When Guidelines Do Not Fit a Midwife’s Reflection on Bias, Safety, and the Urgent Need for Change

Clinical guidelines are often treated as the backbone of safe practice: neutral, evidence‑based, and universally applicable. But in reality, they are built on research that has historically centred white, middle‑class bodies. Their physiology becomes the template. Everyone else is expected to fit.

As a midwife, I have seen how this plays out. Guidelines meant to “guide” become rigid rules. Nurses and midwives cling to them out of fear of being disciplined, fear of litigation, fear of stepping outside the line. Yet following a guideline can be just as risky as deviating from it, especially when the woman in front of you looks or acts nothing like the woman the guideline was built around.

Induction guidelines are a clear example. Much of the recent evidence comes from large U.S. studies with unknown demographics, yet these findings are applied globally. Even more troubling is the recommendation that South Asian women be induced before 38 weeks, a guideline that ignores physiological readiness, the inaccuracy of dating scans, and the trauma of unnecessary intervention. Many of these women never fully understand what induction means, and the result is often psychosocial harm disguised as “standard care.”

The problem is not guidelines themselves. It is the structural bias baked into them and the lack of flexibility in their application. Clinicians need the skills and the permission to ask whether a guideline fits the individual they are caring for. Blind obedience is not safety. It is compliance.

If we want equitable outcomes, we must diversify the voices shaping guidelines, support clinicians to think critically, and build systems that honour the woman, not the guideline.