The role of the midwife: time for a review
By Denis Walsh and Mary Steen on 04 June 2008 Midwives Magazine
Reader in midwifery Denis Walsh and research fellow in midwifery Mary Steen at the University of Central Lancashire and the RCM examine both the current situation of impersonalised midwifery and the ideal of combining holistic care with evidence-based practice.
Midwives magazine: July/August 2007
The woman’s statement: ‘I wanted her to be there for me, not for the hospital’ – critical of the lack of support she received from her midwife, reflects the tensions that midwives experience working in UK maternity services. The NMC’s Code of professional conduct (NMC, 2004) stresses advocacy on behalf of women but her contract requires her to comply with hospital policies. If a woman’s choices challenge hospital policy, then the midwife is caught between allegiances. This illustrates a growing ambivalence in many midwives’ understanding of their role.
The origins for this are part professional, part organisational and part practice-related. This paper explores these issues and calls for a radical revisioning and re-orientating in the midwives’ role to grasp current maternity care trends. At the moment there is a consensus emerging around concerns over medicalisation of childbirth (Johanson et al, 2001), a focus on normality and the lowering of intervention rates (RCM, 2002) and the focusing on women’s needs and choices (Department of Health, 2002). The RCM has launched the Campaign for Normal Birth as a marker of their commitment to these areas.
Department of Health policy, as espoused through the National Service Framework positions the midwife centrally in the maternity service provision, stating that 75% of women could be suitable for midwifery-led care during labour and birth (Department of Health, 2002). The International Confederation of Midwives has amended their definition of a midwife to reflect ‘partnership with women’ and ‘the promotion of normality’. It now reads: ‘The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures’ (International Confederation of Midwives, 2005). The time is right for a review, not only in legislative and statutory terms, but in an appraisal of the meaning of the role in practice environments.
Defining the characteristics of the profession
The authors offer four defining characteristics of what it means to be a midwife. These come from years of practice in midwifery, reflection and reading around professionalism.
This is a traditional hallmark of a profession and should remain so in the authors’ view (Saks, 1992). With it comes both responsibility and accountability. Autonomy may have been abused in the past by professional groups when it was invoked to support out-of-date practices and non-evidence-based interventions, but it does not equate to unilateral decision- making. It requires midwives to be up-to-date with evidence, to be responsible for their own professional development and accountable.
One of autonomy’s main foci is in defining relationships with other professional groups and, in the maternity care context. It enshrines a parity with obstetrics from where mutual collaboration and inter-disciplinary working can flourish. Autonomy engenders assertiveness, honesty and respect.
Normality is a defining characteristic of midwives’ sphere of practice and although a problematic word, it retains enough meaning to be relevant to midwives. What it does not mean is ‘the usual’, which as Downe (2004) pointed out could mean a number of routine interventions on many birth suites. What it refers to is the physiological process of childbearing. It is better then, to align it with wellbeing or ‘salutogenesis’ (Downe and McCourt, 2004). As a defining characteristic of the midwife’s role, the vast majority of midwives would expect to work within this domain.
Holism requires a midwife to engage the full context of a woman’s experience of labour and birth. The hermeneutic intent of midwifery, to be ‘with woman’, finds expression here, premised as it is in relationship. To date, only Kirkham’s (2000) text, The midwife/woman relationship has fully examined this bond. The relationship between the midwife and a woman provides time and space for getting to know each other beyond the profound physical experiences of pregnancy and birth. Fragmented care, where midwives only work in hospital or community, or only postnatal wards or birth suites within a hospital, seriously undermines this relationship. Research around relational components of care such as continuity (Hodnett, 2005) and oneto- one support (Hodnett et al, 2005) has constantly challenged the service to take the benefits of holistic care seriously.
A focus on the needs of women is axiomatic for maternity services, but experience shows it is far easier to sign up to this rhetoric than to apply it in practice. We suggest two areas in current provision that fail to reflect this ideal. One is the persistent paternalism that is exhibited from time to time in care encounters (Walsh, 2005a), and the other is the response of the service to assertive women who challenge policies and protocols. Recently a woman expecting her 12th baby came into a birth suite in labour and refused a venflon. Her rationale was simple: she had never had a third-stage problem with any of the other births. As practitioners, our presumptions here are often to supervalue our knowledge (population-based generalisations) over her particular body knowledge and to label her as ‘difficult’.
