Learning to be a midwife: the need to believe

EBM March 2007





B Gail Thomas PhD, MSc, PGCEA, ADM, RM, RN.
Head, Institute of Health and Community Studies, Bournemouth University, Christchurch Road, Bournemouth BH1 3LT England. Email: thomasg@bournemouth.ac.uk
Funding towards this research was received from the HSA Charitable Trust via the RCM. The author would also like to thank the participants, and Professor Lesley Page,
Dr Chris McCourt and Professor Mavis Kirkham for their supervision.


Abstract

Background. The historical development of midwifery demonstrates a changing pattern of autonomy and control over practice, and midwives working in the NHS have reported frustrations about being constrained in their practice that could have implications for midwifery education.
Aim. To explore themes and concepts involved in the journey to becoming a midwife with a sample of midwives who work outside the NHS.
Method. A grounded theory approach was used to analyse data from individual and group interviews with nine midwives.
Results. The key theme identified in this research was that of ‘believing’, which helped midwives to transcend environmental and organisational constraints to be able to practise ‘woman-centredness’.
Conclusions. The midwives interviewed appeared to have increased confidence in supporting women to achieve their goals around childbirth.

Key words: Midwifery, woman-centredness, grounded theory, educational strategy, believing


Introduction

The overall aim of this research project was to generate an educational strategy that would enable students of midwifery to become ‘woman-centred’ practitioners. In order to determine the theoretical basis for the educational strategy, the researcher sought to identify key concepts in midwifery that should underpin its teaching and learning approaches.

In the first phase of the project, 14 midwives working in the NHS were interviewed and they described diverse experiences, both positive and negative (Thomas, 2006). The key findings included positive outcomes when the midwives felt they could ‘make a difference’ for women, leading to satisfaction for both parties. In addition, they described a sense of responsibility in needing to ‘prepare’ women for birth and motherhood but showed some reluctance in being completely truthful about the intensity of the birth experience, wanting to protect women from harsh realities. This paternalistic approach linked to the final theme of ‘making sure’, where interviewees indicated that they had a role to play in ensuring normality for mother and baby. This somewhat unrealistic expectation led to feelings of guilt when complications arose and frustration when responsibility for care was taken away from them. There seemed to be a lack of conviction that women can birth without intervention given the right circumstances and support. It may have been that repeated negative experiences had reduced their confidence, and that control by others eroded their authority.

This paper presents the concepts and themes from interviews with nine midwives practising outside of conventional NHS maternity services as a means of contrast and to consider the effect of conditions on midwives’ satisfaction.


Literature review

As this phase of the research related to the conditions in which midwives practise, the literature review focused on the historical development of midwifery as it relates to patterns of maternity service delivery and to the power base of midwives presently in the UK rather than elsewhere in the world.

The historical development of midwifery demonstrates a changing pattern of autonomy and control over practice. The majority of midwives before the 17th century were women (Kirkham, 1996) and so, on a gender basis alone, it could be anticipated that their status in society may have been limited. Hobby (1999), introducing a manual written in 1671 by practising midwife Jane Sharp, creates a somewhat different impression. She identifies that the midwife may have been in a unique position as, at a time when a woman was ‘supposedly absorbed into her husband’s identity’, the midwife ‘could earn enough to make a comfortable living in a line of work still largely closed to men’ (Hobby, 1999: xi). Midwives may have had a status that most women of that time were denied, by virtue of their employment in an allfemale sphere where men posed no threat to their authority.

However, increasing scientific knowledge led to greater interest in pregnancy and childbirth and more involvement of medical men in this sphere. Bourdillon (1988) identifies that, by the mid-18th century, accoucheurs were the most highly paid practitioners employed by the upper classes, which created an additional interest in birth for male practitioners. The working classes continued to be served by lay midwives or local handywomen (Kirkham, 1996) who were not organised in any way to challenge the increasing control over birth that was being exerted. These women did not receive any formal educational preparation for their work but were apprenticed, often for lengthy periods (Marland, 1993) into learning the skills necessary to support women through the birth process. But the value of this learning was becoming less recognised as important and considered by some as inferior to the new ‘scientific’ knowledge.

