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Consent in birth and the Montgomery ruling: why doulas need to understand it

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Emma Ashworth is a Nurturing Birth doula, a trustee of AIMS and she is currently the AIMS Journal Editor. She has a special interest in consent and has written extensively on women’s rights in birth.

What is the Montgomery ruling?

‘Montgomery’ refers to a legal case, formally known as ‘Montgomery V Lanarkshire’, where Montgomery is Mrs Nadine Montgomery, and Lanarkshire is the Lanarkshire Health Board in Scotland. The case was brought after Mrs Montgomery’s son was severely injured during his birth. During pregnancy, Mrs Montgomery was very concerned about her forthcoming birth because she felt that her baby was too big for her to birth vaginally. She had diabetes, was very small herself, and the baby appeared to be large. However, her obstetrician did not offer her a caesarean birth as an option to consider.

During the birth, Mrs Montgomery’s son experienced a very severe shoulder dystocia. After a variety of interventions he was born by caesarean, and now lives with cerebral palsy and a damaged shoulder.

The injuries that occurred during his birth are rare, and, statistically speaking, were unlikely to occur even with the risk factors that Mrs Montgomery had. However, the legal case came about not because of the complications themselves, nor how they were handled, but because the obstetrician made the decision to not share the information about the possible outcomes of a vaginal birth and a caesarean with Mrs Montgomery, thus stopping her from being able to make an informed decision herself over what was right for her. Ultimately, the case came down to whether or not information was shared to support informed decision making – and, the case found, it was not.

What did it change about consent and birth?

Before the Montgomery case, what doctors shared with pregnant women depended, basically, on what other health care providers were sharing. They could decide to limit what information they shared with women as long as other doctors were doing the same. This was known as the ‘Bolam Test’, and it states, “If a doctor reaches the standard of a responsible body of medical opinion, he is not negligent”. This applied to all areas of medicine, and led to many outdated principles still occurring (eg immediate cord clamping) because, from the practitioner’s point of view, if they did what most other doctors did, they had more protection against being sued.

With Montgomery, all this changed. Rather than just relying on what most other people did, practitioners are now obliged to share information on ‘all material risks’, meaning any risk (of an intervention or NOT intervening) that might be important to that pregnant woman or person, irrespective of what was normally done by their colleagues. If followed, this gives the pregnant person information they need to be able to make an informed decision about their own care.

Why do doulas need to know about it?

Sadly, no single legal ruling can resolve all of the problems that we have within the maternity system. Montgomery has given us a hugely valuable legal framework to support informed decision making.  It means that the pregnant woman or person must be offered information to ensure that they are able to make an informed decision about their care. If your client isn’t experiencing this, you can suggest that they raise this as an issue with their health care provider, and remind them that they alone can make decisions about their body.

Unfortunately, there are downsides to this ruling in practice, if not within the aims of the law. The ruling states that providers should ensure that they take “reasonable care” to ensure that “patients” are aware of “material risks”.

The text reads, ‘The test of materiality is whether, in the circumstances of the particular case, a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it.’

What this should mean is that individualised care is offered, with doctors and midwives ensuring that women are given information that is relevant to them, personally, depending on their personal needs and wishes. What is happening in reality is that doctors and midwives misunderstand this to mean that they have to tell women of every possible horrific outcome that might happen if they decide to decline an intervention, or birth outside the hospital. They seem to be forgetting that their obligation is to offer a balanced picture of all of the material consequences of interventions and non-intervention (when was the last time that you heard all the potential risks of an induction, for example?), and they also seem to be forgetting that women are not obliged to listen to any of this!

Pregnant women are still autonomous beings, and they alone can decide what they want to hear. Our clients do not have to attend meetings with doctors or midwives who they don’t feel are supportive of their rights or decisions if they don’t want to. They don’t have to listen to a stream of possible horrific outcomes if they don’t want to. If they want the information, they can choose to ask for another midwife or doctor, and they can point out that being told only one part of the picture is coercion, not informed consent, and is going against the Montgomery ruling just as much as not being offered information is.

Further reading

The online content of Nurturing Birth’s Expansive Doula Course has a video on consent which includes information on Montgomery.  This presentation is also available to Nurturing Birth graduates who purchase the online modules after completing their Intensive Doula Course. 

