This paper sets out the story of one route to undertaking midwifery research. It starts with a vocational call to be a midwife, and describes a subsequent research programme that has evolved over 25 years.
Evidence Based Midwifery: March 2012
Soo Downe OBE PhD, MSc, BA, RM.
Professor of midwifery studies, Research in Childbirth and Health (ReaCH) group, University of Central Lancashire, Preston PR1 2HE England. Email: email@example.com
This paper is part of a series celebrating the contribution of professors to the midwifery profession.
This paper sets out the story of one route to undertaking midwifery research. It starts with a vocational call to be a midwife, and describes a subsequent research programme that has evolved over 25 years. The key theme that characterises the programme is the understanding and promotion of physiological birth, at the macro, meso and micro level. This covers policy, how services are organised, how practice is delivered, and the nature of normal birth physiology. The work has been based on looking for what makes things go well (a salutogenic perspective) and on understanding birth as a complex, dynamic process. It involves collaborations with clinical, policy, service delivery and professional colleagues in the UK and overseas. The fundamental aim is to maximise the provision of ‘skilled help from the heart’ for women, their babies, and their families, through a comprehensive understanding of the nature, meaning and consequences of physiological childbirth, and of the values, contexts and policies that support the best possible maternity care provision in any given situation.
Normal birth, research, professorship, complexity, salutogenesis, physiology, values, evidence-based midwifery
There are many ways of getting to a particular position in life. Some plan their career meticulously, working out the qualifications they need and the jobs they should get as stepping stones to that position. As this paper illustrates, in my case, most of what happened – just kind of happened. But there was always a common theme of persistent curiosity, and of wanting to make a difference. Sometimes, as they say, the journey is the destination.
My interest in research started before I began my midwifery career. After school I went to the University of York where I undertook a degree in English language and literature. This introduced me to the joy of following up questions that interested and fascinated me. However, in all the excitement about and delight in learning that came with full-time undergraduate study, I was dimly aware that, at some point, I would need to get a job and earn some kind of living. I had no idea what this might be: the idea of working as a midwife had never crossed my mind. However, in 1979, as a member of the Girl Guides, I had the opportunity to work at the Girl Guide Association chalet in Switzerland over the university summer holiday. With a colleague, I was then invited over to South Africa for their jubilee event the following year. I was vaguely conscious of the effects of apartheid (which was still in operation at that time) and, in my naivety, I arranged to visit the ‘real’ South Africa, by way of a couple of weeks in the homeland of Bophuthatswana. Somehow, I ended up at a mission station where nuns were providing maternity care: black African rural women having babies under the care of white African nuns. I was absolutely amazed by the strength of the women, by the calmness, courage, and support of the nuns, and by the whole sense that something fundamentally creative and dynamic was happening here. It was at that point I started to think if we get childbirth right, we get the world right. And it was at that point that I got my vocation in life, and that the seeds of my research passion, physiological labour and birth, were sewn.
On my return, and on the completion of my degree, I spent some months working in Guy’s Hospital as a healthcare assistant, just to see whether doing midwifery in the UK was the same as doing it in South Africa. At that time, I thought the training inevitably involved doing nursing first, so I applied to St Thomas’ Hospital to do nursing. However, while I was waiting to hear back from them, I found out that Derby City Hospital ran a direct-entry midwifery programme. So, I applied there and, to my delight, was accepted. At that time, the midwifery qualification was not even at the level of diploma. Despite this, it was most difficult qualification I have obtained, because getting midwifery right fundamentally affects the lives of women, babies and families. This has made me reflect on how difficult it is for students who are now undertaking midwifery degree courses to tackle the academic level of thinking necessary to obtain their degree at the same time as gaining the in-depth clinical expertise they need to practise safely, empathically and confidently, while also (and this is often overlooked) getting to grips with the peculiar cultures of health care that predominate in many maternity settings today. I hope that the kind of casual disregard that we experienced as students and as newly qualified staff (that often led to tears in the sluice) has gone, but I am sure that the shock of crossing the boundary into the local labour ward is still profound for many students.
My first encounters in this context also taught me how powerfully transformative positive collaborative relationships can be; and this is another strand of our research programme.
