From MIDWIFERY MATTERS, Issue No. 100, Spring 2004
A Culture of Fear: The midwifery perspective
Astrid Osbourne, Consultant Midwife.
Elizabeth Garrett Anderson and Obstetric Hospital, University College London
Why are midwives often accused of not meeting the needs of ordinary women? Reports
over recent years from hospital
complaints services and consumer organisations like AIMS (Association for Improvements
in Maternity Services) and the NCT
(National Childbirth Trust) clearly demonstrate that complaints about midwives
are increasing. How can this be when
midwives are generally caring people? They are mainly women and many have also
experienced childbirth and motherhood.
Yet when ordinary women speak of their needs and preferences our maternity services
often let them down.
How can this be happening? We have a profession that is led by midwives, governed
by midwifery supervisors and trained
by expert midwives. It is difficult to comprehend that we have such a problem.
I want to explore the reason for this and I'll
begin by examining our history. Understanding how we arrived at where we are,
should help us to see more clearly where we
are going. Understanding our past may provide us with an incentive to be more
pro-active in shaping services that are women
centred in our future.
In 1946, prior to the start of the National Health Service, the Royal College of Obstetricians and Gynaecologists commissioned a birth survey. 50.2% of the 15,130 women asked reported that they would prefer a home birth. A further 16% would have preferred home birth if their home conditions were better (Campbell and Macfarlane, 1994). This was the last socially focused survey for many years, the surveys of 1958, 1970 and 1984 focused on medicalised birth outcomes and were not evidence based.
However, the survey by the expert maternity committee in 1992 showed that 72%
of women would have liked to be
offered an alternative to doctor led care in hospital. Of these women 44% preferred
home birth. This survey formed the basis
for Changing Childbirth (DoH, 1993). It is interesting to note that after half
a century of medicalised childbirth, that around 50%
of the childbearing population have remained in favour of birth in a social
setting. The reality is that only between I- 8% of
women in the United Kingdom achieve a home birth.
Medicalisation of childbirth,
What has happened to midwifery during this half a century of medicalisation?
There are several factors to consider. First,
powerful pressures have eroded the autonomy of the majority of midwives. One
of the pressures came from punitive
supervision by doctors and this contributed to the 'blame' culture that we find
so difficult to dispel to this day. When midwifery
was recognised as a profession in the UK in 1903, midwives were 'supervised'
by medical men; safety was cited as the main
reason for this. A second pressure is the development of care systems that distort
the way that midwives think; for example
the seductive power of active management of labour. The Dublin experience (The
Active Management of Labour, Kieran
O'Driscoll, I st edition 1980, O'Driscoll et al, 1993) introduced more than
the augmentation of labour; it heralded a new labour
ward culture which gave the control to those who supplied the care. Professional
control of the length of each stage of labour
involves a complex process of monitoring, drug giving and intervention. Hunt
(1995) speaks of a powerful labour ward
hierarchy where medical treatment and technology control the actions of midwives
and women remain alone, firmly at the
bottom of the pile. This is probably best described as the opposite to 'being
with woman' and is a long way from the spiritual
philosophy of midwifery care.
We could just say that midwives are the victims of a powerful and wealthy medical
industry - itself a collusion between
medicine and machines. It is true that many midwives are led by and enjoy medicalisation
and there are those who, far from
being victimised by the present system, embrace the 'rescue' philosophy of medicalised
childbirth. Hunt (1995) did find that
many midwives actively hide behind technology, to avoid reaching out emotionally
to the women in their care.
The greatest pressure is on new midwives, the next generation. They need to
be aware that their training system clings to
medical control while paying lip-service to women centred care. When midwives
fail to forge successful partnerships with
women not only do they disempower women but they disempower the next generation
of midwives who are looking to them
as role models.
The social context of birth
When the medicalisation of childbirth began, medicine thought that it had the
answers to many childbirth problems which
have since found to be socially rooted. For example, there is evidence to support
that the poorer women are, the more likely
they are to suffer from a whole range of illnesses. Childbirth complications
are just a small part of the social deprivation cycle
(Townsend et al, 1992). Increased medicalisation of childbirth has done nothing
to address the deep rooted problems
associated with poverty. Oakley et al (1996) demonstrated the importance of
social support and providing care that is centred
on women and their families. Many midwifery schemes have added weight to this
research demonstrating better outcomes when
known carers support women throughout their whole childbirth experience (Page,
2003).
Exploring, monitoring and reporting adverse outcomes has a major influence on
the practice of both doctors and midwives.
An interesting study by Julia Allison (1996) compared the outcomes of midwifery
led care versus medical hospital care from
1948 until 1972. The study focused on Nottingham at a time when equal numbers
of women were looked after in each care
system. The outcomes for the women cared for in the community midwifery system
were as good and often better than the
outcomes for women who were cared for in the hospital system. There were no
great differences in obstetric emergencies
and stillbirth rates.