The professional dimension
The sociological critique of professions is well developed in literature but not well-disseminated among health practitioners. The critique is particularly relevant to midwifery, because some of the values underpinning professionalism may be damaging to the profession’s ideals. Kirkham (1996) first articulated these concerns a decade ago. She questioned the esoteric knowledge base that underpins professions and establishes them as experts. This expert status resonates with the authoritative knowledge claims of Jordan (1993), where knowledge is hierarchical and expert knowledge is superior to lay knowledge. The marginalisation of lay knowledge of childbirth is a very recent phenomena. For thousands of years, lay knowledge that can be aligned with women’s wisdom was a collective resource in local communities (Kitzinger, 2000). The rise of medical knowledge in the past 200 years has largely supplanted this in the west and rendered lay knowledge at best a curiosity and at worst, dangerous. There is no better example of this than the intersection between western obstetric techniques with indigenous birth practices where the latter is discredited and discarded. In the developing world, outdated obstetric practices such as routine episiotomy and lithotomy position are a sad legacy of this.
Wilkins (2000) mounts another challenge to professionalism by asserting that it makes a paradigm, ‘that locates midwives and women in different planes of being’ – meaning that the professional/ client relationship is uni-directional, non-reciprocal and hierarchical. These factors fundamentally depersonalise and objectify it. It is an androcentric, rationalist ‘take’ on the care encounter and has been criticised by feminists. LoCicero (1993) writes that: ‘Androcentric rationalism super values detached, objective observation in decision-making on delivery suites.’ This model screens out emotional effects, which are likely to obscure rational thought, so that the professional can respond to labour complications and make an impartial judgement of the appropriate actions, unencumbered by personal feelings. Davis-Floyd and Davis (1997), by contrast, believe that connectedness and interpersonal relationships are keys to making clinical judgements. Empathy, intuition and insight are what are required to individualise decisions at moments of crisis and these are grounded in active listening, rapport-building and sensitive communication with those intimately involved. Fox (1999) extends this critique by juxtaposing two discourses of professional/client relationship: ‘care as vigil’ and ‘care as gift’.
Fox argues that ‘care as vigil’ is premised on control that the professional achieves through surveillance as opposed to ‘gift relationships’ pertaining to generosity. He suggests that those in the helping professions deconstruct the artificial boundaries imposed by discourses of caring and actively seek non-possessive, non-reciprocal, non-hierarchical relationships.
The organsiational dimension
Ball et al’s (2003) analysis of why midwives leave the profession exposed the organisational flaws in current models of maternity care that primarily pitch midwives as employees of large bureaucratic institutions. Walsh (2005b) has written of the predominantly Fordist/Taylorist organisational model of large maternity hospitals. Midwives working with this assembly-line approach have little autonomy, are under constant surveillance and pressure to increase productivity. Many midwives within this model feel more like skilled technicians than autonomous professionals and a significant number ‘vote with their feet’, causing crises in retention.
Institutional and bureaucratic practices are rife within these boundaries. Policies and protocols abound and ongoing measurement is endemic. Kirkham (1999) revealed some of the consequences of what can be described as this ‘high control/low trust’ milieu. Lipsky, much earlier (1980), articulated the resistance of shop-floor level employees in highly bureaucratic workplaces who ‘work the system’. These militate against a woman-centred focus as these checks and balances primarily protect and serve the system, not the clients.
It is our view that this centralised model has no evidence-based foundation and has evolved largely to suit management and professional agendas. As Perkins (2004) argues in the US context, it is an industrial model, taken from private enterprise. Its benefits are said to be economies of scale and greater efficiency, but ‘the bigger the better’ does not translate well to childbirth. The German economist Schumacher wrote a seminal book on economic theory entitled Small is beautiful (1973). He could have been writing about maternity so well do his values and approaches cross over, discussing concepts such as local, personalised, small-scale units of production suffused with humane interpersonal dynamics.