When I started my midwifery training, the provision of direct-entry midwifery training was being reduced, and by the time I finished my training, Derby City Hospital was the only place still providing this route to being a midwife. I joined the Association of Radical Midwives early in my training, and in doing so also joined the pressure group that was fighting to expand the provision of direct-entry midwifery training in the UK. This was the spark for my first research study.
My first research question was – what are the experiences of practising midwives who have been direct entrants? It resulted in a large survey of over 1000 questionnaires which, to my shame, were never fully analysed, although a column did appear in Nursing Times
(Downe, 1986). Probably more importantly, I was asked to present the results at a meeting at the Royal Society of Medicine. Whether it’s coincidence or whether the study did have some impact on the debate, as I remember it, within a year or two, decisions had been made to expand direct-entry training once more. The rest, of course, is history.
I’ve only just, 20 years later, destroyed these questionnaires. I always believed I would be able to analyse them, but I’ve concluded that, realistically, this is not going to be possible. I do empathise strongly with people who have data that are really interesting, which they cannot write up. In fact, if I could find a technique for making this happen, this would be one of the achievements of my research career.
I began thinking and writing about the nature of normal birth at about this time (Downe, 1991). The next research project was built on a desire to normalise childbirth as much as possible, especially for women who might need an intervention, such as an epidural. It formed part of a masters and then a PhD degree, and the fact that it was completed and published was, to a large degree, due to the support and encouragement of my supervisors, David Gerrett and Mary Renfrew. I’m very grateful to them both for this. It was a study of the use of the lateral position in the passive second stage for women having their first babies and using epidural anaesthetic (Downe et al, 2004). The research question was stimulated by my clinical experience of seeing women struggle to push actively once they had an epidural sited, and the observation that babies in this circumstance did not seem to negotiate rotation effectively. The study built on the theory that if the pelvic floor was anaesthetised it did not offer the usual resistance to the fetal head, but that using the lateral position (as midwives did traditionally) might offer increased lateral resistance, and so facilitate rotation more effectively.
This was the first randomised controlled (RCT) trial I had attempted, and I had a lot to learn. By the end of it I knew there were a lot of things I could have done much better, and, importantly, that it is more difficult to recruit to research studies than even the most careful and conservative pre-study planning might suggest. Later, I learned that almost every researcher feels their research could have been done better after virtually every study they ever do. Despite the shortcomings, however, the results did suggest that using the lateral position, particularly when the fetus is in the OP position at the beginning of the passive second stage of labour, might reduce the need for forceps to expedite the birth.
The questions for both of my first research studies were directly generated from personal experience, and from observing women in labour. The next large study we did was stimulated by the policy change in government thinking at the time, towards team midwifery. In response to this, the local hospital (this is pre-Trust days) set up pilot sites to run team midwifery schemes. With my colleague, Sheila McFarlane, we ran an extensive review of the scheme, incorporating questionnaires and interviews with midwives, managers and service users, and taking a longitudinal perspective as the team schemes matured. This was published in The Practising Midwife
(McFarlane and Downe, 1999).
Again, we learnt important lessons from trying to undertake such a complex mixed methods study. One of the main frustrations was wanting to undertake specific tasks (such as complex statistical modelling of the longitudinal data) without the support of experts on hand who knew how to do them. On reflection, this experience prefigured the development, much later, of the National Institute for Health Research (NIHR) Research Design Service, that is set up to link clinical staff with good research ideas to academic methodologists who know how to make those ideas researchable. If there is anyone out there in clinical practice who feels the frustration we felt then the NIHR Research Design Service is the place to go for help.
Consolidation: moving towards a theory of physiological labour and birth
Having said that the team midwifery study was frustrating because of lack of sophisticated expertise in certain areas, one of the most important studies I have been involved in was a simple survey, that required no external funding, and that was undertaken by a group of us as clinical midwives, in collaboration with the Association for Improvements in Maternity Services (Downe et al, 2001). This was the Trent regional study of interventions that women experienced while having a so-called normal birth. It was published in the British Journal of Midwifery
, which is not indexed on Medline, and which does not have an impact factor – but it has probably been the most influential study I have been involved in to date. Directly or indirectly, the findings have influenced the set up of the RCM Campaign for Normal Birth (and, through that, campaigns in a range of other countries, including Spain and Portugal).
