Supporting women seeking care outside guidance

By Lia Brigante, Policy & Practice Advisor Midwives NHS

The notion of woman-centred care has been at the heart of RCM policy and at the core of maternity policy in the UK for decades. We know that personalised care is safer care, and that having choice and control improves clinical outcomes for women and their babies. Midwives have a key role as advocates and facilitator of women’s choices, particularly when women and families have to negotiate with fragmented and under-resourced healthcare systems. Those systems bring challenges to midwives too, often unable to have enough time to provide the high-quality care they would like to give.

New advice from the RCM around care outside guidance provides midwives with guiding principles on facilitating personalised care and women’s choices, including when those fall outside clinical recommendations. Personalised care requires a relationship of mutual trust between a woman and her midwife, and multi-disciplinary collaboration, often facilitated by models of midwifery continuity of carer (MCoC). This new RCM guidance helps support midwives working in different models and includes indications on how to support the implementation of personalised care and support plans (PCSP) for women seeking choices that fall outside guidance. It is underpinned by the principles of consent as a fundamental right of individuals and by the changes in UK law due the landmark ruling of Montgomery v Lanarkshire.

In my clinical career, I have been able to work in a supportive environment, in a Trust with an established ‘OutWith’ guidance clinic, run by a consultant midwife. The clinic not only enabled women with medical and social complexities to be supported with personalised care planning by a consultant midwife, but it also enabled midwives (at all stages of their career) to be supported to provide out of guidance care confidently and safely. The mantra from the multi-disciplinary team is “we may not recommend it, but we will support it”.

This supportive environment taught me a lot and in turn enabled me to mentor and support more junior colleagues and student midwives with their skills in counselling women and supporting their choices. In my first year as a caseload midwife, I cherished the support I received by senior midwifery coordinators as well as my own caseload colleagues when called out to a ‘out of guidance’ homebirth. The experience I have developed has enabled me to support other midwives, often skilled and experienced in obstetric-led settings, to support women at ‘higher risk’ to birth at home or in a midwifery-led unit. However, it can be very difficult for midwives to provide care in certain circumstances, particularly if they are experiencing a conflict between duty of care and the wishes of a woman in their care. This can be particularly challenging if working in fragmented systems lacking in midwifery leadership and a positive organisational culture.

This guidance looks to address those barriers by providing the knowledge necessary to midwives to feel able to provide personalised care. It was developed by the RCM, with input from an independent advisory group of experts on the topic, from consultant midwives to academics. If we listen to women and trust them to make informed decisions, even if those decisions we would not make for ourselves, we will improve outcomes and ensure safer care. It is important to remember that women are more likely to access and engage with services when their physical, emotional, psychological, and social needs are met and when cultural safety is respected.


Download the Care Outside Guidance