Executive summary: Birthrights welcomes the NMC’s expression of commitment to human-rights centred maternity care in its new Principles. However, to achieve this goal, principles which breach human rights law requirements must be amended, the role of doulas must be respected, and more attention must be paid to the support needed by midwives from their employers.
The background
In August 2025, the Nursing and Midwifery Council (NMC) published its new “Principles for supporting women’s choices in maternity care”. These were developed in response to a changing maternity landscape, including emerging evidence that freebirth is increasing, more women and birthing people are choosing alternatives to standard care pathways, and a growing use of doulas and other birthworkers.
In September 2025, the NMC hosted a webinar, with guests from Doula UK, the Ambulance Service and the Police to discuss the new Principles.
Our involvement
We wish to provide clarity regarding our organisation’s involvement in this work. We participated in several group discussions with the NMC relating to this workstream over the past year or so, providing expert information and challenge about what the human rights framework really requires in maternity care. However, we did not participate in the final drafting of the Principles, and were not part of the webinar in September 2025.
Whilst we welcome some of the Principles, and recognise the efforts towards human rights respecting maternity care, there are some Principles that we would not approve in their current form. This article offers a constructive response, and we invite the NMC to review and amend the Principles in order to align with their goal of protecting rights and choice.
A positive approach: commitment to human-rights centred care
We welcome the emphasis the Principles place on the autonomy of women and birthing people to make their own choices about all aspects of their maternity care (including the choice to decline specific care), without being required to justify their decisions. This is a key step towards rights-centred practice.
The Principles also rightly require that a meaningful range of birthplace options be made available to women and birthing people, including home birth, midwifery-led units, and obstetric units. The Principles remind employers that every request for a particular care option must be considered individually, with the woman’s circumstances considered and options explored as to how their rights can be upheld.
Certain Principles require amendment to prevent human rights law breaches
The Principles require substantial amendments to ensure they are consistent with the human rights law framework. Here, we highlight two areas of key concern.
This conflates two distinct scenarios that carry vastly different legal and practical implications.
- Midwife requested to be present in the home (e.g. just outside the door to the birth room/in another room).
We would expect such a request to be supported and accommodated. Declining one aspect of care, namely the midwife carrying out constant visual assessments, does not mean that the woman/birthing person is declining all care, and high quality, non-coercive discussions should be offered by midwives antenatally to ensure that the woman or birthing person is fully informed as to what monitoring and other options are open to her during her homebirth, and the midwives are clear what types of care and support the woman or birthing person would like to accept.
In such a case, if the midwives’ safety is being put at risk it may be proportionate to refuse this request.
This is absolutely not a human rights-centred approach.
When a person in labour calls the maternity service and asks for midwife assistance, this is not a “freebirth” but is a request for an urgent, midwife- supported homebirth.
Therefore, if the local homebirth service is running and midwives are available, midwives should ordinarily attend that birth.
We believe that the suggestion that a service can pre-emptively state that a midwife will not attend requested homebirths (except where these have been pre-planned), is inconsistent with human rights law requirements. It amounts to a blanket policy and would therefore be highly unlikely to be regarded as a “necessary and proportionate” restriction on a woman’s right to choose her place of birth under article 8 of the Human Rights Act 1998. Furthermore, midwives have a professional duty to provide care within the scope of their practice when available, especially when requested.
Whilst limited antenatal engagement may impact the advice and support that midwives are able to provide in a home setting (as less would be known of the woman’s history etc), if the impact of that has been explained and the woman still wishes to remain at home to birth, then their right to make this choice must be respected and available midwives should be sent. The only legally permissible exception to this would be if there are reasons why in the particular circumstances, declining to support that individual at home would be lawful, in pursuance of a legitimate aim, and necessary and proportionate.
More employer support for midwives is needed
We would have liked to see more in the document encouraging employers to provide appropriate support to staff to help them to process difficult and traumatic situations they are exposed to as midwives, so as to be able to continue to truly support women and birthing people’s autonomy, and not pass on their own trauma.
We would have also liked to see references to the importance of employers providing anti-racism, cultural safety, human rights, and other essential training programmes to staff. Whilst the “role of the midwife” section mentions attending training and being culturally competent, it is crucial to recognise that midwives cannot necessarily achieve this without the active support of their employers.)
Respect for choice must extend to the choice to engage doulas and birthworkers
We were concerned by the use of the term “unregulated people” to describe doulas and other birthworkers in the Principles. Language is powerful and this wording creates the impression that the involvement of a doula or birthworker is inherently risky, potentially discouraging collaboration between midwives and doulas, and undermining the important role doulas play in providing emotional and practical support across all types of births.
Our concerns were heightened by some of the webinar discussions. In particular, we were alarmed by the suggestion in the webinar that midwives should consider referring individual doulas to the new NMC email “hotline” and, even the police, without any evidence or reasonable belief that the doula provided clinical care, nor any suggestion that the woman or birthing person was dissatisfied with their doula’s support. We believe this approach is legally questionable, and it undoubtedly undermines trust, endangers women and birthing people, and their babies, and creates an environment where no one can feel safe.
We published a fuller response to our concerns with this approach here.
“Out of guidance” guidelines are not the answer
We are concerned at the suggestion in the “employers” section that employers should develop an “out of guidance” guideline. Formalising such guidelines risks cementing systems that default to restriction, coercion, and stigmatisation rather than support for those making “out of guidance” choices. We firmly believe that the priority should be to ensure that personalised care and informed decision making are embedded as standard practice for all (regardless of whether they are considering making an “out of guidance” choice), in line with the human rights framework. See our position statement on the worrying rise of this approach.
Lack of transparent accountability mechanisms
In the “role of the NMC” section, we would have liked to have seen a reference to working towards more transparent accountability mechanisms.
Our proposals for next steps
We would welcome the opportunity to work with the NMC in amending the Principles to reflect the legal and ethical points identified above. By sharing our human rights law expertise, we believe we can support the NMC to create a legally sound set of principles that truly centres women and birthing people’s rights and choices.
The NMC needs to meaningfully engage with doula and birthkeeper communities on the issues. To do this, the NMC must acknowledge that doulas and birthworkers are not a monolith, and are not all represented by the same (or, indeed, any) body. A key part of this will be for the NMC to ensure that the message reaches midwives that women and birthing people’s choice to employ doulas must be respected, and can be welcomed. A climate of fear and mistrust serves nobody, least of all women and birthing people and their babies. The definition of doulas given in the Principles should also be reiterated: they are non-medical professionals who provide (often critical) emotional and practical support during pregnancy, birth and postnatally. Despite the odd language in the webinar, they are not there to “reinforce psychologically” what midwives say, nor to “support the midwives or medical care providers” during a birth.
We note that, in the September webinar, it was announced that the NMC would soon be publishing a new Criminal Offences policy and statement of practice. No doubt many will be watching those developments extremely closely, and we would strongly encourage that the NMC engage meaningfully with a wide variety of stakeholders throughout the drafting and production of these materials.