The early 19th century saw significant change as a result of increasing knowledge – no longer was birth alone of interest to accoucheurs, but pregnancy began to be framed as a pathological possibility and so not safe in the hands of midwives. A number of groups tried to take control of the organisation and education of midwifery in the UK during the 19th century, the most successful of which was the Midwives’ Institute. This group consisted of middle and upper class nurses and trained midwives who sought to provide respectable employment for middle class women (Heagerty, 1997). They were instrumental in bringing about the Midwives Act of 1902, which made the training of midwives compulsory to stop the perpetuation of the attendance at birth by lay (and largely working-class) women. The social standing of this group was crucial to the outcome of their energies. They aligned themselves to the prestigious medical community and had little in common with either the midwives or women from the working class, and unlikely to take into account the needs and desires of these groups. Witz (1992) suggests that, when midwifery was first regulated in the UK by the Midwives Act, there were three options available – midwifery as autonomous with status similar to medical men, its dissolution into obstetric nursing (as was the case in the US) or its strict control in terms of sphere of practice (i.e. ‘normal’ childbirth). The first was considered too challenging to be possible, so in order to prevent all of midwifery practice being under the direct supervision of a doctor, it was agreed by politically active midwives and their supporters at the time that the third option would be preferable. This ‘demarcationary strategy of deskilling’ (Witz, 1992: 116) clearly identified a sphere of competence that limited the potential control of midwives. They were relegated to a sphere that was considered to be less important than that of medicine because it related to the female role of caring rather than the male one of curing.

The developments in midwifery within the 20th century reflect a continued battle for recognised status. The introduction of the NHS Act in 1946 provided free access for all women to doctors as well as midwives, and it was at this point that GPs began to see women regularly through pregnancy, affecting midwives’ sphere of responsibility. Increasing rates of hospital births supported by successive government reports (Department of Health and Social Services, 1956, 1970, 1980), the technologies and interventions that became much more commonplace in the late 1960s and early 1970s (induction, use of synthetic oxytocin for augmentation, electronic fetal heart rate monitoring, episiotomies) and the increased proportion of obstetricians employed within maternity services all impacted on the autonomy of the midwives’ role (Towler and Bramall, 1986). Changing childbirth (Department of Health, 1993) provided an opportunity for both women and midwives to regain some control over birth. However the vision of this report has not been fulfilled in any consistent or permanent way in the NHS.

In the first phase of this research project, midwives working in the NHS shared some frustrations about being constrained in their practice. Recognising the impact that interventionist, medically-dominated care can have on midwives working in conventional services, it seemed important to seek an alternative sample to elicit a more informed understanding of midwifery practice.


Methodology

This study was based on the grounded theory approach. In grounded theory, processes (as opposed to products or static conditions) are described; each section of data is compared  with every other section as part of the ‘constant comparative analysis’ (Strauss and Corbin, 1990). Data collection and analysis are undertaken simultaneously (Baker et al, 1992); the questions that the researcher asks of the data and the concurrent analysis help to determine the next phase of sampling (‘theoretical sampling’). Therefore, a grounded theory study is one that grows as a result of the ongoing analysis – when an interesting feature is elicited, it is tested out on the next sample to see if it remains relevant. The sample can change to be able to explore emerging concepts more fully (Glaser, 1999; Strauss, 1987) and the selection of subsequent sources of data is based on the questions and answers of earlier samples.

As a result of the first phase of the study, where midwives working in an NHS maternity service were found to have mixed experiences, the subsequent phase looked to different samples and data to make sense of this. Therefore, nine midwives who practise outside of conventional maternity services (caseload holders or midwives practising in other countries) were interviewed individually (two midwives) or in small groups (two groups, one of three and one of four). This sample was purposive, defined by the place of employment and status, but it was also opportunistic on the basis of access and willingness to participate. Five of the midwives were working in the UK at the time, the remainder worked in Canada, Australia and New Zealand (all but one had worked in the UK at some point in their careers). Access to all midwives was obtained through personal contact by the research supervisor and their informed consent to be interviewed was sought prior to the start of each interview. Before starting the research project, ethics approval was obtained from the local research ethics committee.

The themes that had been elicited in the first phase of the study were used as prompts for discussion. These midwives helped to validate these themes by agreeing that they seemed to ‘fit’, ‘work’ and have ‘relevance’ (Glaser, 1978) for midwifery in the NHS. The data they provided gave a contrasting dimension to the emerging themes from the initial interviews, and this data was checked with the participants at the end of each interview to ensure common understanding of the issues raised.

