When Your Choices and Your Midwife’s Circle of Safety No Longer Align

By Jill Snelson, CPM

One of the things I value most about midwifery care is autonomy.

I believe you have the right to ask questions. You have the right to understand what is being recommended and why. You have the right to weigh the evidence differently than I do. You have the right to accept or decline testing, treatment, consultation, or intervention after receiving the information you need to make that decision.

But there is another part of informed choice that we don't talk about nearly as often.

Your autonomy gives you the right to make your own decision. It does not automatically require your midwife to continue providing care for that decision when it falls outside what she believes she can safely support.

That is where what I call my circle of safety comes in.

What is a midwife's circle of safety?

Every midwife has one, whether she calls it that or not.

My circle of safety is the space in which I believe I can responsibly provide home birth care based on my education, training, clinical experience, skills, practice guidelines, available equipment and medications, consultation resources, and the limitations of an out-of-hospital setting.

And I want to be very clear about something: my circle of safety is not the same thing as my circle of preference.

There are plenty of choices a client can make that may not be the choice I would make for myself. There are situations in which I may recommend one option, explain why I recommend it, and the client chooses another. That does not necessarily mean we can no longer work together.

Good informed consent would be pretty meaningless if the only “choice” you were allowed to make was agreeing with me.

Sometimes we discuss the risks, benefits, alternatives, and available evidence, you tell me what matters to you, and together we develop a plan I may not have originally recommended but that I can still responsibly support.

That's shared decision-making.

But there is a point at which a decision may move beyond, “This isn't what I would choose,” and into, “I do not believe I can safely provide care under these circumstances.”

Those are very different things.

Your right to say no does not disappear because you are pregnant.

If I recommend a lab, ultrasound, consultation, hospital evaluation, medication, or transfer, you are still the person making the decision.

My recommendation does not override your bodily autonomy.

My job is to tell you what I am seeing, what concerns me, what I recommend, why I recommend it, what the alternatives are, and what I believe the potential consequences of those choices may be. I want you to understand the information well enough to make a truly informed decision—not simply comply because I am the midwife.

Sometimes you will agree with me.

Sometimes you won't.

Disagreement by itself does not make someone a difficult client, and declining a recommendation does not mean a woman suddenly loses her right to participate in decisions about her own care.

But informed refusal is not the same thing as transferring responsibility for that decision to the midwife.

That distinction matters.

“I accept the risk” doesn't automatically make the risk mine to take.

This is probably the most difficult part of this conversation.

Sometimes a client will say, “I understand the risks, and I'm willing to accept them.”

And I respect that.

But there may be circumstances in which I am not willing—or professionally able—to accept the responsibility of continuing to provide home birth care under those conditions.

Signing an informed refusal does not turn every situation into an appropriate home birth situation.

Informed consent is not a magical piece of paper that says, “I understand something could go wrong, so now my midwife has to attend me anyway.”

There are risks I can discuss with a family and continue to navigate alongside them. There are circumstances where additional consultation or evaluation gives us enough information to create a reasonable plan. There are gray areas where thoughtful shared decision-making matters tremendously.

And then there are situations where, based on the clinical picture in front of me, I believe we have moved outside my circle of safety.

That is the line I have to be willing to honor.

That line won't always be in exactly the same place for every midwife.

This is another reason choosing your midwife carefully matters.

Two competent midwives may not have identical practice guidelines. They may have different training, different levels of experience with a particular condition, different consultation relationships, different emergency skills, or different resources available to them.

One midwife may have extensive experience managing a particular clinical situation and feel completely comfortable continuing care under specific parameters. Another may recognize that the same situation exceeds her training or experience and recommend consultation or transfer.

I actually think there is integrity in knowing that.

I am much more interested in a midwife who knows where the edge of her competency lies than one who believes she doesn't have an edge.

The goal should not be finding the midwife with the biggest circle.

The goal is finding a midwife who knows where her circle is, can explain why those boundaries exist, and is willing to be honest when you reach one.

So what happens when we don't agree?

First, we talk.