AIMS has published a helpful article on the Montgomery ruling by a solicitor who looks at the ways it can be used in medical negligence cases within maternity: https://www.aims.org.uk/journal/item/montgomery

The MDU (Medical Defence Union) has a web page on Montgomery which clearly explains the legal situation: https://www.themdu.com/guidance-and-advice/guides/montgomery-and-informed-consent

Birthrights is continuing its work on consent, following the Montgomery ruling, by offering workshops to midwives and doctors on this topic, and they are part of a team launching an app for women to use in labour: https://www.birthrights.org.uk/campaigns-research/montgomery-and-consent/

Birth and consent: the basics!

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Emma Ashworth is a Nurturing Birth doula, a trustee of AIMS and she is currently the AIMS Journal Editor. She has a special interest in consent and has written extensively on women’s rights in birth.

Your baby… Your body… Your decisions!

When we’re pregnant we are offered so many tests and checks, we’re poked and prodded and our bellies are listened to. We’re even told to “leave our dignity at the door”.

But did you know that you have the absolute right to decide what happens to your body? Did you know that it’s only you who gets to decide whether you have any of the tests, checks or interventions that are offered in pregnancy and while giving birth? Did you know that they are an option, even if they’re not presented to you in that way?

If you’re told that you “have to” do something or you’re “not allowed” to do something, remember that they can’t allow you any more than you can allow them. If you are told what to do, try to change it in your head from, “do this” to “I’m suggesting that you do this and you’re welcome to ask me more about it if you wish, before making your own decision.”

Making your decisions about tests in pregnancy

You have the right to ask as many questions as you want to before you make a decision, and often this is necessary as some of the decisions we need to make are complicated, and need serious thought about the pros and cons. In many cases, it isn’t solely about taking the test, it’s about what the consequences may be, of how your care may change, if you take it and you’re diagnosed with whatever they are testing for.

So let’s look at some of the questions that you might want to consider asking your midwife or doctor, to help you to get the information you need to be able to make an informed decision.

  1. What are the benefits and risks of the test itself?
  2. If I am diagnosed, what will the treatment options be?
  3. What changes to care would be recommended, if any, and why?

A commonly used acronym that can also help is “BRAIN”:

B – Benefits
R – Risks
A – Alternatives
I – What does your Intuition say?
N – What happens if you do Nothing?

You have the right to have as much time as you need to make your decision, even if this means another appointment to talk it through again. Usually you can go away to think about it and come back when you’re ready, if you choose to.

Making your decisions about labour

A common decision that many pregnant women and people have to make is whether or not to accept the offer of an induction at the end of pregnancy. Inductions are not a risk-free process, and this should be explained to you before you decide whether or not to accept one. Unfortunately, as induction has become more common, there is often little time allocated to explaining the risks and benefits, and yet without knowing all of this information the health care providers are not fulfilling their legal duty to obtain informed consent for the intervention. In fact, they are obliged to ensure that you have this information, and it must be unbiased, and where possible, evidence-based. If the advice that they are giving is not based on evidence, but their own opinion or something else, this must be made clear.

If you feel that you don’t have the information that you need to make your decision, you have the right to spend the necessary time with your doctor or midwife until you do. This might not be possible in one appointment but you should be given an additional appointment for as detailed a discussion as you wish. When you make your decision, it must be respected.

Making decisions while in labour

While you are in labour, it is sometimes harder to make decisions and for this reason it can be very valuable to think through in advance what you would or wouldn’t want to accept. One important decision is how you feel about vaginal exams. They are not compulsory. Nobody can put their fingers in your vagina without your consent, at any time, ever, and this doesn’t change during birth. Other common interventions include monitoring your baby’s heartbeat, and you might want to find out about options for pain relief and what the pros and cons are of each type on offer at your chosen place of birth.

During your labour, whether you’ve investigated something thoroughly or something completely new comes up, you still have the right to make your own decision about whether or not to accept it. If you want more information to make that decision you can ask for it.

How can a doula help with your birth rights?

While it’s helpful to know that you can ask for more information, not all midwives and doctors are helpful, and sometimes they can feel challenged, and become defensive or dismissive. The situation can sometimes feel confrontational, and that can be very upsetting for many people.

