Principles for supporting women's choices in maternity care

These principles that have been developed to support midwives and organisations providing personalised care for women during pregnancy, birth and the postnatal period, wherever the care takes place.

The principles are designed to support women in receiving kind, compassionate, high quality and safe, personalised care throughout the childbirth continuum and have been developed in collaboration with a wide range of interdisciplinary and multiagency key stakeholders. Their input and support have been invaluable in shaping this work. Experience and knowledge of current midwifery maternity-related practice and considered evidence and research, combined with the voice of women has resulted in principles that can be applied in:

• Situations where women's choices of care relate to birth in hospital or at home
• Care 'outside of guidance'
• Instances where midwifery care at any stage of the childbirth continuum is declined

The words woman and women have been used throughout this document as this is the way that the majority of those who are pregnant and having a baby will identify. For the purpose of this document, this term includes girls. It also includes people whose gender identity does not correspond with their birth sex or who may have a non-binary identity'.

We worked together with people from around the UK to coproduce these principles. We engaged with service users and midwives in practice, leadership, management, education, research, policy, regulation and ambulance service roles. Collectively, and with participation and input from user voices, student midwives, doctors, doulas, police and relevant professional and arm's length bodies, we all worked in partnership to develop these principles – thank you.

Introduction

The role of the midwife is to provide professional, skilled, knowledgeable, respectful and compassionate care for all women, newborn infants and their families. Midwives are fully accountable as the lead professionals throughout the maternity continuum, and provide care based on the best available evidence. They are required to keep up to date with current knowledge and skills.

Midwives work in partnership with women enabling their views, preferences and decisions to be listened to and heard. When a woman makes an informed decision to decline aspects of maternity care, and/or choose freebirth, midwives and organisations should make every effort to work in partnership with the woman to support them to ensure the best outcomes for the woman and the baby.

Women can make their own choices about their maternity care, including the place of birth, those present with them at the birth and whether they wish to access all, some or no maternity care.

Legislation supports the autonomy and agency of women to choose where they wish to give birth, who they wish to have with them and whether they choose some or no midwifery or medical input during the childbirth continuum. This may include having a non-registered person (without midwifery or medical registration) with them for non-clinical support and reassurance. The place of birth may include home, midwife-led or consultant-led units. Alternatively, women may select to freebirth in their place of birth. Freebirths are a legal option for a woman in the UK. Freebirth can be defined as the deliberate decision to give birth without a regulated healthcare professional or more recently, the practice to self-care during birth in contexts where emergency maternity care is readily available.

Article 45 of The Nursing and Midwifery Order 2001 makes it a criminal offence for any person who is not a midwife, meaning someone who has a qualification in midwifery and is registered with the Nursing and Midwifery Council (NMC) or a registered medical practitioner, meaning a General Medical Council (GMC) registered doctor with a licence to practise, to attend a woman in childbirth. The only exception to this is in a case of 'sudden or urgent necessity', or when a student undergoing education and training to become a midwife or medical practitioner attends a woman in childbirth as part of an approved education programme.

If an unregulated person misrepresents themselves as a midwife or performs actions associated with the protected function of a midwife, there could also be an increased risk of an adverse clinical outcome to the woman, her baby (or both), and a potential breach of Article 44 and 45 of the Nursing and Midwifery Order, which can be found in Appendices 1 and 2.

Midwife is a protected title in the UK and as such, gives users of services and the public confidence that registered professionals are qualified, hold appropriate indemnity cover for their role and meet the standards the NMC sets for the profession. Once a registered midwife has established a professional relationship with a woman they can only attend that woman during birth if they have appropriate indemnity cover. They cannot work the requirement to hold appropriate indemnity cover by attending a birth in a 'non-midwife' capacity such as a doula. For midwives working within the NHS, this indemnity cover is provided by their employer.

