There should be consideration of whether there are safeguarding concerns for every woman accessing NHSGGC Maternity services. Declining care does not, in itself, warrant any referrals to Blossom Team, Maternity and Neonatal Psychological Interventions (MNPI) Team or Public Protection.

However, it may be appropriate to exclude safeguarding concerns. These can be discussed with the Blossom Team and the Public Protection Team, and referrals made if indicated. Blossom Team referral criteria

All women should be able to access and discuss current reliable evidence based information with their midwife and obstetrician.  Midwives should signpost women to reliable sources of information including:

• GGC resources

• guidelines platform Maternity | Right Decisions (scot.nhs.uk)
• website
• Badger app
• NHS Scotland resources [Scottish health information you can trust | NHS inform, Ready Steady Baby!]
• NICE guidelines Find guidance | NICE
• AIMS For a better birth | AIMS
• Birthrights Birthrights - your human rights during pregnancy and maternity

Staff should ensure that they access reliable sources of information to support them in providing care to women asking for care outside guidance, including:

• RCM Care outside guidance: caring for those women seeking choices that fall outside guidance
• RCM Informed decision making
• NMC Standards of proficiency for midwives
• RCOG Green top Guidelines, Patient Information Leaflets, Consent
• GMC - The dialogue leading to a decision part one of four - professional standards

To support a woman requesting care or making choices outwith recommended GGC guidance, maternity staff should work in partnership with the woman to develop an individualised plan of care and to provide assurance through documentation of the discussions that choices and decisions are informed.

Building a trusting relationship is a key element of supporting women who are choosing care outside guidance and contributes to minimising risk.  Advocating for a woman’s informed choices is an essential element of building a trusting relationship. Continuity of carer should be maximised for all appointments.  If there are difficulties in continuing this development of a trusting relationship, women should be advised that they are able to request a different primary midwife. 

Aspects of care may include:

• A trauma informed approach: National Trauma Transformation Programme
• Referrals to MNPI Birth Matters clinic: Perinatal mental health referral guidance
• The provision of unbiased, evidence based information to inform a woman's decision making in a suitable format/language/style
• Provision of appropriate interpreting support and translated materials
• Facilitating meaningful conversations with the woman about the information provided
• Liaison with wider multidisciplinary team to explore options
• Accompanying women to appointments with the multidisciplinary team (MDT) and advocating for her
• Consideration of safeguarding concerns, with referrals if indicated
• Co-producing a detailed birth plan.

It should be recognised that discussions to explore birth options and to develop an individualised plan of care require adequate time. Facilitating these conversations from early in pregnancy is best practice for all women, but particularly so for women considering choices outwith NHSGGC recommended guidance. Consideration should be given to additional or double appointments. Documentation of consultations and co-produced care plans should be shared to BadgerNet to allow visibility to all involved in the woman’s care, including the woman.

Birth choice discussions are the within the remit and responsibility of the primary midwife as part of the universal midwifery care pathway. Where the GGC recommended plan of care includes the wider maternity multidisciplinary team, that collaborative discussion should involve escalation or referral to the appropriate professional.

It is important that the primary midwife is confident to discuss the evidence around the particular choice being made.  This should include sharing robust, clear evidence about potential risks and benefits of different choices in a format that is comprehensible for the woman and her family.  The primary midwife should seek any support needed in accessing this evidence from their senior charge midwife, the service librarian for literature searches and obstetric and other specialist colleagues. 

Midwives are encouraged to seek support from a senior/experienced midwife, usually the relevant Senior Charge Midwife, for case review/supervision. With a woman's agreement a group meeting with both the primary and senior charge midwife can be facilitated.

If a woman has already been counselled, and this is clearly and comprehensively documented, respect and honour her choices.

Women may choose to decline some aspects of maternity care offered to them, such as consultant obstetrician appointments, or choose not to engage with maternity services. In this situation the Lead Midwife for Community and Outpatients (Glasgow) or the Lead Midwife (Clyde) should be informed.

In the absence of safeguarding concerns, the next step is to communicate to the woman, both verbally and in writing, that maternity care remains accessible, and can recommence at any time during the antenatal, intrapartum or postnatal period. Advice should be shared around birth notification, the legality around acting as a midwife, and safety/what to do in an emergency (see appendix for suggested draft letter).

Supporting women who choose to make choices out with NHSGGC guidance may be emotionally and professionally challenging for maternity staff. Staff have access to:

• Clinical supervision [restorative model]
• MNPI service [staff access]
• Case review/supervision [caseload specific with SCM or other senior midwife]
• Education or refresher programmes [Core Mandatory Training +/- bespoke training]

Suggested draft letter for women declining all maternity care (pdf)

Woman expresses desire to choose care outside NHSGGC guidance

Conversation facilitated by Primary midwife to discuss any concerns associated with choices, using evidence based information.

Care should be taken to ensure an unbiased approach is taken.

Documentation of conversation, including detail of topics discussed, with an outcome or plan included

[Management Plan, with use of critical alerts for appropriate dissemination of pertinent information]

Liaise with the MDT and action referrals if criteria are met.

Consider MNPI, Blossom Team, Public Protection helpline, named obstetrician.

Update/escalate to Senior Charge Midwife for support and case review/supervision