I studied social psychology between 1971 and 74 and then for a masters degree in psychopathology. This introduced me to the work of Klaus and Kennell on the interaction of mothers with their newborn babies. This work touched me deeply. Also about this time, the mid-1970s, there was much discussion in the media about the medicalisation of childbirth: the increasing rate of induction of labour, the demise of direct entry courses for midwifery training and the newly formed Association of Radical Midwives. These influences came together and I wondered if, since I believed that early relationships were vital in their influence on later mental health, good midwifery could be a kind of preventative psychotherapy. I became a student on a direct entry course in 1978 and qualified in 1980.
I would never have completed the course without my fellow students: Sue Blennerhassett, Avril Levi, Alison Forward (known then as Alison Hughes) and Sarah Rose. Like the original founders of ARM I was shocked by the authoritarianism of the practice and the mindlessness of the teaching. We were addressed by our surnames and expected to learn things by rote and not question what was evidently extremely questionable (examples: if women do not eat liver during pregnancy they will become unhealthily anaemic; all first-time mothers need an episiotomy and a previous episiotomy is an indication for a subsequent one). It evoked distressing memories of my four years at Christ's Hospital. But from the fellow students in my set and Nicky Leap who was a student the following year I learnt a lot about feminist theory and practice.
I practised for seven years, in both hospital and community. In 1987 I gave birth to my first son and decided that the statutory maternity leave was incompatible with the kind of care I wished to give him. I had been training as a psychotherapist and, after a diagnosis of multiple sclerosis in 1985, undertook the unique counselling training at South West London College.
This course which was inaugurated in 1975 by John Heron was entirely peer and self directed and assessed. After our first year, 1987 to 88, it was closed: it required too high a staff: student ratio. A number of us carried the course on, hiring tutors, and after two terms in the second academic year the course was taken up by London University's Institute of Education as an educational experiment. It was closed after, I think, less than five years. I imagine this was because it was too experimental. However, it was the most intense learning experience I have ever undergone, integrating theory and practice in a way I found entirely appropriate for the subject matter.
I worked for two years as district staff counsellor to Tower Hamlets Health District and nine years in private practice as a psychotherapist. I am now retired as a result of the multiple sclerosis.
The births of both my sons, at home, have strongly influenced my understanding of spirituality. I practise Tibetan Buddhism.
These writings are themed, but to some extent this is arbitrary, since the psychological, political and theoretical, also to some extent the sexual, are all intertwined.
There is much repetition in these writings. Some of it is due to lazy copying and pasting, a laziness which was impossible before the advent of the computer. But the impetus behind this laziness reflects something more honourable. There are themes which are repeated because I believe that they are profoundly important and that their importance is insufficiently recognised and that if it were to be recognised and taken on board there would be significant improvements for childbearing women, babies and midwives.
These themes include:
1) The importance of understanding and working with normal physiology. I think it is not unreasonable to say that those midwives who truly understand the physiology of the process of childbirth are in a minority, not only among midwives but among other health professionals including obstetricians. Tricia Anderson, in what I believe was her last column for The Practising Midwife, said in the context of midwives developing greater assertiveness that we, midwives, know what nobody else does. I assume she meant that midwives' knowledge of physiology implies a holistic appreciation of those factors other than the physical which affect physiological functioning.
Routine interference in normal physiology implies that certain important items of knowledge have been lost. There has been a recent recommendation that clamping and cutting of the cord be delayed so that the newborn baby receives the blood which he or she would otherwise have lost. This recommendation would be entirely superfluous if midwives and obstetricians had retained the knowledge of how to manage the third stage of labour without the use of artificial oxytocics. It is almost a research cliché that when childbearing women receive continuity of known and trusted carer the use of pharmacological pain relief is much reduced, the rates of normal birth are raised and post-traumatic stress disorder following childbirth is almost eliminated. The provision of this kind of care demands building a good relationship between professional and client and trust can only be built on informed consent. Informed consent implies that the professional is skilled in the entire range of practices including those which are not based on electronic technology and is comfortable with following the woman's wishes. It is this basis of trust and good communication which leads to positive outcomes. All interventions carry risks; unnecessary interventions therefore carry unnecessary risks and raise the incidence of instrumental and surgical birth with their concomitant complications.
When I read Umberto Eco's description of physiology as the basis of ethics I got very excited because it seemed to me to imply that any intervention causing a deviation from normal physiology has to be justified on ethical grounds. The situation at the moment is that many deviations from the normal are so routine that they are not recognised as abnormal.
2) The importance of Winnicott and the way in which he is the psychoanalytic thinker par excellence for midwifery theory because, unlike other psychoanalysts, his background was not in neurology as Freud's was or psychiatry as Jung's was but in paediatrics where he met children who were sick physically not emotionally. In other words his basis, like that of midwives, was one of normality. He also, very unusually for anybody never mind a psychoanalyst, was a happy person. His concept of primary maternal preoccupation is crucial. I would argue that much of the way in which maternity care is delivered -- and mishandled -- is an attempt to avoid recognising the strength of this relationship.