Women using maternity services

Should expect to:

• Be central in all decision-making about their care
• Be provided with the range of options and/or alternatives available to them in a respectful, non-coercive manner, including explanations of the risks and benefits of their care choices and alternatives
• Be presented information in a way that is easy to understand, using a range of formats to ensure accessibility and being mindful of potential issues such as language and neurodiversity
• Have a personalised care and support plan that reflects and respects their views, preferences and decisions, including where care is declined and does not require them to justify their decision
• Be able to decide to decline or stop conversations around their care, regardless of their reason to do so
• Be provided with the appropriate advice about the roles and benefits of a midwife, obstetrician and neonatologist during the maternity pathway
• Be provided with evidence-based information to make an informed choice
• Receive personalised care, ideally with continuity of care and carer, as an important element of an ongoing, supportive relationship
• Know how to contact their midwife and maternity unit and have confidence that they will receive the advice and support they need
• Feel safe with care that meets their physical, psychological, social, cultural, and spiritual needs and expectations
• Be able to use these principles to support them in receiving kind, compassionate, high quality, safe and personalised care throughout the childbirth continuum

The role of the midwife

• Be professionally curious, taking steps to understand the reasons why women are making their individual choices and promote positive relationships with them during all contacts and conversations
• Be able to describe the role of the midwife in supporting women, enhancing safety and reducing risk during their maternity journey
• Keep the woman at the centre of their decision-making
• Respect the woman's decision whether (or not) to engage with any or all parts of the midwifery care offered
• Support person-centred holistic care in line with the NMC Code and the Standards of proficiency for midwives
• Be informed by and work within the relevant laws of the country in which they are practising
• Use evidence-based and up-to-date policies and procedures
• Provide care that is respectful, fair, free from discrimination and without bias, including any bias against protected characteristics
• Recognise that some women may be fearful about giving birth, particularly in an NHS setting
• Use a culturally competent approach to understand the reasons why women choose to freebirth or birth 'outside of guidance'
• Promote evidence-based discussions with the woman, including information in respect to pathways and support that can be offered to mitigate risks should they be present, or develop throughout the pregnancy and childbirth experience
• Respect and work in partnership with the woman in a non-coercive manner to explore options and the full range of available choices of environments for her midwifery care. Explain the risks and benefits in care choices
• Provide care that is based on the informed consent of the woman
• Emphasise to women opting out of midwifery care that they can resume the care whenever they choose, without judgement or prejudice; in such cases, ensure that the woman knows how and who to contact about this
• Discuss and give a clear rationale for alternative care pathways
• Develop a person-centred care and support plan in partnership with the woman that reflects their individual views, preferences and decisions and the level of care she wants to receive in any care setting
• Use trauma-informed communication skills, respect a woman's informed choice and promote a positive relationship
• Be aware that a woman opting for a freebirth does not constitute a safeguarding concern unless there is a formally diagnosed lack of capacity to make decisions or there are other issues such as domestic abuse
• Be knowledgeable of local guidance and able to present contemporary evidence in an unbiased way to enable women to make evidence-informed decisions
• Keep professionally up-to-date and participate in mandatory training to make sure they have the knowledge and skills to support women and babies with additional needs or any complications that may arise
• Agree lines of communication between the midwife and woman, to support an ongoing professional relationship
• Have clear channels to access the appropriate further information, professional advice and support they need from senior interdisciplinary colleagues to better inform quality, woman-centred care that works in partnership with the woman. This includes having the opportunity for a supportive debrief with a consultant midwife or another senior colleague
• Liaise, work and train with the multidisciplinary team to promote best outcomes for the woman and newborn infant
• Work with the wider maternity team, using all their knowledge and skills to ensure the physical, psychological, social, cultural, and spiritual safety of women and adapt the care to meet their needs
• Work with the wider maternity team, including the ambulance service, and receive training on emergencies to rehearse scenarios and situations that they might face

The role of the employer

• Enable midwives to fulfil their role to support woman-centred holistic care, so that they are practising in line with the NMC Code and the Standards of proficiency for midwives
• Have clear, up-to-date, evidence-based guidelines based on the NMC Code and Standards of proficiency for midwives to support the provision of care deemed outside guidance and make sure these guidelines are available to women accessing maternity services
• Provide the options for where a woman can give birth; including home birth, midwifery-led and consultant-led care. Ensure that it is clear that the ambulance service is for emergency purposes only
• Engage constructively with requests for home birth, supported by midwives
• Ensure that evidence-based information and resources including the organisation's evidence-based guidelines and policies are available for midwives to share with the women they are working in partnership with
• Ensure every request for a particular care option is considered individually, with the woman's circumstances considered and options explored as to how their rights could be upheld
• Ensure that all healthcare professionals who are involved in the care of women are respected and supported to work in partnership with the woman in a non-coercive manner, to explore the best options and the full range of available choices of environments for her care
• Ensure that infrastructure and support systems are in place for midwives to provide safe care to women and their newborn infants
• Ensure that a midwife is not put in any situation that compromises their own safety or limits access to any basic human rights such as water, sanitation and hygiene
• Assess the feasibility of requests where a woman asks for a midwife to be present at a home birth but not providing direct care to the woman, such as being asked to wait outside the birthing space during labour
• For a known freebirth, be clear prior to labour about arrangements with the local maternity services and whether or not a midwife will attend if called
• Ensure that current information about the birth notification process following a freebirth is available
• Ensure collaborative working and promote learning together to foster a better understanding of the role of each member of the maternity team, including with the ambulance service
• Be transparent with women about the range of maternity care available, including explaining when a care option is temporarily unavailable due to service pressures and the likely reinstatement
• Ensure that any temporary withdrawal of a service, for example due to lack of availability of staff, is proportionate, absolutely necessary and reviewed on a continuing basis to ensure maternity services are reinstated at the earliest opportunity