A fundamental question for the profession is what model and style of care is most likely to facilitate normal physiological birth. The profession’s current path is leading midwives toward the increasing medicalisation of labour and birth. Although rising caesarean rates are the primary focus of these concerns, the authors believe, along with Odent (2001) and Buckley (2005) that the neutralising of the labour experience through anaesthesia and bypassing of it altogether in elective caesarean section is a grave development in the evolution of human childbirth. This is because of what is now known about the hormonal cocktail of physiological labour and its effects, such as the impact on the initial connection and bonding between mother and baby (Odent, 2001), the impact on the self-esteem and sense of fulfilment of the mother (Buckley, 2005), the trigger to altruistic and protective maternal behaviours (Buckley, 2005) and the catalysing joy and pleasure in mother and baby (Leap, 2000).
If these emotional and affective components are compromised and watered down by managed childbirth and this occurs across whole populations of women, then the authors are very concerned about the long-term impact on public health. Already preliminary epidemiological work is linking destructive adult behaviours to interventionist birth experiences (Jacobson and Bygddeman, 1989). Much of the blame for medicalised birth has been linked to the unequal historical power struggle with the medical profession (Donnison, 1980) and in particular with obstetrics (Arney,1982). Over the last five years in the UK, there has been an acceptance that midwives can assume responsibility for women deemed to be at low risk. During labour and birth, the midwife can work quite independently as she is the lead carer in the majority of births. The advent of integrated birth centres and midwifery-led units has accelerated these trends. These alternatives need to be predicated on an explicit social, salutogenic model of care and their values made explicit in a unit philosophy.
The authors suggest four areas for reflection: midwifery education, organisational models for practice, setting for practice and skills for midwifery practice.
An interesting recent development in the US is the accreditation of the ‘lay midwifery’ route into practice. Much of the debate has been about the merits of apprenticeship-style training, a strong tradition within lay midwifery. Midwifery courses in the UK could explore this option more, particularly, the requirement to attend half of a student midwife’s statutory births in birth centres, midwifery-led units or at home. The other component of their apprenticeship-style course was caseload work, this is being incorporated into some curricula already.
A second area for exploration for midwifery courses is the explicit inclusion of political lobbying skills. One of the lessons of maternity service reform internationally over the past ten years has been the effectiveness of an alliance of women and midwives in bringing about strategic change. Their political astuteness has kept birth centres open, established new midwifery-led units and influenced government policy. The midwife in the 21st century needs to have both the political awareness and the skills to make a difference. In other words, reform of medical models of care is a core midwifery responsibility.
Caseload midwifery practice has been on the agenda for new ways of working for over a decade in the UK. Caseload practice directly addresses the four criteria stated earlier. Firstly, it is more successful than other models at reflecting a woman-centred philosophy – its underlying rationale is relationship. This is a recurrent theme in evaluations of caseload models (Walsh, 1999; Page et al, 1999). Midwives and women build a mutual rapport that enables another criterion to be addressed – holistic care. Continuity over time enables a full appreciation of a woman’s life – a challenge for the birth suite midwife meeting a woman for the first time in labour.
A little-recognised dimension of caseload work is skill acquisition. Because midwives get to see the consequence of their decisions due to continuity, they quickly learn from their good and bad decisions. When the first author worked as a research and development midwife in a large hospital, it was common knowledge that the caseload midwives were among the most competent and skillful staff, particularly around low-technology birth.
Caseload care also seems to promote an ethos that is a robust demonstration of being ‘with woman’. McCourt and Pearce (2000) wrote about how this sometimes resulted in challenging protocols and policies, as midwives act as advocates for women. Partnership also means compassionate responses to pregnancy and birth traumas, such as, the loss of a baby. Key aspects of a fulfilling caseload work include:
- Having discrete, manageable numbers
- Control over one’s working pattern
- High trust/low control management
- Working in partnerships or small teams
If these are in place, then midwives are more fulfilled, with higher levels of job satisfaction than are experienced in other models (Sandall, 1997).
