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We, as midwives, have a responsibility to educate ourselves and others regarding our values and ethics and to reflect them in our practices. Our exploration of ethical midwifery is a critical reflection of moral issues as they pertain to maternal and child health on every level. This statement is intended to provide guidance for professional conduct in the practice of midwifery, as well as for MANA’s policy making, thereby promoting quality care for childbearing families. MANA recognizes this document as an open, ongoing articulation of our evolution regarding values and ethics.

We recognize that values often go unstated, and yet our ethics (how we act), proceed directly from a foundation of values. Since what we hold precious—that is—what we value, infuses and informs our ethical decisions and actions, the Midwives Alliance of North America wishes to explicitly affirm our values¹ as follows:

I. Woman as an Individual with Unique Value and Worth:

A. We value women and their creative, life-affirming and life-giving powers, which find expression in a diversity of ways.

B. We value a woman’s right to make choices regarding all aspects of her life.

II. Mother and Baby as Whole:

A. We value the oneness of the pregnant mother and her unborn child, an inseparable and interdependent whole.

B. We value the birth experience as a rite of passage; the sentient and sensitive nature of the newborn; and the right of each baby to be born in a caring and loving manner, without separation from mother and family.

C. We value the integrity of a woman’s body and the right of each woman and baby to be totally supported in their efforts to achieve a natural, spontaneous vaginal birth.

D. We value the breastfeeding relationship as the ideal way of nourishing and nurturing the newborn.

III. The Nature of Birth:

A. We value the essential mystery of birth.²

B. We value pregnancy and birth as natural processes that technology will never supplant.³

C. We value the integrity of life’s experiences; the physical, emotional, mental, psychological and spiritual components of a process are inseparable.

D. We value pregnancy and birth as personal, intimate, internal, sexual, and social events to be shared in the environment and with the attendants a woman chooses.⁴

E. We value the learning experiences of life and birth.

F. We value pregnancy and birth as processes that have lifelong impact on a woman’s self-esteem, her health, her ability to nurture and her personal growth.

IV. The Art of Midwifery:

A. We value our right to practice the art of midwifery. We value our work as an ancient vocation of women that has existed as long as humans have lived on earth.

B. We value expertise that incorporates academic knowledge, clinical skill, intuitive judgment and spiritual awareness.⁵

C. We value all forms of midwifery education and acknowledge the ongoing wisdom of apprenticeship as the original model for training midwives.

D. We value the art of nurturing the intrinsic normalcy of birth and recognize that each woman and baby have parameters of well-being unique to themselves.

E. We value the empowerment of women in all aspects of life and particularly as their strength is realized during pregnancy, birth and the period thereafter. We value the art of encouraging the open expression of that strength so women can birth unhindered and confident in their abilities and in our support.

F. We value skills that support a complicated pregnancy or birth to move toward a state of greater well-being or to be brought to the most healing conclusion possible. We value the art of letting go.⁶

G. We value the acceptance of death as a possible outcome of birth. We value our focus as supporting life rather than avoiding death.⁷

H. We value standing for what we believe in the face of social and political oppression.

V. Woman as mother:

A. We value a mother’s intuitive knowledge of herself and her baby before, during and after birth.⁸

B. We value a woman’s innate ability to nurture her pregnancy and birth her baby, the power and beauty of her body as it grows and the awesome strength summoned in labor.

C. We value the mother as the only direct care provider for her unborn child.⁹

D. We value supporting women in a nonjudgmental way, whatever their state of physical, emotional, social or spiritual health. We value the broadening of available resources whenever possible so that the desired goals of health, happiness and personal growth are realized according to a woman’s needs and perceptions.

E. We value the right of each woman to choose a care giver appropriate to her needs and compatible with her belief system.

F. We value pregnancy and birth as rites of passage integral to a woman’s evolution into mothering.

G. We value the potential of partners, family and community to support women in all aspects of birth and mothering.¹⁰

VI. The Nature of Relationship:

A. We value relationships. The quality, integrity, equality and uniqueness of our interactions inform and critique our choices and decisions.

B. We value honesty in relationships.

C. We value caring for women to the best of our ability without prejudice against their age, race, religion, culture, sexual orientation, physical abilities or socioeconomic background.

D. We value the concept of personal responsibility and the right of individuals to make choices regarding what they deem best for themselves. We value the right to true informed choice, not merely informed consent, to what we think is best.

E. We value our relationship to a process larger than ourselves, recognizing that birth is something we can seek to learn from and know, but never control.

F. We value humility in our work.

G. We value the recognition of our own limits and limitations.

H. We value direct access to information readily understood by all.

I. We value sharing information and our understanding about birth experiences, skills and knowledge.

J. We value the midwifery community as a support system and an essential place of learning and sisterhood.

K. We value diversity among midwives, recognizing that it broadens our collective resources and challenges us to work for greater understanding of birth and each other.

L. We value mutual trust and respect, which grow from a realization of all of the above.

Making decisions and acting ethically

These values reflect our feelings regarding how we frame midwifery in our hearts and minds. However, due to the broad range of geographic, religious, cultural, political, educational and personal backgrounds among our membership, how we act based on these values will be very individual. Acting ethically is a complex merging of our values and these background influences, combined with the relationship we have to others who may be involved in the process taking place. We call upon all these resources when deciding how to respond in the moment to each situation.