Yet in 1970 the Peel Report (DoH, 1970) said: We think that sufficient facilities should be provided to allow 100% hospital delivery. The greater safety of hospital confinement for mother and child justifies this objective. At a time when midwives were performing so well that women birthing in their own communities had outcomes similar to those in hospital, they were informed that midwifery care was risky and childbirth needed medical support to be safe. From a feminist point of view Figes (1996) describes this phenomena as 'medical fascism', a component of patriarchal control that coerces women into medical services for the perceived greater good of the family and the fetus. We must not lose sight of the fact that midwifery is traditionally a female profession and, therefore, also susceptible to patriarchal forces.
Since 1970 innovative midwives have sought to provide evidence that convinces
us as midwives and women that the Peel
report may have got it wrong. However, to further compound the theme of the
Peel report was an unsubstantiated statement
by the Government Maternity Services Advisory Committee in 1984;
The practice of delivering nearly all babies in hospital has contributed to
the dramatic reduction in stillbirths and neonatal deaths and to the avoidance
of many handicaps. This statement was made at a time when the improved social
status of the nation was not recognised as a huge contributor to health and
wellbeing. The divide between rich and poor had not been identified in terms
of health and childbirth outcomes. Further there is no acknowledgement that
cerebral palsy remained at 2 per 1,000 births
throughout the twentieth century (Banks, 1998) despite increased medical intervention.
Can we conclude that medicine has manoeuvred midwifery into submission? The
complaints and reports from women
might make us think so. As a practising midwife I hope not! I believe that we
are in a new era for midwifery care, a post
Changing Childbirth era that acknowledges the gaps in both midwifery expertise
and lack of confidence. There are many
midwives nationwide who are working upon a strategy that seeks to support, encourage
and empower midwives and the
women in their care; a strategy that listens to women and reacts to their needs.
Empowering Midwives to Make a Difference
Midwives can be empowered to be 'with women' by several routes. As a profession
we are lucky to have a supervision
structure in place that is now far from punitive. The system is more democratic
than at any time in midwifery history and helps
midwives to draw on their strengths. Take this process a step further to mentorship,
peer support and reflective practice and
we are moving successfully away from the old blaming culture that has suppressed
the practice of many midwives. The second
and essential component of rebuilding practice is the importance of having easy
access to learning programs that enhance care
and encourage audit of care, organisations need to be prepared to help with
provision of this. We must accept as a profession
that learning is life long and that it is a powerful force that works for the
individual, the women and the profession. Midwives
should be supported to learn and relearn both by funded education programs that
do not hit the individual's pocket and by
active clinical midwifery leadership. Midwives who have up to date knowledge
are more aware and less fearful of the ever-
looming spectre of litigation and risk.
Midwifery leaders are called upon to do more than manage a service. A diversity
of leadership roles are emerging as we
acknowledge that practice requires greater and more innovative forms of leadership.
Midwife leaders are not just holding Head
of Midwifery posts; there is a need to support and examine practice and this
requires diverse methods of support and
leadership. The current methods of support are by embracing practice development
roles, public health roles, research,
collaborative working and consultancy.
Midwifery is moving into its own once again, or at least it is well on its way
to make its mark for women in the twenty first
century. For the first time since the medicalisation of childbirth, midwifery
has a clear opportunity for reclaiming childbirth in
midwife led settings. Don't loose heart, remember that right now most women
still prefer midwifery care; it's up to us to make
sure that it stays that way.
Allison J (1996). Delivered at Home, Chapman & Hall, London.
Banks M (1998). Breech Birth Woman -Wise. Birth Spirit Books, New Zealand.
Campbell R and MacfarlaneA (1994). Where to be born.The Debate and the Evidence.
2nd Edition. Oxford National
Epidemiology Unit.
Department of Health (1993). Changing Childbirth, The Report of the Expert Maternity
Committee, HMSO.
Department of Health (1970). The Peel Report HMSO.
Figes K (1994). Because of her sex: the myth of equality for women in Britain
Macmillan, London.
Hunt S C and Symonds A (1995). The Social Meaning of Midwifery. Macmillan, London.
Oakley A, Hickey D and Rajan L (1996).'Social support in pregnancy: does it
have long term effects?' Journal of
Reproductive and Infant Psychology, 14, 1,7-22.
O'Driscoll K and Meagher D (1980). The Active Management of Labour, Balliere
Tindal!, Eastbourne.
O'Driscoll K, Meagher D and Boylan P (1993). Active Management of Labour: the
Dublin Experience. Mosby, London.
Page L (2003). 'One-to-one midwifery: Restoring the 'with woman' relationship
in midwifery', Journal of Midwifery and
Women's Health, 48,2, 119-122.
Townsend P, Davidson N and Whitehead M (1992). Inequalities in Health. New Edition.
Penguin, London.
LW updated February 4, 2005