Very soon after this study was published, I moved from the NHS to higher education, at the University of Central Lancashire. At this time, despite the exciting arrival of Changing Childbirth
in 1993 (DH, 1993), the caesarean section rate was rising inexorably, and the findings of the Trent Normal Birth Survey were depressing: more than 70% of women in the survey who had a so-called ‘normal birth’ had at least one intervention in labour (Downe et al, 2001). I was thinking about how we could make normal physiological childbirth matter to women, midwives, managers, economists and policy-makers, but I was drawing a blank.
Then one conversation with a colleague at UCLan, Tilly Padden, provided the answer. She introduced me to the concept of salutogenesis, as one of a series of theories she was thinking about to measure capacity in parents who had babies in neonatal units. Salutogenesis is a term coined by Aaron Antonovsky (Antonovsky, 1987), professor of medical sociology.
He noticed that, contrary to expectation, some of the concentration camp survivors he was researching had a remarkably positive outlook on life. Instead of seeing these individuals as outliers, as they did not express the psychological pathology that might be expected in their situation, he began to wonder what it was that made them so resilient, despite their experience.
Salutogenesis can be roughly translated as the generation of wellbeing. The term describes an approach which focuses on factors that support and promote human health and wellbeing, rather than looking at factors that cause disease (Sinclair and Stockdale, 2011). Antonovsky uses it broadly in contrast to pathogenesis – what is it that makes things go well as opposed to making them go badly? He also developed a psychological model, based on what he termed the ‘sense of coherence’ concept. This model predicts that if an individual can see the world as manageable, comprehensible, and meaningful, they are more likely to be able to cope with adverse events positively, no matter how extreme their experiences might be: ‘A salutogenic orientation facilitates seeing things that experts in a given pathology might well fail to see…it… pressures one to think in systems terms… it leads one to deal with (both) entropic (disorder-promoting) forces and… negentropic (order-promoting) forces’
Antonovsky’s work led me to consider the potential power of turning the usual pathological debate about pregnancy and childbirth (how can we prevent things going wrong?) towards one of saltutogensis (how can we learn from what goes right?).
My thinking was then further developed by an encounter with complexity theory. This theory holds that many aspects of the world (systems of care delivery, the weather, our heart beats, and so on) are not linear, fixed and simple, but dynamic, variable, and complex. In other words, these aspects of life respond in unexpected ways. Applying this theory to labour and birth opens up the potential of seeing each labour and birth as ‘uniquely normal’ where the dynamic biological systems and psychological orientation of mother and baby interact in unique and unpredictable ways with the context in which labour is happening – including the attitudes, beliefs and care practices of her birth companion and attending staff, and the setting in which she is giving birth.
Complexity also allows us to rethink the potential salutogenic effect of childbirth: maybe, rather than trying to control what might (in very few cases) go wrong by standardising care for everyone, we should understand the dynamic possibilities for each person, to maximise what might go well?
The impact of applying these two theories to childbirth was first described in a book chapter, as part of an edited book on normal childbirth (Downe and McCourt, 2004, reprinted 2008). Thinking on this topic has subsequently been extended (Downe, 2004; Downe, 2006; Downe and Walsh, 2007; Downe and McCourt, 2008; Schmidt and Downe, 2010; Downe, 2010a; Downe and Walsh, 2010). It has also been translated into a masters module on normal birth that is based on clinical story telling (Perez-Botella and Downe, 2006a, 2006b; Downe, 2010b). There are many synergies with our approach in these texts, and the new way of thinking about evidence, termed ‘realist research’, that has been developed by Ray Pawson and colleagues (Pawson et al, 2005). In summary, both approaches are interested in what works, for who, in what context.