We acknowledge the limitations of ethical codes that present a list of rules that must be followed, recognizing that such a code may interfere with, rather than enhance, our ability to make choices. To apply such rules, we must have moral integrity, an ability to make judgments, and adequate information; with all of these, an appeal to a code becomes superfluous. Furthermore, when we set up rigid ethical codes, we may begin to cease considering the transformations we go through as a result of our choices as well as negate our wish to foster truly diversified practice. Rules are not something we can appeal to when all else fails. This, however, is the illusion fostered by traditional codes of ethics.¹¹ MANA’s support of the individual’s moral integrity grows out of an understanding that there cannot possibly be one right answer for all situations.

We acknowledge the following basic concepts and believe that ethical judgments can be made with these thoughts in mind:

• Moral agency and integrity are born within the heart of each individual.
• Judgments are fundamentally based on awareness and understanding of ourselves and others and are primarily derived from one’s own sense of moral integrity with reference to clearly articulated values. Becoming aware and increasing our understanding are ongoing processes facilitated by our efforts at personal growth on every level. The wisdom gained by this process cannot be taught or dictated, but one can learn to realize, experience and evaluate it.
• The choices we can or will actually make may be limited by the oppressive nature of the medical, legal or cultural framework in which we live. The more our values conflict with those of the dominant culture, the more risky it becomes to act truly in accord with our values.
• The pregnant woman and midwife are both individual moral agents unique to themselves, having independent value and worth.
• We support ourselves, and the women and families we serve, to follow and make known the dictates of our own consciences as our relationship begins and evolves, especially when decisions must be made that impact us or the care being provided. It is up to all of us to work out a mutually satisfactory relationship when and if that is possible.

It is useful to understand the two basic theories on which moral judgments and decision-making processes are based. These processes become particularly important when one considers that in our profession a given woman’s rights may not be absolute in all cases and in certain situations the woman may not be considered autonomous or competent to make her own decisions.

One of the main theories of ethics states that one should look to the consequences of the act (that is, the outcome) and not the act itself to determine if it is appropriate care. This point of view looks for the greatest good for the greatest number. The other primary ethical theory states that one should look to the act itself (that is, type of care provided) and, if it is right, then this could override the net outcome. This is a more process-oriented, feminist perspective. As midwives, we weave these two perspectives in the process of making decisions in our practices. Since the outcome of pregnancy is ultimately unknown and is always unknowable, it is inevitable that in certain circumstances our best decisions in the moment will lead to consequences we could not foresee.

In summary, acting ethically is facilitated by:

• Carefully defining our values.
• Weighing the values in consideration with those of the community of midwives, families and culture in which we find ourselves.
• Acting in accord with our values to the best of our ability as the situation demands.
• Engaging in ongoing self-examination and evaluation.

There are both individual and social implications to any decision-making process. The actual rules and oppressive aspects of a society are never exact, and therefore conflicts may arise. We must weigh which choices or obligations take precedence over others. There are inevitably times when resolution does not occur and we will be unable to make peace with any course of action or may feel conflicted about a choice already made. The community of women, both midwives and those we serve, will provide a fruitful resource for continued moral support and guidance.

Notes:

1. The membership largely agrees with the values that follow. However, some may word them differently or may leave out a few. This document is intended to prompt personal reflection and clarification, not to represent absolute opinions.
2. Mystery is defined as something that has not or cannot be explained or understood; the quality or state of being incomprehensible or inexplicable; a tenet that cannot be understood in terms of human reason.
3. Supplant means to supersede by force or cunning, to take the place of.
4. In this context internal refers to birth happening within the body and psyche of the woman: ultimately she and only she can give birth.
5. An expert is one whose knowledge and skill is specialized and profound, especially as the result of practical experience.
6. This addresses our desire for an uncomplicated birth whenever possible and recognizes that there are times when it is impossible. That is to say, a woman may be least traumatized by having a Cesarean and a live baby, when a spontaneous vaginal birth is not possible. We let go of that goal to achieve the possibility of a healthy baby. Likewise, the situation in which parents may choose to allow a very ill, premature or deformed infant to die in their arms rather than being subjected to multiple surgeries, separations and ICU stays. This too, is a letting-go of the normal for the most healing choice possible, given the circumstances, within the framework of the parent’s ethics. What is most healing will, of course, vary from individual to individual.
7. We place the emphasis of our care on supporting life (preventive measures, good nutrition, emotional health, etc.) and not pathology, diagnosis, treatment of problems, and heroic solutions in an attempt to preserve life at any cost of quality.
8. This addresses the medical model’s tendency to ignore a woman’s sense of well-being or danger in many aspects of health care, but particularly in regard to her pregnancy.
9. This acknowledges that the thrust of our care centers on the mother, her health, her well-being, her nutrition, her habits and emotional balance so that, in turn, the baby benefits. This view is diametrically opposed to the medical model which often attempts to care for the fetus or baby while dismissing or even excluding the mother.
10. While partners, other family members and a woman’s larger community can and often do provide her with vital support, in using the word potential we wish to acknowledge that many women find themselves pregnant and mothering in abusive and unsafe environments.
11. Sarah Lucia Hoagland, paraphrased from her book Lesbian Ethics.

Bibliography:

Cross, Star, MANA Ethics Chair, 1989, unpublished draft of Ethics code.

Daly, Mary, Gynecology: The Metaethics of Radical Feminism, Beacon Press, Boston, MA 1978.

Hoaglaod, Sarah Lucia, Lesbian Ethics: Toward New Value, Institute of Lesbian Studies, Pale Alto. CA. 1988.

Johnson, Sonia, Going Out of Our Minds: The Metaphysics of Liberation, Crossing Press, Freedom, CA 1987

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