Midwives online: Aug/Sept 2008
Midwifery is an ever-changing profession, whose public image may be at variance with the reality of the role (Harrison, 2005). It cannot be assumed that individuals entering midwifery share a common understanding about their future occupation. Different approaches and priorities have resulted in midwives practising in very different ways, and with differing philosophies of care. Midwives continue to struggle for professional recognition, and many newly-qualified midwives leave midwifery because they cannot practise as they wish to. This suggests a mismatch between entrants’ perceptions of midwifery and the reality of the role. During a larger study to explore students’ attitudes to collaborative learning and working, a cohort of students entering a three-year direct-entry midwifery programme in an English university answered two open-ended survey questions. The questions concerned their reasons for becoming midwives and their perceptions about the public view of midwifery. A total of 43 students (95.6% of the cohort) completed the survey. Data were analysed thematically. Respondents wished to support childbearing women and their families, and considered midwives primarily as NHS professionals. Many students appeared to be expecting to gain social privileges associated with being a ‘professional’, for example, respect and status within the community. Some students referred to women as ‘patients’; there was little awareness demonstrated concerning issues of women’s choice and control. Many respondents appeared to accept medicalised birth as the norm, and there was little indication that any students might work outside the NHS in the future. Given midwives’ ongoing struggles for professional recognition, the perceived threat to normal birth in our society, and the difficulties that many midwives experience working inside the NHS, these attitudes may impact on students’ future career options and the promotion of normal birth. More research is needed to discover whether these findings constitute an isolated pattern or a wider social trend.
Midwifery is an ever-changing profession, whose public image may be at variance with the reality of the role (Harrison, 2005). Midwives have shown concern about their lack of recognition outside the profession and insufficient public distinction between midwifery and nursing (Pollard, 2003). It therefore cannot be assumed that individuals entering the profession share a common understanding about their future occupation. Factors appearing to contribute to this situation include the approach to birth, as well as different practice environments and ideas about the professional status of midwives.
Midwives aim to promote normal birth (Downe, 2006). However, different approaches to birth conceptualise the midwife’s role differently. One approach, which will be referred to as holistic midwifery, sees the midwife as an expert working with childbearing women, who themselves are regarded as sources of knowledge and authority (Lavender and Baker, 2003; Slome-Cohain, 2004). Alternatively, in the medicalised approach, midwives monitor and control the process of childbirth in terms of medically-defined risk (Thornton, 2001). From this perspective, women themselves are often presumed to have very little relevant knowledge (Pollard, 2005).
Midwives can accordingly practise in very different ways, as can be seen by contrasting the working life of a self-employed independent midwife practising mainly in domiciliary settings with that of a hospital-based midwife practising within a technological medicalised environment (Hobbs, 1997; Duerden, 2002). There are of course, many midwives whose practice incorporates elements of both approaches. However, most midwives in the UK work in medicalised environments in NHS settings. In this context, ‘medicalised’ means that midwives practise according to organisational protocols and policies based on medical, rather than midwifery, principles and priorities. Medical professionals generally have higher status than midwives in the institutional hierarchy.
For the last two decades, midwives have been attempting to challenge the dominance of the medical profession, in what Witz (1992) termed their ‘professionalisation project’. Strategies to support this development include the move to an all-graduate profession (Neglia, 2003). However, an alternative view considers that this desire for greater professional status endangers the midwife-woman relationship, and threatens holistic midwifery care and normal birth (Wilkins, 2000; Meakin, 2003). Davis-Floyd (2005) posited the idea of the ‘post-modern’ midwife being a professional practitioner who adheres to the holistic midwifery ethos, while taking advantage of technological advances.
Some midwives struggle to reconcile the demands and culture of their working environment with their own conception of what their role should be (Hunter, 2005). In a national study of midwifery attrition, Ball et al (2002) found that many UK midwives, particularly those younger and more recently qualified, left midwifery because they could not practise in the way that they wished to. This suggests a possible mismatch between potential candidates’ ideas about midwifery, and the reality of the role.
There has been very little research exploring students’ reasons for entering midwifery, or their ideas about their future role. In the only study of its kind, a wish to support and empower women was a strong factor influencing first-year students’ motivation and understanding of midwifery (Williams, 2006). Many of Williams’ participants accepted the medicalisation of birth, and expected to work only in hospital settings. In the paper presented here, the author reports research findings concerning new students’ reasons for choosing to become midwives, and their perception of what the general public think about the profession.
With university ethics committee approval, a survey was conducted to measure student attitudes towards collaborative learning and working in a Faculty of Health and Social Care in 2001. The survey questionnaire collected demographic data, and contained three attitude scales. Results from responses to the scales, and details concerning their development and validation, have been reported elsewhere (Pollard et al, 2004, 2005, 2006). The questionnaire also contained two open-ended questions:
Students could cite more than one reason or professional feature in response to these questions. The questionnaire was designed for administration to all students entering three-year programmes leading to a professional qualification. It was anticipated that answers to these questions would allow the faculty to gain a picture of students’ motivation across different professional programmes, and greater understanding of how students entering different professions perceived their chosen occupation in relation to the wider social context. This paper focuses on findings concerning midwifery students’ responses to these two questions.
