You are thrilled to see that your previous client is returning to your clinic for their second pregnancy. During your 20-week visit, your client explains that they feel their previous planned hospital birth gave them access to interventions which, they feel, ultimately led to their birth by caesarean section. This time, they wish to avoid the hospital altogether, and are planning a home birth.
Midwives provide choice of birthplace to their clients. Each midwife is responsible for providing information related to health care choices which positions the client as the ultimate decision-maker in their own health care. In the Professional Standards for Midwives, there are numerous standards which explain a midwife’s duty of care in this respect.
- 15. Support clients to be active participants in managing their own health and the health of their newborns.
- 16. Recognize clients as the primary decision-makers and provide informed choice in all aspects of care by:
- 16.1. providing information so that clients are informed when making decisions about their care
- 16.2. advising clients about the nature of any proposed treatment, including the expected benefits, material risks and side effects, alternative courses of action, and likely consequences of not having the treatment
- 16.3. making efforts to understand and appreciate what is motivating clients’ choices
- 16.4. allowing clients adequate time for decision-making
- 16.5. ensuring treatment is only provided with the client’s informed and voluntary consent unless otherwise permitted by law
- 16.6. supporting clients’ rights to accept or refuse treatment
- 16.7. respecting the degree to which clients want to be involved in decisions about their care.
- 18. Provide clients with a choice between home and hospital births.
- 19. Provide care during labour and birth in the setting chosen by the client.
The College of Midwives of Ontario will retire the Vaginal Birth After Caesarean Section (VBAC) and Choice of Birthplace Statement as of January 5, 2024 as the information provided in the statement is already reflected in the Professional Standards. As in many other clinical scenarios, the decision to birth outside of hospital for this population may require additional layers of consent documentation and care planning to mitigate risks, reduce harm, and support client autonomy.
Midwives have the knowledge, skills, and judgment to support out of hospital birth for clients with a history like prior caesarean section.
Midwives should work to their fullest possible scope and to their greatest level of skill to maintain a trusting and mutually respectful relationship with their clients in order to reduce harm and address points of conflict over care. Additionally, it is appropriate to advocate for client choice with community health partners, including at point of transfer of care and in development of hospital policies around supporting client choices.