Doulas can be excellent mediators. They can take away the confrontation and instead support positive communication, helping you to ask the questions you need, and suggesting questions that you may not have thought of. Although doulas can’t give medical advice, they can signpost you to information that you may not have been given. They can remind you that you have rights, and encourage you to recognise your own empowerment.

A doula can help you to plan your birth and they will have knowledge about the options that you might want to consider in advance which you may not otherwise think of. So many people come out of birth saying, “I wish I’d known XYZ”. Having a doula means that you know more – and knowledge is power.

During your birth, doulas can help you to stay grounded and strong. If you feel that you are being pushed into something that you don’t want, they can be another voice to remind the staff that they need to listen to you. They can help you to remember what you wanted, and support you in that decision, or, if you change your mind, your new decision. Crucially, they can help to facilitate communication if there’s an emergency, helping you to understand what’s going on even if the staff feel too busy to take the time to talk to you properly.

Sadly, many women who have experienced birth trauma say that the trauma came from feeling out of control of what happened to their bodies. By knowing that we are the ones who can make decisions for ourselves, we know that we can insist on that information before we agree to anything happening to us, and that itself can lead to a much higher chance of a positive birth, no matter how it ends up. And, if we want support with that, our doula will be there for us.

In February I’ll be looking at the Montgomery ruling, and why we all need to know about it

What experience do you need to be a doula?

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It’s one of the most common questions we are asked at Nurturing Birth.

Do I need to have had children? Do I need to have a nursing or midwifery background? Do I need to have worked with families before? Do I need complementary skills/qualifications? Do I need to have experienced birth in a particular way? Do I need to have breastfed my babies? Do I need GCSE Maths?!

The answer to all of those is no! Being a doula is not about the certificates you hold or whether you have been through pregnancy or childbirth yourself. Doulaing is about being with families as they navigate their journey into parenthood, and you can guarantee that someone else’s journey won’t be the same as yours. There may be parallels, you may see similarities, but what you experienced and felt won’t be the same.

Sometimes, and maybe this will surprise some, it is those who haven’t experienced pregnancy, birth and parenting who find it easiest to step in to the doula role. They aren’t having to process their own experiences in order to be clear to support others. They can be truly present without being hampered by the “I did it this way” thoughts. If we think about it many Obstetricians and Midwives haven’t experienced birth – it doesn’t stop them being able to do their job competently and compassionately (in the majority of cases).

Unless you’ve spent your life in on a remote island with only trees for company you are likely to have many of the necessary qualities to be a doula – an ability to relate to people, to listen, to nurture and care. What we are able to do on our courses is help you to refine your natural doula qualities so that you go out in to the world full of compassion, with healthy boundaries, able to signpost and actively listen to your clients.

What more experience do you need?

If you want to chat to us about becoming a doula then send us an expression of interest and we can call you back. We love to nurture doulas right from the start of the journey, so don’t hesitate to get in touch.

Slimline Your Christmas Marketing & Slay the Festive Guilt

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Slimline your christmas marketing

Oooh… there’s a whiff of excitement in the air and it smells like cinnamon and mulled wine! People are officially using the C word… which can mean only one thing. How the jeepers did Christmas creep round so quickly?

The Christmas holidays are just around the corner, and those festive fairs and Christmas markets don’t just mark the end of another year.  Second only to the six week summer slog, the Christmas holidays can be a bit of a panic season for doulas, particularly those of you working around children!

Are you already feeling those panic twinges about managing your Christmas marketing? Wondering how to keep your doula offerings visible while you’re taking care of kids, working on a leaner schedule, and relishing in a big plate of turkey, stuffing and sprouts?

Perhaps the odd Cadbury’s Roses or two… three… four!

Well don’t worry! The Nurturing Birth team is on the case and we’re here to share four secrets to keeping your marketing efforts on point so you can slay that festive guilt, and focus on more pressing things, like your next cocktail choice, thinking up creative ideas for Elf on the Shelf or which present to open first!

You see the secret to staying visible, active and sustaining your marketing efforts throughout the Christmas holidays is to take a more relaxed, slimline approach.  This way you’ll still look like you’re blogging, posting on social media, and chatting with your subscribers, but, secretly, you could be lying (totally laptop-less) on the sofa letting your lunch go down and catching up on TV.