The survey sample comprised two cohorts of first-year students (n=943) from ten different allied health, midwifery, nursing and social work programmes, of whom 45 were direct-entry midwifery students. The survey did not include any midwifery students with a nursing qualification. The midwifery students were all from the same cohort (the second cohort contained only nursing students).
Data collection and analysis
Students completed the questionnaire during their first week in the faculty. The analysis of the midwifery students’ responses to the two questions occurred in two phases. Firstly, qualitative data for the entire sample were subjected to thematic content analysis and coded for categories (Bryman, 2001). Each answer was coded for up to four categories. In view of the large sample size, categories were treated as quantitative variables, using SPSS Version 11 (Miers et al, 2007). Data from the midwifery students were then explored separately, and analysed thematically (Bryman, 2001). This analysis drew initially on the categories found for the entire data set (see Tables 1 and 2). Further categories relating specifically to midwifery were subsequently developed from the data: the function of the midwife, the social implications of birth, the midwife-woman relationship, control and choice in childbirth, and the appropriate context for birth.
A total of 43 midwifery students (95.6% of the cohort) completed the questionnaire, answering both questions. They were all female, between 18 and 40 years old. The mean age was 24.5 years, and 19 respondents (44.19%) were mature students (older than 21 years) (see Table 3). The findings below give an example of the types of responses received.
Wanting to become a midwife
Most students gave more than one reason for becoming a midwife. The most frequent reason given was to gain the rewards and status of a recognised profession (23 responses, 53.5%):
‘To have a respected career…’ (R24, 19 years).
Altruism and personal interest in the area were also often mentioned (21 responses, 48.8%):
‘To give support to mothers during pregnancy’ (R10, 33 years).
‘The area of midwifery really interests me and is based on one specific area, i.e. delivering babies…’ (R33, 18 years).
Public view of the profession
The provision of care and support (18 responses, 41.7%) and the availability of expertise and professionalism (18 responses, 41.7%) were seen as most valuable to the public. Six respondents (14%) explicitly stated that the public respected midwives, for example:
‘…lots of people respect the job…’ (R43, 19 years).
What is a midwife?
Many students considered midwifery to be primarily about supporting women and their families, and delivering babies. Some 31 respondents (72.1%) mentioned providing women with care and support, for example:
‘…to help women and their families through pregnancies’ (R35, 18 years).
Students demonstrated awareness of the social implications of birth, with 13 respondents (30.2%) mentioning the midwife’s input at an ‘important’ or ‘special’ time in people’s lives, for example:
‘Providing specialised care at a particularly important time in a woman’s life …’
(R13, 18 years).
The family context was also mentioned:
‘…to help couples become families and help them to have positive birthing experiences’ (R11, 33 years).
Eight respondents (18.6%) showed expectations of forming relationships with women in their care:
‘…seen much more as a partner in care rather than as a patient – less of a hierarchical relationship’ (R28, 40 years).
Three respondents (7.0%) indicated awareness of issues of women’s choice and control. However, women were not assumed to have ultimate power over decision-making:
‘…the patient (mother) has the opportunity to decide/choose which form of care/treatment that is available (to a degree)’ (R31, 25 years).
Six respondents (14%) spoke about childbearing women as ‘patients’ or as receiving ‘treatment’, implying that they located birth within a medicalised context. For many respondents, the midwife’s role was located within this context, as a respected health professional with specific expertise. There was no evidence that any of the students viewed midwifery as an occupation existing outside the NHS, or even as being distinct from nursing. Frequent comparisons were made between midwives and other health professions (nurses, doctors and health visitors), and 13 respondents (30.2%) made explicit reference to the NHS or nursing:
‘I have a great interest in pregnancy and would love to join the nursing profession’ (R5, 24 years).
‘It is the pathway into the NHS that I feel that I have the most to offer’ (R40, 38 years).
‘It is an area of health care/nursing that I am interested in’ (R31, 25 years).
The rewards and benefits of belonging to a profession were cited by 23 respondents (53.5%) as a reason for becoming a midwife:
‘The job would be very rewarding and highly respected. A professional qualification would be achieved’ (R33, 18 years).
‘…to have a respectable job and be recognised in the community’ (R6, 19 years).
A total of 15 students (34.9%) implied that they expected to gain greater social status. Although some intimated that personal experiences of birth had influenced their choice of career, this was couched in terms of empathy or passion, rather than suggesting that they already possessed any valid knowledge about birth. There was no representation of women themselves possessing any relevant knowledge. Some students appeared to be anticipating achieving higher social status than the women they would attend, through attaining a professional qualification.