The role of the Nursing and Midwifery Council (NMC)

• Set evidence-based standards – the NMC Code and Standards of proficiency for midwives
• Ensure midwives on the NMC register have the education and training required to provide safe, kind and effective care
• Oversee the revalidation process that ensures midwives are keeping their skills and knowledge up to date
• Ensure midwives, wherever they work in the UK, have appropriate indemnity arrangements in place for the care that they provide
• Investigate when a concern about a midwife's practice is raised and consider the context in which the midwife was practising when investigating the concern
• Adopt a person-centred, just and learning culture approach to fitness to practise, with regulatory practices that are timely, fair and effective and make sure that a midwife meets the standards we set to practise safely
• Identify any risks to safety and take appropriate action when the NMC is informed or becomes aware that an unregulated person may have committed an Article 44 or Article 45 offence
• Maintain a dedicated mailbox registration.investigations@nmc-uk.org and take appropriate action where concerns are raised that an offence may have been committed under Article 44 or 45, in line with our Criminal Offences Policy and our safeguarding responsibilities
• Mitigate risks by working with other stakeholders, supporting partners and the public to promote understanding of the role of a registered midwife so that informed choices can be made

Further information

Endnotes

1. Woman: glossary in Standards-of-proficiency-for-midwives.pdf.
2. In accordance with Articles 8 and 9 of the ECHR and case law including Ternovszky v Hungary (2010) and Dubska v Czech Republic (2014), Konovalova v Russia (2014) and Pinted Mulla v Spain (2024).
3. Velo Higueras M; Douglas, F; Kennedy, C. (2024). Exploring women's motivations to freebirth and their experience of maternity care: A systematic qualitative evidence synthesis – ScienceDirect Midwifery 134.
4. NMC (2022) Professional indemnity arrangement - The Nursing and Midwifery Council (nmc.org.uk).
5. You can check the NMC register for a midwife here.
6. McCulloch v Forth Valley Health Board (2023) and Montgomery v Lanarkshire Health Board (2015).
7. Acknowledging that the NMC as a professional regulator does not set standards for, or comment on workforce or deployment issues, Paragraph 41.
8. Choosing maternity services: https://www.gov.uk/government/publications/the-nhs-choice-framework/the-nhs-choice-framework-what-choices-are-available-to-me-in-the-nhs#choosing-maternity-services
9. If an offence under the NMC's legislation, possible breaches of articles 44 or 45 may be referred to the local police force.
10. NMC Criminal Offences Policy 2025. Paragraph 41.
11. With thanks to the Association of Ambulance Chief Executives (AACE).
12. NMC Criminal Offences Policy 2025. Paragraph 41.

References and guidance

Birthrights - your human rights during pregnancy and childbirth

Feeley, C; and Thomson, G. (2016a). Why do some women choose to freebirth in the UK? An interpretative phenomenological study. BMC Pregnancy and Childbirth, 16(59).

Feeley, C; and Thomson, G. (2016b). Tensions and conflicts in 'choice': Women's experiences of freebirthing in the w. Midwifery, 41, 16-21.

Madeley, AM; Earle, S; O'Dell, L. (2023) Challenging norms: Making non-normative choices in childbearing. Results of a meta ethnographic review of the literature. Midwifery, 114.

McKenzie, G; and Montgomery, E. (2021) Undisturbed Physiological Birth: Insights from Women Who Freebirth in the United Kingdom. Midwifery, 101.

Mental Capacity Acts: Northern Ireland, England and Wales and Scotland. Maternity staff and their employers have a duty to ensure they know how to use the acts.