The wholesale movement of midwifery provision from acute to primary care is a priority for maternity services and midwifery. This shift would bring about fundamental change in how the service is delivered, how women experience it and how midwives practise. We see no rationale for maintaining the current centralised birthing model.
The primary care setting is deeply resonant with key midwifery themes seeing childbirth as:
- A normal physiological event
- A deeply personal, private event
- Taking place in a nurturing, nesting place
- A salutogenic, ‘rite of passage’ transition
- Likely to foster midwifery autonomy
- Likely to foster a woman-centred ethos
The acute setting is appropriate for a maternity care worker but not for the midwife, unless she is a specialist. Even in these roles, she maintains a responsibility to champion normality and ensure that holistic care is provided. In relation to technology, its application must be based on a robust evidence base. This may be a challenge for the specialist midwife working under the direction of an obstetrician, but many have achieved this without resorting to a doctor/nurse game (Stein, 1967).
The authors would like to use intrapartum care as an exemplar for examining alternative and marginal skills for midwifery practice. So often on qualification, the midwife’s acquisition of additional skills is focused on the technical: epidurals, suturing, intravenous drugs, cardiotocograph interpretation and emergency drills.
Below is a list of alternative skills that may be a better focus for development:
- Working with pain
- Emotional nuance reading
- Dimensions of nurture
- Honing optimal birth environment
- Being comfortable with uncertainty
- Embracing an alternative understanding of time (cyclic, rather than clock time)
- At ease with the paradoxes of labour experience
- ‘Sussing out’
- Intuitive responses
These ideas, mostly borrowed from others, are clearly not exhaustive. But the authors suggest that they are fruitful areas for exploration to sit alongside more technical skills. An excellent recent addition to reference materials for traditional birthing skills is Anne Frye’s Holistic midwifery, volume 11 (Frye, 2004). As a repository of evidence-based care and traditional skills, it is second to none.
An exploration of the four areas will enable the characteristics of autonomy, normality, holism and woman-centredness to be more fully realised. A case loading midwife, based in the community with a background in physiological birth in a non-institutionalised setting, a practice philosophy committed to salutogenic childbirth and with well-honed intuitive, evidence-based skills is a midwife for the 21st century. Davis-Floyd and Sargent (1997) have already articulated her role in their work on the ‘post-modern midwife’, where they describe how such a midwife traverses both a social and medical model as she serves women in her care. The task of rethinking the role of the midwife has never been more urgent as the profession reaches crisis point in the future of physiological birth. The opportunity must be grasped.
Arney W. (1982) Power and the profession of obstetrics. The University of Chicago Press: London.
Ball L, Curtis P, Kirkham M. (2003) Why do midwives leave? RCM: London.
Buckley S. (2005) Gentle birth, gentle mothering. One Moon Press: Brisbane.
Department of Health. (2002) The National Service Framework for children, young people and maternity services. See: www.dh.gov.uk/en/publicationsandstatistics/ publications/publicationspolicyandguidance/ DH_4005662 (accessed 25 May 2007).
Davis-Floyd R, Davis E. (1997) Intuition as authoritative knowledge in midwifery and homebirth: In: Davis-Floyd R, Sargent C. (Eds.). Childbirth and authoritative knowledge. University of California Press: London: 315-49.
Davis-Floyd R, Sargent C. (Eds.). (1997) Childbirth and authoritative knowledge: cross-cultural perspectives. University of California Press: Berkeley.
Davis-Floyd R. (2004) Introduction: In: Frye A. Holistic midwifery: a comprehensive textbook for midwives in homebirth practice. Labry’s Press: Portland.
Donnison J. (1988) Midwives and medical men. Historical Publications: London.
Downe S. (2004) The concept of normality in the maternity services: applications and consequences: In: Frith L. (Ed.). Ethics and midwifery: issues in contemporary practice. Butterworth Heinemann: Oxford.
Downe S, McCourt C. (2004) From being to becoming: reconstructing childbirth knowledges: In: Downe S. (Ed.). Normal childbirth: evidence and debate. Churchill Livingstone: London: 3-24.
