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The University of Southampton
PhilosophyPart of Humanities

Birth Choices Outside the Guidelines: ethical, legal and professional perspectives

Some women make birth choices that healthcare professionals consider dangerous. Dr Elselijn Kingma’s research argues that women have the right to make many such choices and that health care providers have a duty to continue caring for them and assist in such choices. Her findings have critically shaped the Dutch legal, medical, activist and policy framework surrounding maternity care.

Research challenge

An expectant mother

Some women make birth choices that healthcare professionals consider dangerous. For example: choosing a home-birth when the baby lies in breech (feet-first). Such choices raise pressing questions: should women be stopped from making these choices? Should health care providers provide care, even if they disagree with the choice, and especially if this means they need to practice in situations that are outside the boundaries of what they normally consider good practice?

Answering these questions requires a careful investigation of the rights and obligations of women during the unique state of pregnancy, as well of the professional rights and duties of health care professionals.


Health care providers – obstetricians and midwives – will advise pregnant women on where and how to give birth, depending on their perceived level of risk. For example, a pregnant woman with no known complications is advised to give birth at home or in a midwifery-led birth centre. But a pregnant woman who is expecting twins or whose baby lies in breech will be advised to give birth in hospital, under close obstetric supervision - or even to plan a caesarean section. 

Sometimes pregnant women want to deviate from this advice. For example: because they experienced a previous birth as traumatic. Such choices, where they are perceived as dangerous, cause a lot of questions amongst health care providers: should they respect the woman’s wishes or must they make her do what they think is safer for her child? And can they be involved in care that, by their own standards, they consider unsafe? A failure to resolve these questions can result in even more dangerous situations: the woman who wants to give birth in hospital, supervised by a midwife, but is refused, may end up giving birth at home, without any health care assistance at all.

The Solution

Dr Elselijn Kingma’s research establishes that

  • women have a near-absolute right to refuse invasive medical procedures even if this choice results in the injury or death of another person, including their child;
  • women are therefore entitled to make many choices about their birth that deviate from medical advice,
  • and health care professionals continue to have a duty of care to the woman and her future child, which compels them to assist positively with safest acceptable version of the chosen alternative. 
An expected mother with a doctor

What was the Impact?

Kingma’s research has changed legal precedent and influenced health policy and professional practice in the Netherlands.

Kingma’s research influenced a landmark legal judgment which established that health care providers are allowed to practice outside the guidelines where women refuse to be treated according to guidelines. Subsequently her research influenced the development of professional guidelines that advice health care providers on how to respond to requests for maternity care outside the guidelines. 

Jointly these developments have ensured there is now clarity about the importance of respecting women’s autonomous choices about her birth. They also ensure that health care professionals can feel ethically and legally secure when supporting women who make choice they seem unsafe, which means even more unsafe situations can be avoided.

Key Publications

List of all staff members in
Staff MemberPrimary Position
Elselijn KingmaAssociate Professor
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