Data analysis using grounded theory is conducted by coding – the use of ‘words that describe the action in the setting’ (Hutchison 1986). Data are separated, conceptualised and reassembled in new ways and phenomena restructured in order to attach meaningful names to them. This coding procedure persists throughout the data collection and helps the researcher to break through any biases and assumptions that may have been brought to the study. It is this process that gives grounded theory its credibility through analytical rigour. The process builds ‘density’, which is perceived to be the essence of sound theory generation. It requires a balance between attention to detail and creativity as, without the latter, creation of new meaning would be impossible.

Discussion of findings

Through coding and categorising, the key theme that emerged from the analysis of these interviews was that of ‘believing’ (see Figure 1). This included believing both in women and women’s abilities to become mothers without medical intervention and in midwives as competent practitioners in supporting normal childbirth. The numbers by which midwives are identified throughout the findings indicate the order in which the interviews took place.


Believing in women

The first four codes from these interviews demonstrated a confidence and trust in women, a belief that they are able to birth without intervention in the right conditions. The role of the midwife seemed relatively inactive in these interviews and the focus was on ensuring that the woman gets what she wants.


Women can do it

‘Believing in women rather than in us or anyone else (including the all-powerful medical intervention) means we need to recognise that crutches are not necessary’ (midwife 3).
This comment raises two key points – believing in women is critical to midwifery and despite this, some midwives use ‘crutches’ to make themselves feel useful or perhaps important. This second point was expanded upon:
‘Doing things, for some midwives, is important to autonomy... you have to do things (not necessarily traditional interventions but interventions nonetheless) like sweeping membranes, massage, complementary therapies, herbal compresses on the perineum. These all undermine the woman’s own capacity, her belief in herself. It replaces a medical crutch with an alternative one but it is still a crutch’  (midwife 3).

This suggests that there are some midwives who do not believe that birth can be accomplished without some sort of external support or action. Flint (1995) identified two distinct views of childbirth – that nature can always be given a helping hand, and that nature should only be meddled with in dire emergency. There are many examples of how ‘lending a hand’ has become common practice in maternity care, such as induction and active management of labour, episiotomy or elective caesarean section. When intervention is the norm of practice, midwives’ confidence in the efficiency and effectiveness of natural processes can be eroded, and those who have only ever practised in technologically-managed environments may have difficulty in distinguishing the midwifery role from the obstetric one (Mander, 2002). In addition, the midwife quoted above recognised that a practitioner’s reliance on intervention may strip the woman’s confidence in herself. The implication is that the midwife needs to believe that routine intervention is unnecessary in order to be able to help women believe in their own resources.

Feminism versus femininity

Some of the midwives interviewed specifically defined themselves as feminists and felt that this ideological viewpoint had played a significant role in shaping them as midwives who believed in women:

‘In my teens, I developed a strong socialist and feminist ideology that has remained with me all my adult life and even now influences the broader context of my practice’ (midwife 1).
‘I did a training course with a very radical group of women academics and learnt more about midwifery than I ever did in my hospital training programme’ (midwife 2).
‘I found the woman’s movement in the late 60s and early 70s... When I read Germaine Greer’s ‘The female eunuch’, the lights went on’ (midwife 4).
However, it was recognised by some that midwives may use their femininity rather than a feminist ideology to achieve the best results:
‘...there are games midwives play on delivery suite. They often flirt with the male obstetricians, and they say that it’s the only way to do it as it a male-dominated environment. The only way to stand up to them is by playing games’
(midwife 2).

The ‘doctor-nurse’ game was first described by Stein in 1978, and despite further studies finding that this type of interplay is becoming less common (Porter, 1991), some of the midwives interviewed still identified these games as being played. The most central and common belief shared by all feminists is that women are oppressed (Stanley and Wise, 2002). Midwives playing gender games with obstetric colleagues would appear to be in a subordinate position, not considering themselves as equal in status. Although some of the midwives described colleagues who played games with doctors, they did not put themselves in the same category, presenting an impression of being able to interact as equals rather than inferiors (this will be discussed further under ‘refer not defer’). They seemed proud of the work they did in supporting women and empowered in that role.


Community spirit

The belief that women need each other much more than they need healthcare professionals was an issue raised specifically in one interview:
‘Women need their own friends and companions, the midwife is not there to fill this role. The idea of community is very important’ (midwife 3).