Your doula biz doesn’t have to take a back seat, just because you are. So with that in mind, here are…

4 Ways to Slimline Your Christmas Marketing Strategy and Slay the Festive Guilt

Republish your Blogs

You don’t always have to create brand new blogs you know. If you’ve been blogging for a while you’ve probably got more than enough content to republish some of your favourite older articles instead. Your newer followers may not have noticed a particular blog first-time around (or second or third in fact) so don’t worry!

Sharing them again isn’t the lazy-doula’s way out either. Republishing blogs is a great marketing tactic, it gives you the opportunity to update any out-of-date content, it’s great for your SEO and you can even build your mailing list or give your conversions a boost by adding links to your new freebies, products or services.

Schedule Your Social Media

There are stacks of social media scheduling apps around and some are worth their weight in brandy doused Christmas pud! Scheduling your social media in advance gives you that Superdoula feeling of having everything organised for the entire week by 7am on Monday! Scaling back on the number of posts you write and publish is another way to dilute the Christmas biz pressure too.

Maintaining your visibility is important and if the bare minimum is one post a day, then schedule one post a day on each of your social media platforms. Manage your follower expectations by posting that you’re taking a wee break over the festive season. Many of your followers will likely be doing the same so they will totally understand.

Not sure which scheduling app to go for? Here at Nurturing Birth our favourite free social media scheduling platforms are Hootsuite and Later, whilst our fave paid platforms are Post Planner or Buffer.

Create & Schedule Your Newsletter(s)

If you’re a weekly newsletter sender, then ease that festive burden and adopt a monthly approach during December and January. A bumper Christmas edition or two (which also directs your subscribers to your republished blogs) is perfectly acceptable – and sometimes more likely to be consumed. Save more time by creating and scheduling your newsletters in advance and you’ll know your subscribers won’t assume you’ve abandoned them. Ah… the beauty of automation. We love it!

Decide on a Simple Christmas Content Subject and Stick to it

Another great way to avoid trying to post on Facebook while you’re tucking into your trifle is to think about (and plan) the type of content you want to focus on over the next six to ten weeks.  Keep it easy by sifting through your calendar and finding any upcoming National or International days which fit with your industry. Take a handful of your blogs and weave the same subject thread through your social media pages and newsletters too.

In need of inspiration? Check out:

So go and enjoy your Christmas, make family memories (kids grow up so quickly!) and slay that Festive business guilt.

Come January you’ll feel refreshed, rejuvenated and ready to conquer the world, again!

5 important things that might be stopping you getting more doula bookings

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Ok, so you’ve completed your Doula Course and your fabulous doula business is up and running! You’ve got yourself a business card, a fancy logo, leaflets and even a website. You’ve set up your Facebook page, registered your business with Google to get your SEO started and you tell all your friends and family about what you can do and how much you can help.

And then your first ever client books in, hurray! You’re off to a flying start. And then another and another….

But then… a lull.

You market yourself some more and you wait…

And wait…

You nab a few clients, but you notice that getting more doula bookings is becoming harder and harder.

You’re spending more and more time and money on marketing that isn’t bringing you enough clients.

You start to wonder… what’s gone wrong?

You stress and you worry. This self-employed malarkey is so much tougher than you thought it would be!

Don’t panic lovely doula. It doesn’t have to be like that. You have amazing talents; you just need to make a few tweaks to get those clients flowing into your booking diary.

To get you started, here are 5 important things that might be stopping you getting more bookings.

1. You’re throwing your net too wide

As the talented doula you are, you can probably help with many things, you might even offer other services such as placenta encapsulation or sleep consultancy BUT marketing yourself this way could actually be losing you clients. People tend to shop for one solution at a time so if you’re trying to sell them several at once then you risk overwhelming them. Coming across as a jack of all trades and a master of none might not be the best way to convince potential clients of your capability.

Getting more doula bookings comes down to three simple marketing rules… be super clear about who you want to help, what they are struggling with and how you can make it better.

If you offer multiple services, make sure your marketing of these is clear cut and not jumbled up together. Be mindful of what stage your potential client is at and focus on the service that best suits her needs at that time. Help her at the stage she is at NOW and save the upsells for later down the line.

