Pregnancy and severe mental illness: Birth choices, best interests and the untapped potential of advance decisions

Choice is a central tenet of maternity care; its importance is emphasised in policy documents, clinical guidelines, and the law. However, the lived experience is often rather different and that is particularly the case in the context of pregnant women with a severe mental illness (SMI). The biomedical discourse is powerful and has successfully constructed pregnancy and birth as risky, as a procedure to be managed by experts using technology to ensure that nothing goes wrong. Within that already risky process, women with SMI are constructed as risky, rather than at risk, posing a risk to themselves and the foetus they carry, as well as to the healthcare professionals who care for them. It is not merely their treatment decisions that are questioned, but their very ability to make those decisions. The consequence of this is reduced choice for women with SMI who are cautioned to act responsibly, but where they fail to acquiesce and comply with medical advice, making the ‘wrong’ choice, their capacity is called into question and, if found to lack capacity, decisions about mode and place of delivery will be determined by someone else on the basis of that third party’s evaluation of her best interests, giving scant regard to her wishes. This article reviews the recent obstetric intervention case law, interrogating the discrepancy between the minimal weight attributed to the birth choices of pregnant women with SMI within the best interests assessment in comparison to the significance accorded to the wishes of non-pregnant individuals in other treatment contexts. It challenges the pregnancy exceptionalism evident in the case law and proposes the use of advance decisions as a tool for women to make birth decisions at a time when their capacity is undiminished, ensuring that their own choices, albeit expressed as refusals of treatment, determine maternity care.