Nursing and Midwifery Council (2018) The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates - The Nursing and Midwifery Council

• 1.5 respect and uphold people's human rights
• 2.5 respect, support and document a person's right to accept or refuse care and treatment.

Nursing and Midwifery Council (2019) Standards of proficiency for midwives

• Key theme: enabling and advocating for the human rights of women and children
• 1.3 understand and act to promote and enable the human rights of women and newborn infants at all times, including women's sexual and reproductive rights.

NHS Resolution: Good practice: care outside of guidance after previous caesarean - NHS Resolution.

Public Health Agency (PHA) in Northern Ireland: Regional framework for midwives and obstetricians who support women requesting care outside of guidance in Northern Ireland | HSC Public Health Agency.

Royal College of Midwives: RCM position statements

• Supporting women seeking care outside guidance.

Velo Higueras M; Douglas, F; Kennedy, C. (2024) Exploring women's motivations to freebirth and their experience of maternity care: A systematic qualitative evidence synthesis. Midwifery, 134.

Wales: Section on supporting alternative choice: wisdom.nhs.wales/all-wales-guidelines/all-wales-guidelines/all-wales-midwifery-led-care-guideline-2022/.

Westbury B, Einion A (2021) Matricentric or medically responsible: an exploration of midwives' attitudes towards caring for women and birthing people who choose to birth outside of guidelines. Practising Midwife 24:10. https://doi.org/10.55975/EJQZ4427.

Appendix 1 – Protected title

Article 44 in The Nursing and Midwifery Order 2001

Offences

44.— (1) [Subject to paragraph (1A), a person commits an offence] if with intent to deceive (whether expressly or by implication)—

1. he falsely represents himself to be registered in the register, or a particular part of it or to be the subject of any entry in the register;
2. he uses a title referred to in article 6(2) to which he is not entitled;
3. he falsely represents himself to possess qualifications in nursing or midwifery [or a qualification as a nursing associate].

[(1A) Where the representations referred to in paragraph (1) relate to the nursing associates' part of the register or a nursing associate qualification, or where a person uses the title of nursing associate when not entitled to, the offence referred to in that paragraph is committed only when those representations are made, or the title is used, in England.]

(2) [Subject to paragraph (2A), a person commits an offence if—

1. with intent that any person shall be deceived (whether expressly or by implication) he causes or permits another person to make any representation about himself which, if made by himself with intent to deceive, would be an offence under paragraph (1); or
2. with intent to deceive, he makes with regard to another person any representation which—

(i) is false to his own knowledge, and

(ii) if made by the other person with that intent would be an offence by him under paragraph (1).

[(2A) Where the representations referred to in paragraph (2) relate to the nursing associates' part of the register or a nursing associate qualification, the offence referred to in that paragraph is committed only when those representations are made in England.]

(3) [Subject to paragraph (3A), a person who fraudulently procures], or tries to procure, the making, amendment, removal or restoration of an entry in the register, is guilty of an offence.

[(3A) Where under paragraph (3), a person fraudulently procures, or tries to procure, the making, amendment, removal or restoration of an entry in the nursing associates' part of the register, the offence referred to in that paragraph is committed only if the fraudulent procurement, or attempted procurement, occurs in England.]

(4) A person who, without reasonable excuse, fails to comply with any requirement imposed by—

1. the Council, or
2. a Practice Committee

under article 25(1) or (2) or rules made by virtue of article 32(2)(m) or under any corresponding rule made by virtue of article 26, 33 or 37 is guilty of an offence.

(5) A person guilty of an offence under this article shall be liable on summary conviction to a fine not exceeding level 5 on the standard scale.

Appendix 2 – Protected function

Article 45 in The Nursing and Midwifery Order 2001

Attendance by unqualified persons at childbirth

45.— (1) A person other than a registered midwife or a registered medical practitioner shall not attend a woman in childbirth.

(2) Paragraph (1) does not apply—

1. where the attention is given in a case of sudden or urgent necessity; or
2. in the case of a person who, while undergoing training with a view to becoming a medical practitioner or to becoming a midwife, attends a woman in childbirth as part of a course of practical instruction in midwifery recognised by the Nursing and Midwifery Council or by the General Medical Council.

(3) A person who contravenes paragraph (1) shall be liable on summary conviction to a fine not exceeding level 5 on the standard scale.