Fox N. (1999) Beyond health: postmodernism and embodiment. Free Association Books: London.
Frye A. (2004) Holistic midwifery: a comprehensive textbook for midwives in homebirth practice. Labry’s Press: Portland.
Hodnett ED. (2005) Continuity of caregivers for care during pregnancy and childbirth (Cochrane Review): In: The Cochrane Library 4. John Wiley and Sons: Chichester.
Hodnett ED, Gates S, Hofmeyr G J, Sakala C. (2005) Continuous support for women during childbirth (Cochrane Review): In: The Cochrane Library 4. John Wiley and Sons: Chichester.
International Confederation of Midwives. (2005) Definition of the midwife. International Confederation of Midwives Council meeting: Brisbane. Quickening September/ October: 3.
Jacobson B, Bygddeman M. (1998) Obstetric care and proneness of offspring to suicide as adults: a case control study. British Medical Journal 317: 1346-9.
Johanson R, Newburn M, Macfarlane A. (2002) Has medicalisation of childbirth gone too far? British Medical Journal 321: 892-5.
Jordan B. (1993) Birth in four cultures: a cross-cultural investigation of childbirth in Yucatan, Holland, Sweden and the United States. Waveland Press: Prospect Heights, US.
Kershaw B. (1992) Nursing models: In: Jolley M, Brykczynska G. (Eds.). Nursing care: the challenge to change. Edward Arnold: London.
Kirkham M. (1996) Professionalisation past and present: In: Kroll D. (Ed.). Midwifery care of the future: meeting the
challenge. Bailliere Tindall: London: 164-201.
Kirkham M. (1999) The culture of midwifery in the NHS in England. Journal of Advanced Nursing 30: 732-9.
Kirkham M. (2000) The midwife-woman relationship. MacMillan: London.
Kitzinger S. (2000) Rediscovering birth. Little Brown and Company: London.
Leap N. (2000) The less we do, the more we give: In: Kirkham M. (Ed.). The midwife-mother relationship. London: MacMillan: 1-18.
Lipsky M. (1980) Street-level bureaucracy: dilemmas of the individual in public services. Russell Sage Foundation: New York.
LoCicero AK. (1993) Explaining excessive rates of caesareans and other childbirth interventions: contributions from contemporary theories of gender and psychosocial development. Social Science and Medicine 37(10): 1261-9.
McCourt C, Pearce A. (2000) Does continuity of carer matter to women from minority ethnic groups? Midwifery 16(2): 145-54.
NMC. (2004) The NMC code of professional conduct: standards for conduct, performance and ethics. NMC: London.
Odent M. (2001) New reasons and new ways to study birth physiology. International Journal of Gynaecology and Obstetrics 75: S39-S45.
Page L, McCourt C, Beake S, Hewison J. (1999) Clinical interventions and outcomes of one-to-one midwifery practice. Journal of Public Health Medicine 21(3): 243-8.
Perkins B. (2004) The medical delivery business: health reform, childbirth, and the economic order. Rutgers University Press: London.
RCM. (2002) Vision 2000: into practice. Toolkits 1 to 7. RCM Publications in Wales: Cardiff.
Saks M. (1992) Alternative medicine in Britain. Clarendon Press: Oxford.
Sandall J. (1997) Midwives’ burnout and continuity of care. British Journal of Midwifery 5(2): 106-11. Schumacher E. (1974) Small is beautiful. Abacus: London.
Stein L. (1967) The doctor-nurse game. Archives of General Psychiatry 16: 698-703.
Walsh D. (1999) An ethnographic study of women’s experience of partnership caseload midwifery practice: the professional as friend. Midwifery 15(3): 165-76.
Walsh D. (2005a) Professional power in maternity care: the many faces of paternalism: Birthwrite. British Journal of Midwifery 13(11): 708.
Walsh D. (2005b) Subverting assembly-line birth: childbirth in a free-standing birth centre. Social Science and Medicine 62(6): 1330-40.
Wilkins R. (2000) Poor relations: the paucity of the professional paradigm: In: Kirkham M. (Ed.). The midwife-mother relationship. MacMillan Press: London: 28-54.