From theory to practice: the current situation
Now, at UCLan, I work with a team of researchers that includes midwifery, biomedicine, alternative therapy, history, psychology, and sociology, in our Research in Childbirth and Health (ReaCH) unit. We work in synergy with Professor Fiona Dykes, who leads Maternal and Infant Nurture and Nutrition (MaINN). The MaINN group have undertaken a wide range of important work in mother and child nutrition. In collaboration with our postgraduate students, clinical colleagues and local service users, ReaCH has undertaken studies on topics that include the early urge to push (Downe et al, 2008), place of birth (Walsh and Downe, 2004; Hodnett et al, 2005, 2010), women’s choice for caesarean section (Lavender and Kingdon, 2009; Kingdon et al, 2009), the nature of the ‘good’ midwife (Byrom and Downe, 2010), and of the ‘good’ midwifery leader (Downe, Simpson and Byrom, 2011), the nature of midwifery expertise in intrapartum care (Downe , Simpson and Trafford, 2007; Downe and Simpson, 2011), management of the fetal nuchal cord (Jackson et al, 2007; Melvin and Downe, 2007) what it means to women to have a positive birth after a previous traumatic experience (Thomson and Downe, 2008; Thomson and Downe, 2010), how midwives maximise physiological birth in hospital environments (O’Connell and Downe, 2009), how to build collaboration between midwives and obstetricians (Downe, Finlayson and Fleming, 2011a, 2011b), why women don’t access antenatal care (Downe et al, 2009), dealing with relationship conflict in the antenatal period (Steen et al, 2010) and fathers experiences of intrapartum care (Steen et al, 2011; Longworth and Kingdon, 2011).
With clinical colleagues and service users, we are currently undertaking studies that look at the amount and effect of record-keeping (a linear intervention in a complex environment) on the workload and options of midwives and obstetricians, an RCT where the intervention is teaching women having their first baby to self-hypnotise while they are pregnant so they can use this to minimise their need for epidurals, and on the impact of computerisation in the labour ward on staff and service users.
Our methods include systematic reviews (qualitative and quantitative) ethnography, phenomenology (Thomson et al, 2011; Downe, Thomson and Dykes, 2011), RCTs, surveys, mixed methods, and action research (Downe et al, 2007). Methodologically, we have suggested simplified tools for assessing the quality of qualitative research (Walsh and Downe, 2006; Downe, Simpson and Trafford, 2007) and new approaches to metasynthesis (Walsh and Downe, 2005; Downe, 2008).Our group has, over the last ten years, included Tina Lavender, Denis Walsh, Grace Edwards, Sheena Byrom, Anita Fleming and Mary Steen. Grace, Anita, and Sheena were all joint clinical appointments, and Mary worked on a shared contract with the RCM. These joint posts have added significant value to our work over the last ten years.
Since the midwifery research group was formed at UCLan, we have developed a wide range of international work. This includes studies with Hannah Dahlen and her team at the University of Western Sydney, using observational techniques to look at how women use space in different kinds of settings, including a centralised hospital, a birth centre, and at home. Collaboration with a team in Belgium involved better methods of assessing the quality of antenatal care (Beeckman et al, 2011). We are also working with a team at the University of Gotenburg, led by Marie Berg, to look at the experience of women and their partners of the first encounter on the labour ward (Nyman et al, 2011). Our international work includes a large EU study across 21 countries, (within the EU, and in China, South Africa, Australia and Israel) called Childbirth cultures, concerns, and consequences: creating a dynamic EU framework for optimal maternity care
(Downe et al, 2010), designed to find out what works well in maternity systems, and introduce those elements into other systems across Europe.
As well as our contribution to teaching undergraduate students in our area of research expertise, we also teach and supervise postgraduate students (most, but not all of whom are midwives), from the UK, Ireland, Hong Kong, Africa, Israel, and Malta.
What use is research, anyway? Making a difference
The whole aim of our research endeavour is to provide the evidence to maximise positive childbirth for women, babies, families and maternity care staff. We are also, therefore, actively engaged in translating our academic work into action for change. At the academic level, for instance, as noted above, we run a module on normal childbirth, which has been developed to be very interactive and to be built on midwife story telling (Downe, 2010b). Along with face-to-face teaching sessions, people who access the module tell stories of seminal events relating to normal birth (when it went unexpectedly well, or unexpectedly badly, for instance). As they each tell their stories, the rest of the group start to deconstruct them, to try to unravel at each decision point what the midwife felt, what the woman/partner/other staff might have felt, and why, what the women’s personal physiology/history might indicate, what the formal evidence base would suggest, what the theoretical explanations might be, and so on.