I regard psychoanalysis not as scientific theory but as an imaginative discourse which is relevant to midwifery because it expresses the way in which psychic processes are learnt as the result of early relationships; midwifery deals with the mother-child relationship from about as early as anybody can. It therefore hypothesises a link between midwifery and psychology which could be profound. It could be seen as providing a level of academic justification for midwifery processes.
I don't think the unscientific nature of psychoanalysis is a problem. I think an imaginative discourse is a good basis on which to justify practice. I think it is evident that much of what is popularly seen as scientific is not so: much of scientific development as driven by commercial concerns and the way in which scientific discourse is popularly described depends largely on journalists not educated scientifically. Given the way in which obstetric intervention in childbirth has not been mitigated in response to research based evidence (had it been, the relationship between obstetrics and midwifery would be very different, since the bulk of research evidence shows that good quality midwifery care causes less morbidity) I think it is evident that obstetrics is no more scientific than a midwifery practice which gives some regard to imaginative discourse. I think that midwifery, while of course it has biomedical aspects, should not be limited to the biomedical but should include the political, social, psychological and spiritual domains as well. (I think that medicine would do well to consider these aspects also.)
3) The reason for the perpetuation of the quasi-scientific in medicine, and its unquestioned dominance as a discourse, has to do with many factors, but one of the most important given that we are concerned with childbearing is that of gender inequality. The medical profession has many more women now than thirty years ago but its norms and mores have not greatly changed and its dominance is intertwined with the powerful financial clout of the pharmaceutical and technological industries. So the third point I am considering here is that of feminism. I consider childbirth to be a feminist issue. By feminism I do not mean gender equality, although I do not consider discrimination on the basis of sex in any way legitimated by this statement. I think that the sexes are intrinsically different and that women's capacity for childbirth is a major part of that difference. I think that this capacity has been one reason why women have experienced discrimination at least since the agricultural revolution and I think that modern childbirth practices, by perverting normal female physiology, are more than discriminatory: they are abusive. I believe that if women were to be truly liberated they would have embraced midwifery skills as part of their general knowledge and would only consult the medical profession when it was truly necessary. This statement seems considerably less reasonable now than it did in the 1970s and it was probably pretty extreme then. But in the intervening 30 years medicalisation has increased to such an extent that parents no longer know how to treat childhood ailments without recourse to a doctor and the caesarean section rates among first-time mothers in many hospitals is now approximately one in three.
The vast majority of healthy, well nourished women in the affluent world are perfectly capable of giving birth to their babies without recourse to any medical intervention. And I want to state very strongly that no pharmacological pain relief is ever to the benefit of the baby. I believe that it is by sundering the profound bond between a mother and her newborn baby that a great deal of discrimination against women can be perpetrated because it instils a profound terror on an unconscious level. I believe that this phenomenon, this discrimination, is not entirely conscious, although aspects of it are. Every time an expectant mother is admonished that an intervention about which she is dubious is 'for the benefit of the baby' in order to induce an unthinking compliance without her being engaged in a reasonable and unbiased discussion of the circumstances the health professionals responsible must surely know what they are doing. In fact I know that they indicate their consciousness of this in the remarks which are shared between themselves in private.
4) I wish to consider another psychoanalyst, but one whose work is concerned with institutions rather than individuals. The work of Isabel Menzies- Lyth on nursing was carried out in the 1950s but I maintain that it has never been superseded and that its importance has never been adequately taken on board. It is relevant to not only the nursing profession but any profession where emotions are intrinsic to the interaction between client and professional. This includes midwifery but also medicine, the law and even such mundane and low status interactions as buying milk. But of course buying and selling milk is unlikely to lead to post-traumatic stress disorder whereas childbearing women who are treated inhumanely, and a large proportion of them are, at a time when they are exquisitely sensitive may be not only wounded themselves but their wounded condition can impact on the next generation.
Isabel Menzies-Lyth was asked to observe the situation in a well-known London school of nursing in order to try to establish why their level of staff retention was so poor. She noticed that the work was conceived and allocated in such a way as to minimise the extent to which the nurses related to their patients as three-dimensional human beings. She postulated that this reduced the extent to which the nurses, who as a profession dealt most closely with the patients, needed to take on board the patients' anxiety, that of their relatives or indeed themselves in circumstances which were intrinsically highly anxiety provoking. She described how institutions are structured in such a way as to bolster individuals' psychological defences. I maintain that this intermeshing of institutions and individual defensive structure is very powerful. When it also is perceived as financially beneficial then it is almost impregnable. But it is so powerful that even when it is financially more onerous, as the present institutions of childbirth are when compared with, for example, case holding midwifery practices, it is still preferred.
I believe that the biomedical model of childbirth is counter-productive to the provision of good care. Its dominance is bad for women and their babies. It is a paradigm which does not suit the phenomenon of childbirth which is multifarious and cannot be reduced to the physical. Of course the physical is profoundly important and medicine can be life-saving. But medicine has always overstated its case. The cause of most of the reduction in mortality generally and in childbirth in particular has been due to an understanding of the transmission of infection, in other words good hygiene; the provision of clean water and sanitation and good nutrition. Childbirth includes that which is deeply emotional, cultural, political, sexual and spiritual. It is too important to be reduced to a set of rigid protocols and routines.