Why it’s time to move beyond compliance, reclaim professional judgement, and put birthing people at the heart of care.
Every encounter in maternity care carries more than just clinical meaning. It is a moment of ethical and relational significance. Where power, trust, and autonomy are negotiated. And yet, these complex human exchanges are so often reduced to a single question: Is the woman following the guideline?
This framing is not neutral. It carries with it a host of assumptions: that there is a single right way to give birth, that deviation is inherently risky, that professionals are responsible for securing compliance rather than facilitating choice and that healthcare providers are ultimately responsible for outcomes. These assumptions shape how care is offered, how decisions are documented, and how women are treated, especially when their preferences don’t align with standard recommendations.
I’ve come to believe that we need a radical reframing of how we think and talk about individualised care. The language of “out of guidelines” care doesn’t just fail to serve us; it actively undermines the culture we need to create.
Out of Guidelines…. Guidelines?
I recently had a conversation with a small group of engaged, thoughtful healthcare professionals. We were discussing how trusts are increasingly developing “out of guidelines” guidelines; internal processes to follow when a woman makes a choice that falls outside clinical recommendations.
It struck me as both ironic and illuminating. That such a document even needs to exist reveals something troubling: our current system doesn’t support true individualised care. It tolerates it, but only through special processes, extra paperwork, and a vague sense of unease. That realisation sparked something in me. It was a light bulb moment. I realised we don’t just need better language. We need a radical reframing of the entire way we talk about choice, care, and clinical judgement in maternity services
In that conversation, several issues surfaced. We talked about how individualised care plans are becoming more common, but that only a small number of staff currently feel confident creating them. This places extra strain on those professionals and leaves women vulnerable to inconsistent care. We also discussed the fact that while some guidelines are rooted in strong evidence, many are not, and that this is not always clear to staff. Too often, the guideline is treated as sacred, regardless of the quality or relevance of its evidence base.
Healthcare professionals cling to guidelines for protection in a system built on fear. But in doing so, they often feel unable to practise with the nuance and autonomy that true care requires.
Who Are Guidelines For?
One of the most fundamental misunderstandings in maternity care is the belief that service users are somehow bound by clinical guidelines. But guidelines are not rules. They are not policies. And they are certainly not laws. They are tools designed to support healthcare professionals in what to offer, recommend, or consider based on available evidence and best practice. They are not written for women and birthing people, and therefore cannot be “broken” by them. If the offer or recommendation has been made and documented, the guideline has been followed, regardless of whether it was accepted. The person’s right to choose has not disrupted the system; it has fulfilled it.
And yet, when a woman chooses a path that differs from the guideline, her care is often framed as “out of guideline.” This terminology subtly others her. It positions her as disobedient, difficult or non-compliant and her choice as deviant, unusual, or unsafe It subtly shifts blame onto the woman for making a choice that, in reality, she is entirely entitled to make.
The problem lies not just in the misuse of guidelines, but in the culture that surrounds them. Guidelines have come to dominate clinical practice in ways that stifle autonomy for both service users and professionals. In a system where defensive practice is common and litigation is a looming threat, guidelines feel like protection.
But this protection is an illusion. What we lose in return is flexibility, critical thinking, and trust. Guidelines become a ceiling, not a foundation. They discourage professionals from staying up to date with evolving evidence, from using their clinical judgement, or from engaging deeply with individual circumstances. Worse, they sometimes embolden professionals to cajole, persuade, or coerce people into accepting unwanted or inappropriate care pathways.
A Culture of Risk and Control
Behind the reliance on guidelines lies a deeper issue: our culture treats risk as something to be controlled rather than shared. Professionals are taught to manage risk, reduce risk, avoid risk; but rarely to sit with it, explore it, or hold it in partnership with the people they care for.
When clinicians feel unable to offer more than one path, or when they fear supporting choice will put their registration at risk, we end up with a system that serves no one well. Women feel coerced. Professionals feel trapped. And outcomes, both emotional and clinical, suffer as a result.
For those who are naturally inclined to follow medical advice, this system encourages passivity. The message is clear: do what you’re told, and you’ll be safe. But this illusion of safety can backfire. When something unexpected happens, when the birth doesn’t go to plan, women and birthing people and their families can feel betrayed or traumatised. They believed they were protected by compliance, and the reality hits hard.
For those who question, challenge, or decline recommendations, the consequences can be just as damaging. Guidelines become obstacles. Care becomes conditional. Judgement creeps in. Women are made to feel difficult or irresponsible for making choices that may, in fact, be evidence-based, or simply right for them.
Both groups lose. And trauma rises on all sides.
What If Guidelines Were Tools, Not Rules?
As someone outside the clinical profession, I know I can only speak from the edges. But perhaps that gives me a useful perspective. I’m free to indulge in some blue-sky thinking and imagine something different.
What if guidelines were replaced, or at least supplemented, by dynamic, intelligent, decision-support tools? Imagine every healthcare professional carrying a tablet or interface that offered up-to-date, interactive, evidence-informed flowcharts. These wouldn’t just present a “default” recommendation. They would show the range of reasonable options, along with the quality and limitations of the evidence, any local variations, and guidance on facilitating respectful, individualised discussions.
These tools could support professionals to empower women and birthing people, not persuade or manage them. They could help shift the culture away from binaries (safe/unsafe, compliant/non-compliant) and towards a relational model of care that acknowledges risk, benefit, preference, and uncertainty—all in the same breath.
Reclaiming Clinical Judgement and Rebuilding Trust
Individualised care should not be reserved for those who ask the right questions or challenge the system in the right way. It should be the baseline. Every woman deserves a care plan shaped, not only around clinical indications, but around her life, her body, and her values.
This also means trusting professionals to use their professional judgement, to engage in critical thinking, to weigh up competing risks, and to co-create plans that work for the person in front of them.
We need to stop acting as though personalisation is a departure from standard care. It is standard care (or should be)! The problem is that we’ve built a system where individualisation feels risky, instead of routine.
Let’s change that.
One Cultural Shift
If there’s one cultural shift I would love to see in maternity care, it’s this: we must let go of the belief that healthcare professionals are the decision makers.
Clinicians have expertise. They offer guidance, wisdom, experience, support. But they do not own the decision. The final say always belongs to the person giving birth. That truth is fundamental, and yet, our language, our documentation, and our systems often fail to reflect it.
Let’s stop writing “out of guideline” care plans and start creating a culture in which care that reflects a person’s informed preferences is the norm – not the exception. Let’s replace fear with trust, rigidity with dialogue, and bureaucracy with relationship.
This won’t be easy. But the status quo isn’t safe. It isn’t working. And imagining something better is the first step toward building it.