These midwives discussed the possibility of acting as agents of connection, to help women find other women within their community who are going through the same experiences of pregnancy, birth and motherhood. The role of the midwife was relatively passive in their description – she was there to help women learn from each other rather than to teach them or to solve their problems for them: ‘Midwives are there to help women access resources, to put them in touch with each other’ (midwife 3).

This approach is underpinned by a belief that women with life and birth experience have a valuable role to play in supporting peers, and that midwives are the catalysts for and not the source of that support. The ‘community spirit’ reflected in the discussion highlighted a sharing approach to practice where women’s confidence is developed through their connections with other women. This sense of community is described by feminist authors as a key to effective interaction among women (Butler and Wintram, 1991; Stanley and Wise, 2002) where shared experiences lead to enhanced strength.


Knowing what the woman wants

The midwives who were practising as caseload holders felt that their ability to help the woman achieve her goals was enhanced through getting to know her well during the pregnancy. They were able to help the woman to make informed choices, to develop her confidence in herself and to believe that she could ‘do it’. A positive effect on the midwives’ confidence was also highlighted:
‘Having a relationship with the woman means that you know what the woman wants and you are committed to supporting it... it gives you the confidence to deal with the medical staff, to advocate when things go wrong or when the medics want to intervene’ (midwife 2).

The benefits relating to continuity of carer indicate that both women and midwives gain satisfaction in this pattern of care and there is evidence of the benefits to be gained (Walker, 1999; Walsh, 1999; Page et al, 2001; McCourt and Stevens, 2006). However, the way that an ongoing relationship can contribute to the midwife’s confidence and commitment to helping the woman achieve her goal does not appear to have been described in the literature. This is an extra dimension to caseload practice that may provide positive benefits to women, and it is worthy of further investigation.


Believing in yourself

The belief in women went hand-in-hand with the midwife believing in herself.


Politics

A ‘political apprenticeship’ as part of learning to be a midwife was raised by the first midwife interviewed. She said that midwives need to develop a ‘belief that you can change things’. Using an apprenticeship model of learning, she described a build-up of confidence in developmental stages: ‘I watched it, I did it, I can do it!’ (midwife 1).

The second interviewee raised the issue of knowing the evidence as an important part of gaining confidence: ‘The ability to debate with medical staff and being aware of the evidence, therefore being on the same level academically[led to confidence]’ (midwife 2).

Knowing the evidence to be able to debate with colleagues with confidence (Page, 2000) is seen as important to the continued development of midwifery practice. The confidence described meant that midwives believed in themselves and felt equal to other colleagues:

‘Feeling the equal to medical staff, not the junior ones who are not equal as they don’t have the experience or depth of knowledge, but equal to the senior registrar or consultant’ (midwife 2).

The type of system in which midwifery operates was considered an important element in how confident midwives could feel about their roles. The ‘oppressive British class system’ was raised by the midwives from Australia and New Zealand who saw the New World as having much more openness and ‘pioneering spirit’. These midwives felt that
with less devotion to hierarchy, there was easier collaboration and more willingness to relinquish control. It seemed they were describing a system in which midwives could more easily believe in the valuable role that they fulfil in supporting women. The politics within the country, the maternity services and a specific unit all impact on the way in which a midwife practises. It can foster a belief in the worth of the occupation or can strip midwives of confidence and control.


Role-modelling

The importance of midwives demonstrating a belief in themselves in order to develop this approach in learners was considered key in all of the interviews. The first interviewee talked about learning ‘confidence and competence’ as well as the
ability to project oneself positively:  ‘Educate midwives to know it’s down to them, what they do really matters and ultimately it’s their responsibility’ (midwife 1).

Role-modelling by the leaders of midwifery was raised in another interview:
‘There is a need for strong midwifery leadership – the problem is often obstetricians are on the interview panel [for heads of midwifery positions] and they will be looking for someone who won’t rock the boat and will be a ‘nice little nursey’...’
(midwife 2).

The significance of role-modelling has been well supported by studies of midwifery education (McCrea et al, 1994; Currie, 1999; Hindley, 2000; Fraser, 2000). In addition to learning from strong leaders, the desirability of learning from peers was discussed in further interviews. Peer review, where midwives could gain confidence by expressing their uncertainty in groups while sharing decisions they had made in practice, was described as an important way of developing confidence in midwives. Engaging in discussion with other midwives and opening oneself up to scrutiny by peers in a supportive group has been recognised as a means to develop scholarship in practice (Cooke and Bewley, 1995).


