Influential research: The research that inspired me

By Billie Hunter and Sue Macdonald on 25 May 2018 Midwives Magazine Research Midwives

Two leading midwives explain the research that influenced them and why.

BILLIE: The midwifery research that I continue to find thought-provoking is Professor Mavis Kirkham’s PhD study of interactions between midwives and women during normal labour (Kirkham, 1989; 1987). Although conducted in the 1980s, the findings continue to resonate with current midwifery practice. You only need to watch One born every minute to see that midwives’ communication with women is not always as effective or supportive as we might wish.

Kirkham observed 113 labours, primarily in hospital. Her findings provide important insights into how midwifery culture affects language and behaviour. For example, she described midwives blocking conversations by ending them without answering the woman’s question. For example:

Woman: ‘How long does it take?'
Sister: ‘Babies come when they’re ready’ (Kirkham, 1989: 125).

Kirkham also noted how midwives attempted to reassure women by using phrases such as ‘don’t worry’ and ‘that wasn’t so bad was it?’ However, this approach often negated the woman’s anxieties and shut down the possibility for her to seek further support.

I first read this research studying for an MSc in midwifery, and it had a profound effect on me. Not only did it trigger my interest into researching midwifery culture, but it also influenced the way that I wanted to do it and introduced me to ethnographic research.

This study gave me new insights and explanations into behaviour that I’d noted but hadn’t thought about critically. It helped me to ‘treat the familiar as strange’, influencing both my practice and thinking.

SUE: I was introduced to research while undertaking the advanced diploma of midwifery. Sleep et al’s (1984) study into perineal management was one of the first I learned about that had special resonance, as it was generated and led by a midwife.

The research was developed at a time of huge national variation in the rate of episiotomy (anywhere from 14% to 96%), and Sleep et al were questioning whether it should be carried out. Some people thought, although there was no research evidence, that a perineal tear healed better than an episiotomy. This study involved 1000 women being randomly divided into ‘restrictive’ or ‘liberal’ approach to episiotomy. Instructions to the attending midwife were couched to either ‘try to avoid an episiotomy’ (restrictive) or ‘try and prevent a tear’ (liberal).

The results suggested that neither approach made a significant difference to long-term morbidity, though women in the ‘restrictive’ group tended to resume sex earlier than the liberal group. The research team concluded that there was no real difference in pain, healing and continence between the two groups. A small number of women experienced severe perineal trauma (four in the restrictive and one in the liberal group), which the researchers suggested could have been ‘down to chance’. Interestingly the episiotomy rate in the unit fell from 61% to 20% after this study.

This pioneering study influenced practitioners’ approach to episiotomy and perineal care, and set the scene for further research. It made me realise that midwives could and should be more involved in research, and incorporate research evidence in their practice, as it provides a means of challenging practice, and confers greater confidence in being able to argue for particular aspects of care.

Billie Hunter is a midwifery professor at Cardiff University and Sue Macdonald is a midwife consultant and educationalist


Billie Hunter

Kirkham MJ. (1987) Basic supportive care in labour: Interaction with and around laboring women. Unpublished Phd thesis, Manchester University.

Kirkham MJ. (1989) Midwives and information giving in labour. In: Robinson S, Thomson AM. (Eds.). Midwives, research and childbirth. Springer: Boston, MA.

Sue MacDonald

Sleep J, Grant A, Garcia J, Elbourne D, Spencer J, Chalmers I. (1984) West Berkshire perineal management trial. British Medical Journal 289(6445): 587-90.