Once a client has bought from you once they are much more likely to choose you over a competitor in the future. Get them booked in before you start to throw a list of services at them.

2. You’re focusing too much on the letters

So, your doula training and registration with professional bodies is SUPER important. But ironically, focusing on these in your marketing could actually be putting potential clients off. Your training and CPD is important because it’s what makes you the talented doula you are, but will clients really know what that training is? Or which of your long list of services they need to help them with their thing?

In most cases, all the client wants to know is that you can make them feel better.

Your training and qualifications is your toolbox. You carry it everywhere because it helps you to do your job. But it isn’t what makes you great at your job.

Think about it this way. Every doula out there is carrying around the same toolbox as you… So how are you going to stand out?

How are you going to take your clients from the place they are in now where they are feeling overwhelmed and under-supported (otherwise they wouldn’t be looking for a doula in the first place) to that place they wish they could be, where they feel informed, empowered and positive about pregnancy and birth.

That’s what you’re selling. A great way to do this is to feature customer testimonials and case studies in your marketing. These help your potential customer to recognise herself and her worries and start to see how you are the perfect doula to support her.

3. You’re expecting customers to jump too soon

You spend hours at your computer crafting that perfect Facebook post, you post it, you might even pay to boost it and you sit back and wait for all those new clients to get in touch… But nothing happens.

Is Facebook broken? Are you rubbish at marketing? Is anyone actually reading anything you post?

It might be that you are expecting clients to jump too soon.

Marketing is a journey. It’s so much more than just social media. It’s being on different social media platforms, it’s blogging, it’s having a website that connects with clients, it’s having case studies that showcase your excellent doula talents, it’s building your mailing list, and nurturing and building your relationships with potential clients and other local businesses.

All of these things help to lead potential clients to your diary.

So, posting on social media and then expecting that post to turn into paying clients is asking people to make a HUGE leap. You need to get those marketing steps in place so, through regular contact they can get to know you, like your stuff and trust that you are the person to help them. Only then will they make that booking with you.

4. You’re blending in, rather than standing out

Do you know how many doulas there are in your local area?

Let’s say there are loads… Does that mean you should give up and get a day job? Absolutely not! What it does mean is that you need to stand out in that sea of doulas, because if you blend in you will struggle to get clients to notice you.

The easiest way to start standing out is simply to be you. Yes, there are loads of doulas out there, but there is only one you. Potential clients can be drawn in or put off by your personality, the way you talk, the language you use, even the way you dress. You can’t attract everyone, so use your personal skills to really stand out to those who get you.

No more hiding behind a logo or a brand. Use photos of yourself in your social media and on your website. Create videos of you – yes, it’s scary but it’s a great way to stand out. Don’t be afraid to find and use your voice – there is no ‘right’ way to speak or be as a doula and every woman out there is looking for a doula that fits with who she is too! Your vibe attracts your tribe they say so if you are being you, you’re more likely to attract clients who really value what you do and how you work.

5. You’re staying local

As doulas we are often taught that the client relationship should be a face-to-face one, but that limits you to those people who live in your local area or align with your working hours.

Does all support need to be given face-to-face? If not, why limit yourself when there is a whole world of people out there who could benefit from your help? If you can’t provide a whole support package online then which services could you bundle up and offer remotely?

As well as remote consultations and support you might also consider creating online products; taking your doula skills and turning them into an online programme that clients can buy and use without you even needing to see them one-to-one.

Online products enable you to help more people and allow you to earn an income even when you’re not working. Yay!

So, no more struggling to fill your diary and build the business of your dreams! Just making a few tweaks to the way you work and market yourself could make a massive difference for you. Why not give it a try!

Video interview with Polly Hand, chiropractor

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Sophie chats to chiropractor and doula, Polly Hand, about her work with pregnant women, babies and families, especially when it comes to breech or malpositioned babies. She discusses how she uses the Webster Technique amongst others to help babies move into an optimal position.

For more information about Polly visit her website or follow on Instagram

Click here to watch Sophie’s interview with Aine Homer about baby reflux or click here to watch Sophie chatting with Hannah Wallace of Wear My Baby about baby wearing and the benefits for families.

If you are looking for a respected, quality doula then do visit the Nurturing Birth Directory