Refer not defer

There was discussion about the collaborative nature of midwifery – the fact that midwives need to work with colleagues from other professions, especially medicine.
However, there was a distinctly confident way of engaging with doctors, with midwives seen as needing to ‘refer not defer’ in cases of complication:

‘The sign of a mature, autonomous midwife is the ability to recognise the need to refer, not giving up your role when you do so, asking for advice and asking them to do something that you know this woman needs [but is not in your scope of practice]– the ability to refer not defer’ (midwife 2).

The self-confident midwife is less defensive and is able to work collaboratively with other professionals rather than avoiding them or working alone inappropriately. In later interviews, there was recognition that midwives are not islands unto themselves but need to work with others, being able to identify when the responsibility should be passed to another practitioner: ‘Autonomy does not mean being independent, standing alone, but should involve collaboration. Autonomy requires selfawareness. It is an advanced skill... you must be aware of your own limitations’ (midwife 3).

‘The ability to collaborate not confront develops mutual respect – a two-way process’ (midwife 4).

This confident approach to interprofessional working seems reflective of midwives who believe in the importance of their role without seeing it as an inferior one to medicine. The midwives interviewed in the first phase of this study had shared many experiences in which they had felt disempowered by medical colleagues who had taken over control of the labour or birth situation when consulted on an issue (Thomas, 2006). They appeared to defer to medical opinion rather than meet the doctor as an equal, in contrast to this second group of participants.


Implications

Although the findings in this phase are from a small sample and not generalisable to a larger population of midwives, the issues that arise provide insights that could be used to inform curriculum development. These midwives would appear more similar to contemporaries of Jane Sharpe than some of their colleagues working in the NHS presently. Despite power and control being eroded through the centuries, it seems that some midwives are able to maintain a belief in their role and in women’s abilities to give birth without unnecessary medical interventions or ‘helping hands’. The environment is likely to be influential, but a question remains as to whether the environment shapes the midwife, or the midwife chooses an environment to suit her or his capacity.

Believing is the core theme that has emerged from the analysis of these interviews. In contrast to the NHS midwives interviewed in the first phase of the study, these participants felt able to help women achieve what they want from the birth experience. They did not appear to feel constrained by other healthcare professionals nor the system of hierarchy, unlike some of those working in the NHS. It must be recognised that they had all chosen to work in non-hierarchical environments, and the next phase of the research project investigated issues of personality as a possible means to identify any predisposing factors that may have contributed to their capacity to move outside the norm. They had all worked in conventional services at some point and had developed a strong belief because of or despite that experience. They believed in women’s ability to birth and in their ability to support women without unnecessary intervention. This has been learned, at least in part, from effective role models.

But it is not only from watching and emulating other midwives that this confidence was developed in these midwives. It was suggested that the system of care can have a negative impact on midwives – they may have their ideals and passions squashed by a maternity service that does notplace the needs of women at the fore (Kirkham, 1999). Continuity of carer schemes helped to give some of these midwives the confidence to advocate on behalf of women, as they felt they would know what the woman wants and would be prepared to try and achieve this with and for the woman. Helping women to come together, to learn from each other and to gain strength from the experience, can be supportive to both women and to the midwives themselves in the form of peer review.

These issues are important for students learning the practice of midwifery and have implications for programmes of study. Some recommendations reinforce those from phase one, including the importance of a positive environment of practice, the availability of strong role models and exposure to patterns of care that provide continuity. In addition, an understanding of the politics of maternity care, the ability to do nothing when appropriate, strong midwifery leadership and the development of a supportive peer network could positively contribute to the development of a belief in women and midwifery.

Conclusions

The midwives interviewed seemed to believe that they could consistently make a difference and did not feel that they were relinquishing control when inviting another professional in to care for a woman. Like the initial group, they were positive and enthusiastic about their chosen occupation, but the negativity that was also present in the first interviews was not apparent in these. These midwives had chosen to step out of ‘mainstream’ practice, and it could be argued that the environment in which they practise favours autonomy and does not place constraints on them, so that they are able to help women achieve their goals without interference. However, they have also had opportunities to learn from strong role models, from their peers and from women, giving them confidence and a belief in midwifery.

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