Midwives? experience of personal/professional risk when providing continuity of care to women who decline recommendations: A meta-synthesis of qualitative studies

Problem: Women's autonomous choices in pursuit of physiological childbirth are sometimes limited by the midwife's willingness to support those choices, particularly when those choices are contrary to recommendations or outside of guidelines.Background: Women's reasons for making such choices have received some research attention, however there is a paucity of research examining this phenomenon from the perspective of caseloading midwives' and their perception of personal/professional risk in such situations.Aim: To synthesise qualitative research which includes the voices of midwives working in a continuity of carer model who perceive any kind of risk to themselves when caring for women who decline current established recommendations.Methods: Systematic literature search and meta-synthesis were carried out following a pre-determined search strategy. The search was executed in April 2021 and updated in July 2021. Studies were assessed for quality using JBI Critical Appraisal Checklist for Qualitative Research. Data extraction was assisted by JBI QARI Data Extraction Tool for Qualitative Research. GRADE-CERQual was applied to the findings.Findings: Eight studies qualified for inclusion. Five main themes were synthesised as third order constructs and were incorporated into a line of argument: Women's rights to bodily autonomy and choice in childbearing are violated, and their ability to access safe midwifery care in pursuit of physiological birth is restricted, when midwives practise within a maternity system which is adversarial towards midwives who provide the care which women require. Midwives who provide such care place themselves at risk of damaged reputation, collegial conflict, intimidating disciplinary processes, tensions of 'being torn', and a heavy psychological load. Despite these personal and professional risks, midwives who provide this care do so because it is the ethical and moral thing to do, because they recognise that women need them to, because it can be very rewarding, and because they are able to.Conclusion: Maternity systems and colleagues can be key risk factors for caseloading midwives who facilitate women's right to decline recommendations. These identified risks can make it unsustainable for midwives to continue providing woman-centred care and contribute to workforce attrition, reducing options/choices for women which paradoxically increases risk to women and babies.