A Grumpy Old Woman Considers What Women and Midwives Need and Why They Won't Get It
I am a retired midwife and member of ARM and I live in London, but I am not a member of the London group since I am severely disabled and essentially housebound by multiple sclerosis. This puts me in an anomalous position. What I know about the situation in the maternity services currently I have either learnt from the mass media or from a good friend of mine who is an independent midwife. Whether this perspective has any merit I do not know. It may be that this position provides a useful perspective, in the way that new students may ask a naive question which brings up first principles which have been held for a long time without examination. So what I am about to say is not bound by long-held assumptions and it may seem extreme.
It is difficult for me to access precise references, however everybody referred to will be googleable. Midwifery Matters is not an academic journal and I quite like the idea of producing a primordial soup of speculation out of which testable hypotheses may grow. The hypotheses will be not to do with midwifery but social psychology which is my first subject.
On a very basic physiological level women need to be as healthy as possible and I believe the basis of this health is good nutrition and a reasonable amount of exercise. Swimming and yoga are good. I feel I need to mention this for the sake of completion, but my concern here is primarily with the socio--psychological and political.
What I believe women need is unbiased information so that they can make informed choices about their care. They need professionals, both midwives and obstetricians, who are skilled in the range of practices they may be required to undertake to meet those choices; professionals who understand that if women are to make informed choices they may make different choices from those that they would prefer and who are prepared to defer to women's choices; who understand that if they do not they are essentially guilty of assault. They need professionals with good communication skills who can express themselves clearly in whatever register is required to meet the level of understanding of their clients and who can listen and be prepared to hear what they may not want to hear. They need professionals who are well enough resourced, both financially and emotionally.
What midwives need are all the resources implied above. There should be quite simply sufficient numbers to provide a high quality service: one where each client had her own individual qualities recognised and could receive individual care antenatally, in labour and postnatally. It is most unlikely that these resources will be allocated because the NHS, essentially, is being broken up. Hospitals and primary care trusts are being invited to apply for foundation status. This will give them greater autonomy when it comes to commissioning services and financing them. In order to be granted foundation status trusts have to demonstrate that they are economically prudent. One Foundation Trust in Essex has recently been discovered to have been so economical there was a trolley mattress soiled with excrement, privacy curtains spattered with blood and a suction machine growing mould. It has been decades since cleaning staff were employees of the NHS. Competitive tendering gives services to those who are the cheapest and these are frequently agencies who have no compunction about using staff whose residential status is dubious because they can be fobbed off with less than the minimum wage. Given this kind of intellectual climate it is unlikely that trusts will choose to employ sufficient midwives to offer sensitive, individualised, one-to-one care if they can get away with employing one midwife to read a number of CTG printouts.
Midwives, like their clients, need to be respected. They are, or should be, autonomous professionals whose practice may not meet the default routines of the institution because they are meeting the choices of their clients. The Midwives Rules and Code of Practice make it clear that their priority should be the well-being of the childbearing woman and her baby. Well-being includes not only the biomedical but the psychological, social and spiritual. They need a level of education such that this is not unthinkable. Midwives need support from their supervisors, who should not have their supervisory role confused with managerial responsibility. Midwives need obstetricians to recognise them as possessing a specific expertise which is equal to and different from their own.
Neither women nor midwives get what they need. What they get is a hierarchical institution where their individual needs are subordinated to those of the institution, where they are persuaded or coersed with various degrees of subtlety to conform.
I started training as a direct entry midwife in 1978. Some things have improved for the better and others for the worse. One thing which is distinctly better is that women are no longer given an episiotomy simply because it is their first baby and a cut is so much 'neater' than a tear. Norman Morris's research undertaken at Charing Cross Hospital demonstrating that second degree tears heal better and are less painful than episiotomies seems to have been taken on board.
Some things are definitely worse; some things I find particularly shocking.
I am shocked by the caesarean section rate. I am neither shocked nor surprised, because I am too cynical, by the continuing huge gulf between the rhetoric which students learn and the practice which they are confronted with in reality and expected to conform to. I am aghast at the reintroduction of what I had thought had been abolished before 1980: women giving birth in what is essentially the lithotomy position. And my cynical self notices the way in which evidence is only adhered to if it suits certain purposes of the professionals despite the fact that practice is claimed to be evidence-based. The evidence is that directed pushing is unhelpful because it causes fetal hypoxia but it continues because unnecessary time limits are still frequently policy and so speed becomes an unhelpful priority, staff like to feel they are doing something, and it enables them subtly to bully the woman. The evidence is that continuous fetal monitoring serves no good purpose in terms of reducing mortality or morbidity, it only increases the caesarean section rate, yet it continues to be used. Machines, once bought, are cheaper than human beings and, some believe, are more reliable. They also reduce the need for communication and contact.
There is some research which is well established in the social psychological realm which is simply not taken on board because people find it too difficult. In the years after the Second World War research was carried out on conformity and compliance by theorists such as Milgram, Zimbardo and Asch in an attempt to understand how the nations of Europe had become prey to fascism. This research demonstrates how difficult people find it to stand up to authority or a majority even when it is evidently wrong and how powerful institutional hierarchies are. This accounts in maternity care for the continuation of practices such as encouraging (confining) labouring women to remain on the bed when it is known that altering position facilitates labour and birth. But this knowledge about positioning is derived from midwifery practice and is therefore less prestigious than the research on episiotomy which was carried out by an obstetric professor. So evidence is selected not only for the psychological benefit of the health professional but according to the prestige of the researcher.
