Midwives constitute a valuable resource in health services globally by providing care to women throughout the pregnancy continuum. In Europe, midwifery care, however, is varied in its scope of practice and the quality of its provision. A number of definitions of the midwife also exist, with the World Health Organization’s (WHO) now subtly differing from that of the International Confederation of Midwives (ICM). Both, however, remain clearly focused on the provision of care during a normal pregnancy with the ICM noting that the midwife’s role may extend to sexual and reproductive care. A major break from these definitions occurred in the “State of the World’s Midwifery Report” in which midwifery is defined as
the health services and health workforce needed to support and care for women and newborns, including sexual and reproductive health and especially pregnancy, labour and postnatal care. This includes a full package of sexual and reproductive health services, including preventing mother-to- child transmission of HIV, preventing and treating sexually transmitted infections and HIV, preventing pregnancy, dealing with the consequences of unsafe abortion and providing safe abortion in circumstances where it is not against the law (pp.3-4).
The UNFPA definition clearly moves the midwife into a different role but one which is supported by other UN agencies such as the WHO. Such a move has come about in response to the numbers of women dying from unsafe abortions in countries where legal abortion is not possible. In Europe, however, from the latter half of the 20th century, most countries enacted laws permitting abortion to some extent. The only European countries in which abortion is still forbidden, except when there is a threat to the woman’s life, are Lichtenstein and Malta, each of which punish both the woman and the involved health professionals by a period of imprisonment[7, 8]. Conversely, many European countries permit abortion on the request of the women in the first trimester of pregnancy, while others require medical authorisation from the outset. Despite legislation, abortion remains a very volatile subject, with arguments highly polarised; the topic often being portrayed in the media as pro-life vs pro-choice or even rampant feminism vs religious fanaticism. This has the potential to cause much pain and controversy for both service users and providers. One of the major arguments in the present time, rather than concerning the right of women to have abortions, is about the rights of health professionals to object on conscience grounds to providing abortion services a key issue being that this could create imbalances in the workforce. Such arguments exist despite most countries laws including this right and conscience, as a core element of human rights, being protected in documents such as the European Convention on Human Rights. According to the latest figures from the WHO, of the 30 European countries that permitted abortion at the time of data collection 25 included a so called conscience clause permitting health care providers, who hold a legitimate objection, to desist from participating in the provision of abortion. 
Most of the above arguments are specific to abortion and apply to all relevant health professionals. However, in recent times it is often midwives who are at the centre of controversies relating to conscientious objection.
Abortion and conscientious objection
In the UK, two senior midwives lost a Supreme Court case which ruled that conscientious objection must be restricted to “hands on” activities. Similar cases affecting midwives have also been reported in other European countries notably Croatia and Sweden, the latter of which does not have a legal position on conscientious objection. One of the midwives who lost her case in Sweden has lodged it with the European Court of Human Rights.
The potential workforce issues resulting from midwives who make conscientious objections have never been addressed with a quantitative focus on the associated workload. Having evidence-based information however is essential for a better understanding of and contribution to the debate.
This article therefore, presents an analysis of relevant statistics in 18 European countries in relation to potential exposure to late abortions by midwives in order to throw new light on the controversial topic in relation to the midwifery workforce.
The literature is vague as to the extent to which conscientious objection should be permitted. Taking note of the ambiguities, the authors of one article propose that “European countries should critically assess the laws governing conscientious objection and its effects on women’s rights”. (p. 231)
This position has been supported by writers who suggest that the various treaties permitting conscientious objection on the grounds of human rights have compromised women’s right to abortions. However, in a case study report on four European countries, the conclusion drawn is that, although complex, it is possible to accommodate individuals who object to providing abortion-related care, while still ensuring that women have access to legal health care services in the countries concerned.
The academic commentaries on conscientious objection also are divided. The seminal work of Wicclair provided a comprehensive link between conscience and integrity in medicine, concluding that carte blanche rights of conscientious objection should not be given but rather that respect for moral integrity of the physician, even in practices endorsed by the medical profession, is the best way forward. Claims of conscientious objection thus should derive from the importance attributed to the integrity underpinning them. Weinstock (p. 12) comments that when a health professional’s right to conscientious objection is observed, “respect [is afforded to] the moral agency of those who hold reasonable dissenting views”. In the same vein, Curlin et al (p. 1891) reflected that “acting conscientiously is the heart of the ethical life” hypothesising that if medical practitioners give this up they no longer have the capacity to make moral judgments or act in accordance with them.
Other writers challenge such positions proposing that the rights of health care professionals to allow their private values should not interfere with their work. Conscientious objection to abortion-related care has even been labelled as “dishonourable disobedience” (p .12). Conversely, Pellegrino avers that a health professional’s conscience or religious values must never be placed in a position secondary to the health service’s requirements. Taking a nuanced approach, Neal suggests that the apparent expansion of conscientious objection claims is based on poorly defined or even contradictory professional guidelines and there is a need for sound research establishing working definitions.
Various professional bodies or regulatory authorities have established such guidelines, the International Federation of Obstetricians and Gynaecologists’ (FIGO) criteria for conscientious objection being to provide notice, refer patients timeously and provide emergency care. While brief and practical, the standards, like those of other such bodies, are not based on research with practitioners. A “White Paper” drawing on international, multidisciplinary literature sums up the issue and develops a road map for the future. The authors point out the lack of well carried out empirical research on the topic but conclude from reviewing the available evidence that there is a growing trend towards refusal to provide certain reproductive health services, especially abortion. Acknowledging the difficulty of the situation, they recommend that a standard definition of conscientious objection be developed together with accompanying obligations.
Role of midwives
What is evident from the literature is that its key focus is on medical practitioners and if midwives are mentioned it is in a secondary position despite the WHO’s emphasis on them as key providers of abortion services. This has most recently been discussed in two articles, one specifically focusing on abortion and the other on end of life care, each of which urged nurses and midwives respectively to be more proactive in contributing to the debate.
With the overwhelming change from surgical to medical abortions in both first and second trimesters of pregnancy, there is an increasing role for midwives and the above arguments are clearly relevant to them. In the past, abortions were carried out surgically exclusively by doctors who may have been assisted by nurses or midwives in an operating theatre. Both in the theatre and pre and post operatively, those who expressed a conscientious objection to the procedure, were not expected to participate. With medical abortions, the prescription is generally written by a medical practitioner, but the drug is often administered by a nurse, midwife or the woman herself. While in the first trimester in some countries the woman now may labour at home, in the second trimester in most countries, she is cared for throughout the subsequent labour in an inpatient setting by midwives, or occasionally, nurses, thereby increasing their workload.
Until recently only one article acknowledged this, commenting that many more health professionals are now involved over a much longer period of time. However, in the last two years the topic of midwives or nurses in relation to conscientious objection has come to the fore with two articles emphasising their invisibility.[9, 28]
Taking into account the divergence of opinions shown by both academic writers and policy makers and the lack of visibility of midwives, we believe that the whole debate on conscientious objection would benefit from giving consideration to numerical data, not simply considering the numbers of abortions but their relationship to other variables.
We have chosen to focus on midwives in relation to abortions conducted after the first trimester of pregnancy, because it is mainly midwives who are expected to participate in drug administration and the subsequent care for women in labour, including delivery of the fetus and placenta and the provision of immediate postnatal care.
This background has shown that a controversial debate around conscientious abortion exists and that both philosophical arguments and laws exist for the provision and the opportunity to conscientiously object to the provision of abortion services. There is, however, a lack of quantitative research showing the dimensions of the topic and so accurate workload indices cannot be produced. This study seeks to address the issue.