I want to understand why you are making the decision you're making.

Maybe you've had a traumatic experience with the medical system. Maybe the intervention I'm recommending carries a risk that feels particularly important to you. Maybe you've read something that conflicts with what I'm telling you. Maybe I haven't explained my concern clearly enough. Maybe there is an alternative we haven't considered yet.

Those things deserve conversation.

My goal should never be to frighten, shame, manipulate, or wear you down until you agree with me.

Sometimes, after talking it through, we find a path forward together. That may involve additional monitoring, obtaining more information, consulting with another provider, modifying the plan, or documenting informed refusal and continuing care.

But sometimes the answer remains no.

You may say, “I understand everything you've told me, and I am still choosing this.”

And I may have to say, “I respect that this is your decision. I also cannot continue providing home birth care under these circumstances.”

Both things can be true at the same time.

Transfer of care is not punishment.

This is incredibly important to me.

A midwife should not use the threat of losing care to force a woman into compliance.

There is a tremendous power imbalance when a pregnant woman has built a relationship with a provider, paid for care, imagined that person at her birth, and suddenly hears that continued care may be affected by a decision she is making. That conversation deserves enormous care.

If I reach the point where I truly cannot continue as someone's home birth provider, my goal is not to punish her for disagreeing with me.

It is to be truthful about what I can and cannot responsibly provide.

Whenever circumstances allow, that means explaining my concern clearly, making sure she understands her options, helping connect her with an appropriate level of care, communicating relevant records, and making the transition as thoughtful as possible.

You do not stop deserving respectful care simply because we disagree.

Sometimes the circle changes during pregnancy.

A woman may begin pregnancy as an excellent candidate for home birth and later develop something that changes the clinical picture.

That does not mean anyone did anything wrong.

Pregnancy is not static. Babies grow. Placental function changes. Blood pressure changes. Lab values change. Medical conditions appear. Sometimes the information we have at 36 weeks is simply different from the information we had at 16 weeks.

That is why I do not think of home birth eligibility as a box we check once at the beginning of pregnancy.

I am continually asking: Are we still inside the circle?

Sometimes the answer is an easy yes. Sometimes I need more information before I can answer. Sometimes we need another set of eyes on the situation. And occasionally, the answer becomes no.

When that happens, I understand that it can be deeply disappointing. You may have spent months picturing your baby being born at home. You may fundamentally disagree with my assessment of the risk.

You are allowed to feel disappointed. You are allowed to disagree with me. You are allowed to seek another opinion.

But I also have to practice in a way that allows me to look at myself afterward and know that I did not knowingly continue providing care in a situation I believed had moved beyond what I could safely manage at home.

This is why these conversations should happen before there is a problem.

Ask a prospective midwife where her boundaries are.

Ask what conditions would require consultation. Ask what would make her recommend transferring care during pregnancy. Ask what would make her recommend transport during labor. Ask where she has flexibility and where she does not.

And here's an especially important question:

“What happens if I decline something you recommend?”

Listen carefully to that answer.

You don't want a midwife who believes informed consent means you always do what she says.

But I also don't think you should be looking for a midwife who promises that absolutely nothing you choose could ever cause her to say, “I can't safely continue here.”

Neither extreme reflects what I believe good midwifery care should be.

Autonomy and accountability belong in the same room.

I believe deeply in a woman's authority over her own body and her own healthcare decisions. I also believe deeply in my responsibility for the care I agree to provide.

Those beliefs do not compete with each other.

You are responsible for making decisions that are right for you and your baby. I am responsible for giving you good information, respecting your decisions, maintaining my skills, knowing my limitations, and being truthful about what I can safely offer.

Most of the time, those things fit together beautifully. Occasionally, they don't.

When that happens, respecting your autonomy may mean acknowledging that you are going to make a choice different from the one I recommend.

And respecting my professional responsibility may mean acknowledging that I cannot be the midwife who attends you while you make it.

That isn't a failure of informed choice. In many ways, it is informed choice in its fullest form.

You get to decide where your line is.

And your midwife has to know where hers is too.