Midwives’ and lactation consultants’ fraught relationship with maternal autonomy

My way or the Highway, opposite signs

Medical ethicist Susanne Brauer has written:

Obstetrics and midwifery are value-laden, value-producing and value-reproducing practices, values that constitute the social perception of what it means to be a ‘‘good’’ pregnant woman and to be a ‘‘good’’ (future) mother.

Similarly, professional lactation support is also value-laden, value-producing and value-reproducing.

There’s no better example of this behavior than their fraught relationship with maternal autonomy.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Midwives and lactation consultants sugar coat their paternalism by claiming that women who don’t follow their recommendations need more “support.”[/pullquote]

If there is one thing midwives are sure of, it’s that they are committed to maternal autonomy. They believe deeply that women are entitled to choose place of birth, birth attendant, birth support, vaginal birth, refusal of procedures, refusal of pain medication and refusal of hospital policies (e.g. separation of mother and child after birth) that do not serve their needs.

Yet there’s another thing they’re equally sure of: some maternal choices are better than others.

Similarly, lactation consultants are committed to maternal autonomy: women are entitled to choose where, when and for how long they breastfeed. They are entitled to choose public breastfeeding, breastfeeding in Parliament or locations otherwise restricted to professional behavior, breastfeeding on demand and breastfeeding toddlers or older children.

Yet there’s another thing they’re equally sure of: the choice to breastfeeding is better than the choice to formula feed.

How do midwives and lactation consultants square their ostensible commitment to maternal autonomy with promotion of specific maternal choices? Ironically, they rationalize it with paternalism, a practice thoroughly inconsistent with maternal autonomy.

What do we mean by autonomy in a pregnancy/early motherhood setting?

From a legal point of view every medical intervention, including therapeutic, palliative, diagnostic and preventive measures, is potentially an infringement on the bodily and psychological integrity of the patient—regardless of whe- ther the intervention is medically necessary. Each inter- vention is therefore in need of consent from the (competent) patient in order to be legitimate (special cases are emergency cases and medical decisions concerning incompetent or unconscious patients). This is especially true for routine prenatal care where the purpose of medical intervention is diagnostic and preventive in nature, and not the treatment or eradication of disease.

How can we tell if a mother’s autonomy is being respected?

1. She must receive accurate information.

2. She must receive complete information.

3. She must understand the information.

4. She must have a real choice between options.

5. While it is appropriate for a provider to convey what her choice would be in a similar situation, the provider must not exert pressure to produce that choice.

There is a massive professional and lay literature on the many ways in which obstetricians have failed to respect mothers’ autonomy. To their credit, there has been tremendous progress over the years — offering new options that privileged, primarily white women demand — but there is plenty of room for improvement. Obstetricians have replaced their paternalism, the belief that they know best, with greater respect for patient choices.

Midwives have often presented themselves as more respectful of patient autonomy than obstetricians. They spend more time eliciting patient preferences, discussing fears and making plans. They are quite comfortable, often encouraging, in promoting women’s right to refuse conventional medical tests and treatments and have offered novel options — continuous labor support, homebirth, placenta preservation, etc.

In both theory and practice midwives are actually less respectful of maternal autonomy than obstetricians because they feel no compunction about injecting their personal preferences into patient care. An obstetrician might prefer a maternal request C-section for herself, but she has no problem respecting patient preference for vaginal birth; an obstetrician might prefer an epidural for herself but she has no problem respecting patient preference for unmedicated birth; an obstetrician might prefer every possible prenatal test for her baby but she has no problem acknowledging that some women want as few as possible while still being compatible with safety.

Midwives, in contrast, prefer unmedicated vaginal birth for themselves and tout it to their patients. Indeed, they go so far as to label their preferences as “normal birth” and run campaigns to promote it. They argue vociferously against “interventions,” including effective pain relief in labor. For most midwives maternal request C-sections are anathema.

Lactation consultants don’t even pretend to respect patient autonomy. They have created the Baby Friendly Hospital Initiative and promoted public health campaigns, legislation and restrictions of formula, all explicitly designed to privilege exclusive, extended breastfeeding over any other possible choice (formula feeding, combo feeding).

How do midwives and lactation consultants defend their blatant violations of maternal autonomy? The exact same way that obstetricians always justified their violations of maternal autonomy: with paternalism. They believe unmedicated vaginal birth and breastfeeding are better for mothers and babies and that justifies pressuring women into approved choices.

When you point out to them that they are emulating the worst habits of patriarchal medicine, they double down. Instead of reflecting on the irony that they are promoting specific choices instead of maternal choice, they ignore the issue of autonomy altogether. In their account the problem with obstetricians is not that they failed to offer women choices; but that they offered a single choice that was inferior to the single choice that midwives offer.

For example, they applaud obstetricians offering women the choice of VBACs after multiple C-sections or breech vaginal births, because vaginal birth is better. They decry obstetricians offering women maternal request C-sections because C-sections are inferior.

Midwives and lactation consultants have offered one innovation to the practice of ignoring maternal autonomy, however. Obstetricians were quite forthright in asserting that their education and training justified their paternalism. Midwives and lactation consultants sugar coat their paternalism by claiming that women who don’t follow their recommendations need more “support.” But support means helping each mother to achieve HER goals, not the providers goals. We have another word for that: pressure. Midwives pressure women to have vaginal births; they pressure women to refuse epidurals or they sabotage their efforts to get epidurals. Lactation consultants privately and sometimes publicly deride women who can’t or don’t wish to breastfeeding as lazy, ignorant and manipulated by formula companies.

Obstetrics has a long history of paternalism; but to the credit of obstetricians most now recognize this and try to do better. Midwifery and professional lactation support rest firmly on paternalism, the belief that midwives and lactation consultants know best. Sadly they refuse to recognize their own paternalism and therefore continue to impose it.