In this study, students’ reasons for joining the profession were similar to those found by Williams (2006), in that many respondents reported wanting to support childbearing women and their families. However, many also wanted to become a ‘professional’, which was consistent with the current emphasis on midwifery’s ‘professionalisation project’ (Witz, 1992; Neglia, 2003). This ambition corresponded with many students’ views on the public perception of midwifery, which revealed an impression that they expected to gain status and respect through their ability to provide professional support and expertise.
The students’ view of becoming health professionals (as opposed to holistic midwives) was consistent with the perception that birth is automatically located within the NHS. This also agrees with Williams’ (2006) findings. Responses also reflected current concerns about the profession’s lack of a distinctive public image, particularly its differentiation from nursing (Pollard, 2003).
The reference to women as ‘patients’ and the comparisons made between midwifery and other health professions, particularly nursing suggested a tendency to view birth as being controlled by medicalised health professionals, rather than by childbearing women themselves. These data raise questions about the students’ orientation towards the ideal of the holistic midwife presented in much midwifery literature, that is, of the midwife being a knowledgeable, skilled practitioner working in a supportive partnership with women, with a view to promoting normal birth with as little intervention as possible (Lavender and Baker, 2003). Implicit in this partnership is the concept of choice and control remaining in the hands of the woman, rather than in the hands of the midwife (Leap, 2004). While the students’ responses suggested that many of them had an awareness of wider social issues concerning birth, they appeared to be generally unaware of factors concerning choice and control for childbearing women. Some seemed to assume that as ‘professionals’, they would enjoy enhanced status relative to the women in their care. These responses may be due to the fact that the students were just starting their careers, and so did not appreciate the complexity of the midwife’s role. However, while such a perspective could be considered unsurprising among the wider public, it is noteworthy that it was displayed by women actively choosing close engagement with childbirth.
There is anecdotal evidence suggesting that even candidates with strong personal commitment to holistic midwifery struggle to resist the socialisation processes that occur during professional midwifery education (Humphries, 1997). Williams (2006) found that most of her participants were not even expecting to practise as community midwives, since many of them viewed a hospital environment as the most appropriate place for giving birth, and the most supportive context for midwifery practice. Since there was little evidence even of awareness of holistic midwifery in the students’ responses in the study reported here, they appear unlikely to practise outside the NHS in the future. Greater consideration of this issue is beyond the scope of this paper. However, it is worth noting that there is a perception that normal birth is under threat (Robinson, 2001-2002), and that midwives practising outside the NHS are currently the authentic guardians of normal birth in the UK, since they commonly practise according to midwifery (rather than medical) principles and without pressure to conform to medical priorities and the technological imperative (Frohlich, 2007).
Very few UK midwives practise outside the NHS, and there appear to be few career options for those who find their position within it untenable. Given the current problems facing independent midwifery, these options are ever-diminishing (Frohlich, 2007). Ball et al (2002) found that many midwives who left the profession complained that they could not practise as they wished to. Specific complaints concerned a lack of status, control and respect from colleagues in the NHS. Anticipation of professional rewards, as shown by the students in the study reported here, may not, therefore, bode well for their future careers as midwives.
Given the small scale of the study presented here, consideration of how the students’ views and expectations may impact on the professionalisation of midwifery, and the practice of holistic midwifery, medicalised midwifery, and/or the development of the ‘post-modern’ midwife (Davis-Floyd, 2005) is beyond the scope of this paper. It is not possible to generalise the findings reported here to other midwifery students. More research into students’ reasons for becoming midwives and their perceptions and expectations of midwifery would reveal whether the focus on being ‘professionals’ within the NHS is a widespread trend or an isolated pattern. This could allow consideration of the wider implications for the profession, particularly with respect to midwives’ choice of working environment and its relationship both to their career options and the promotion of normal birth.
There is very little research concerning students’ reasons for entering midwifery, or about what they think being a midwife entails. The lack of a clear and consistent public image for midwifery means that potential entrants to the profession may hold a variety of opinions and expectations about their future role.
In the study presented here, while support for women was often cited as a motivating factor, the reason given most frequently for wanting to become a midwife was that it would mean becoming a ‘professional’. Students intimated that they expected to gain status and respect because of this. Many respondents appeared to accept birth within medicalised settings as the norm. The midwife-woman relationship was characterised mainly in terms of giving and receiving support. These responses raise questions about these students’ orientation to the ideals of holistic midwifery.
The perspective found among these students may be peculiar to their cohort. More research is needed to discover whether other midwifery students share similar views about their future role. Given the perceived increasing threat to normal birth in the UK, and the difficulties many midwives continue to face as professionals in the NHS, student ambitions to be ‘a professional’ rather than a holistic midwife may have long-reaching consequences for UK midwifery and childbearing women.
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