. For example, recent recommendations for homebirth may lead women to choose this as the best option for their own and their babies' health, but they may then be denied the choice in practice if their local Trust cannot accommodate their wishes.

There are important implications for mental health. Schiller expressed concern over ‘the intense pressure on women to do the “right” thing, and the impossibility of doing that’. With increasing evidence that post-traumatic stress following childbirth is related more to women's psychological and emotional experience of childbirth than objective factors that may be perceived as ‘traumatic’ (Greenfield et al, 2016), it is crucial that women feel listened to and empowered by health professionals. There can be little doubt that the myriad demands placed on women around pregnancy and birth have the potential to be detrimental to their mental and emotional wellbeing, as not meeting such high expectations—however unrealistic they may be—will likely invoke a sense of failure.

Mehigan suggested that, for midwives, the key question is how to support women in their choices even when those choices are not what the midwife him/herself would have chosen. ‘There needs to be a sea-change around how we discuss risk with women,’ he said. ‘The ultimate thing, for me, is to remember that it's not my risk.’

The ideal scenario, he suggested, is to be able to discuss potential risks with women based on the evidence available, thus giving them the opportunity to make informed choices, and then support them in those choices and help them to achieve the optimal childbearing experience. He was confident that ‘if we treat pregnant women as individuals, they will make good choices’—a sentiment echoed by other speakers. Hammer said all the women who participated in his study on alcohol consumption stated that their baby's wellbeing was their priority. Diaz-Tello said that, across the spectrum of reproductive choices, women make decisions based on what they think is best for their children, their families and themselves. The speakers all agreed that there is a need for health professionals and policy makers to trust women; it is almost always the case that women will strive to do what is best for their children, and it may be counterproductive for policies to tell them how to do so.

Trusting women

The flurry of messages around how to manage a pregnancy—what to eat, what to drink, what to avoid, when and how to exercise—and the many options for how to give birth—at home, in a midwifery-led unit, in hospital or by caesarean section—mean there are inevitably diverse opinions about what is ‘best’. But every pregnancy and birth is an individual experience, extremely personal to the woman and her family. While there is a need to understand potential risks, and to mitigate those risks as far as possible, it is equally important to allow women to have control over their own experience. There has long been debate in maternity services over how to balance the sometimes conflicting elements of safety and choice, and this will no doubt continue for a long time to come. There is no easy solution, primarily because it is impossible to generalise all women's experiences of having children. The Policing Pregnancy conference, while not presenting explicit answers to the questions it posed, offered a great deal to consider on the subject of maternal autonomy. The essential take-home message was the importance of trusting women. The best interests of the unborn child are at the heart of maternity policy and practice; we should realise that women themselves have their unborn children's best interests at heart, and trust them to make the right decisions.