The point is to develop reflexivity in practice, so that each midwife attending the module might be able to normalise childbirth more confidently in future. The intention is to examine what might be getting in the way of physiological birth, and to share examples of situations when women who are technically high risk have managed to achieve as normal a birth as possible, with positive birth outcomes. We are particularly interested in how this works in collaboration with obstetricians and colleagues (Downe, Simpson and Fleming, 2011; Downe, Simpson and Byrom, 2011; Downe Simpson, 2011; Downe, Finlayson and Fleming, 2011).
Our work has been seminal in the setting up of the RCM Campaign for Normal Birth, and in developing the campaign to date. It has had an influence on the government definition of normal birth, and on the place of birth debate, via our Cochrane review on place of birth (Hodnett et al, 2010).
Locally, we have been involved in the design and set up of the very successful Blackburn free-standing birth centre, which is heading for nearly 1000 births in its first year of operation. I am also a member of the Board of Directors of the International Mother Baby Childbirth Organisation, which has set up demonstration sites to model ways of humanising childbirth in seven countries to date, and, for me, this work is a very exciting link between the values and beliefs we have been developing in the UK, and the potential for mutual learning with colleagues across the world.
Moving towards a values based approach
As our work has progressed, both in terms of research and of talking and meeting with midwives, other professionals, research experts, and service using women, locally, nationally, and internationally, I have begun to think about respect and disrespect and how these polar opposites link normal birth and maternal mortality. This thinking was catalysed by research with a colleague in Egypt, Amina el-Nemer, who undertook an ethnography of a busy Egyptian labour ward (el-Nemer et al, 2006). Her findings raised interesting questions about why women in medium- or low-resource countries don’t access care. As a consequence of our work in this area, I am now involved in a campaign to address disrespect and abuse in maternity care, which is being undertaken by the White Ribbon Alliance. It is becoming increasingly clear to me that all the facilities and skilled birth attendants in the world will not resolve either the persistently high rates of maternal and infant mortality in some countries, or the psychological harm associated with some routine interventions in other settings, if these are not founded in an authentically caring maternity system. These are the poetics of a knowledge-love approach to maternity care, in opposition to a knowledge-power approach.
Questions that remain
Our continuing quest to find out what makes birth go well, and what the complex, emergent, unexpected consequences of this might be, has now taken us into the fascinating but somewhat intimidating area of epigenetics. At its most basic, epigenetics is the study of changes in gene activity that do not involve alterations to the genetic code but that are still passed down to at least one successive generation.
The reason I started to become interested in this area is because there is a growing body of research that tends to suggest that the way a baby is born might affect it in a number of unexpected ways. For instance, there are reported associations between mode of birth, and specifically caesarean section, and asthma, eczema bronchiolitis, type I diabetes, and multiple sclerosis, in the child and, later, young adult. This raises some interesting questions about what birth might be doing to the fetal epigenome. A group of international inter-disciplinary colleagues from the US, Australia and the UK (the EPIgenetic Impact of Childbirth group) has recently been set up to look at these questions. This work is very new and, potentially, very exciting.
So, in conclusion, it’s always been my belief that the whole point of research and of being a professor in a profession like midwifery, is to increase wellbeing where possible. One thing I’ve learned is that the issues that matter to us here in the well-resourced west of the world, are actually the same as those which matter for the under-resourced east and south of the world.
While these concerns may be expressed in different outcomes, for example, postnatal depression and dissatisfaction in the West, and maternal morbidity and mortality in the South, the factors underpinning them primarily are around respect and trust of both individuals and the physiology of their bodies. The work that we do in our team is fundamentally focused on building positive respectful relationships between colleagues, with childbearing women, and with policy-makers, so that we can maximise the capacity of women to give birth to healthy babies, to parent effectively and to build positive societies. If we get even part of the way towards this, it will be worth it.
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