The lived experience of midwives' ethical dilemmas in conscientious objection to abortion using interpretative phenomenological analysis

Background: For some practitioners required professionally to partake in the 73 million abortion procedures carried out worldwide each year (WHO 2023), participation can sometimes be a source of distress which has brings them into conflict with their employers (Fleming et al. 2018; Zaami et al. 2021), colleagues (Adenitire 2016; Boama 2018), service-users (Self 2023; Self et al. 2023) and with governments (Oderberg 2018). ‘Conscientious objection’ (CO) is an opportunity to exercise freedom of conscience by refusal to partake in contentious procedures to which practitioners may have a moral repugnance, invoking legal rights to decline involvement, for whatever reasons. Meeting societal assumptions about what midwives do when pregnancy is unintended, unwanted, or unsustainable creates dilemmas. Providing universal healthcare, realising reproductive justice, and supporting bodily autonomy for the individual may be challenging. Whose rights are right? The debate is polarising. The primary concern is that patients obtain the care they need. Critics believe CO potentially disrupts this (Fiala and Arthur 2014; 2017; Schuklenk and Smalling 2017; Savulescu and Giubilini 2018). Despite commitments to woman-centredness, midwives are caught up in policy-less discrepancies and misinterpretations. Midwives’ perspectives in decision-making remain scant. Knowledge of the mechanisms of moral reasoning remains particularly elusive to explain a concept that essentially is a personal matter of conscience. Insight which this research seeks to provide. Methodology and findings: Using Interpretative Phenomenological Analysis (IPA), most useful in under-researched topics, I explored the lived experiences of 15 midwives to gain an insight into dilemmas related to their making ethical sense of CO. Semi-structured interviews generated data, analysed with Smith, Flowers, and Larkin (2022) IPA approach. Six Group Experiential Themes (GETs) emerged: ‘Practising midwife, practising religion’, ‘Navigating with a moral compass’, ‘Fearing reviving, surviving, and thriving’, ‘Being torn between wearing two hats’, ‘Two signatures and the escape clause’ and ‘The right midwife, delivering the right care’. Discussion and conclusion: Accommodation is inconsistently practised in maternity environments, often non-transparent, ad hoc, and disorganised suggesting poor understanding of rights provisos made in section 4 (i) ‘the conscience clause’ of the 1967 Abortion Act. Data paints a complex picture: objector-led, responding to contemporary ‘CO crises’ and traumatising. A conceptual model to structure operationalisation of procedures and a framework of moral reasoning were devised. As abortion-defenders, participants nevertheless voiced support for CO on the condition that safety and care were not impaired by the realisation of dissenting colleagues’ rights.