Although it may not seem immediately relevant I should like to mention the work on cognitive dissonance carried out by Festinger because I think it is very useful in understanding research findings which apparently demonstrate that women do not value the support of a known and trusted carer in labour. Festinger's work describes how people will change their attitudes in predictable directions in certain contexts. When two attitudes conflict one will need to be changed in order to minimise or avoid the conflict because conflicting attitudes are uncomfortable for a person's sense of self. The attitude that will be changed will be the one which is the easiest in practical terms. In this particular context the thinking would go something like this: I am going to have to give birth in the normal context of the NHS, there is no alternative; I would really like a known and trusted carer, because this would be much less stressful psychologically; it is unlikely that I will have a known carer so I shall minimise the importance this has for me and hope that the carer I have is trustworthy.
Isabel Menzies-Lyth has shown how health professionals will avoid contact when they can and take refuge in task allocation and dehumanisation of the client because it minimises the anxiety of the professional. Health professionals are subject to very high levels of anxiety as a result of the nature of their work. Their work is anxiety provoking because, in medicine and nursing, it involves sickness intrinsically. Both nursing and midwifery involve the taboo: physical contact of a type which can be quite intimate; they involve dealing with excrement and bodily fluids such as blood, sputum, amniotic liquor. In midwifery the emphasis is more on abnormality than it need be because obstetrics is of higher prestige than midwifery so it could be argued that levels of anxiety are higher than they need to be. Paradoxically health professionals find the anxiety of the abnormal easier to tolerate than that of the normal. Acceptance of the abnormal by midwives means delegating responsibility to the medical profession; midwives therefore need not acknowledge that they may bear professional responsibility and doctors are flattered by the status. In all fields death is a possibility. The professionals have their own anxiety to bear; they also have their clients' and their clients' relatives.
I believe that the anxiety intrinsic to maternity is different from that involved in other fields, because to allow things to proceed according to normal physiology requires an ability to tolerate uncertainty and this is so difficult that unnecessary interventions are invoked because it is easier to do something than to do nothing. This accounts for the continuation of what is counter-productive: directed pushing; continuous electronic fetal monitoring; the reintroduction of the lithotomy position, which keeps a woman in one position useful for the professional but not for the mother or the baby since it reduces pelvic capacity; a refusal of midwives to practise at their full autonomy and unnecessary referral 'upwards' to obstetricians, some of whom as senior house officers are still essentially students. It accounted for the unnecessary episiotomies of the years of my training; it accounts for the unnecessarily high rate of caesareans now. The World Health Organisation considers a rate of caesarean section of between 10 and 15% reasonable. When I was training the rate was nearer 5%. Ina May Gaskin has a rate of 1%.
It is possible that many of the women who have caesarean sections prefer this. But what women want may be not the same as what they need. Caesarean sections offer predictability and avoid the animality of giving birth. The recent rise in caesarean section rate has brought with it the idea that certain women are 'too posh to push', often with quite an angry refutation of this. But when I was practising it was notable that those women who used the private Portland Hospital in central London were far more likely to have had a caesarean section than women who used the NHS. I think that at that time it was probably more likely to be the surgeons' choice than the women's, although I do not think that they were reluctant to have undergone surgery. I think some women believed that it reflected their superior social status: they could afford to employ a surgeon and they could avoid the undeniable physicality of childbirth.
Now I do think that there is a reluctance amongst a certain class of woman, well educated and professional, used to exercising autonomy and having their wishes met, to undergo the unpredictability of the nature of normal labour. When will it start? How will I know when it has started? How long will it last? How much will it hurt? What will the birth be like? Twenty or so years ago a wonderful book of women's birth stories was published under the title of Every Birth It Comes Different. Tolerating the unpredictability and the difference can be very hard. And women now are encouraged in certain circles to believe that their physical attributes can be altered surgically. Procedures which I find terrifying are embraced for reasons which I find trivial. In the late eighties I was told that there was a billboard in the United States which read: have a caesarean and keep your passage honeymoon fresh. This seemed shocking and laughable to me at the time but now apparently some women are having caesarean sections accompanied by liposuction. I appreciate that this is an expression of personal ethics, but I believe that motherhood is probably the most important work there is because it influences so profoundly the entire nature of the child's psyche and in comparison with the importance of this work to be so concerned about one's physical appearance is a manifestation of seriously skewed values.
Caesareans are major surgical interventions which necessarily involve cutting through the muscles of the abdomen and the uterus. There is the risk of wound morbidity. I believe it has been recommended that women should take prophylactic antibiotics to avoid this, however antibiotic use has its own risks in terms of unbalancing the body's own ecology. They require anaesthesia which, even if it is not general anaesthesia, still carries some risk to the mother. General anaesthetic carries the risk of respiratory shock which may lead to death. In pregnancy there is the increased risk of Mendelssohn's syndrome because of the effect of progesterone relaxing the cardiac sphincter. Epidural anaesthesia can cause paralysis. With surgery there is a risk of haemorrhage, which on occasions is so bad that women need a hysterectomy to control it. Caesareans also carry risks to the baby: the possibility of laceration by the scalpel, the denial of the helpful compression of the baby's chest by the birth canal in the initiation of respiration. There is more. Many women do not know this. When it comes to informed consent women are very seldom informed about the risks of hospital admission or obstetric procedures.
The reason for the high level of caesarean section is complex. There have been suggestions from the Department of Health that the caesarean section rate needs to be reduced for reasons of physical benefit to both women and babies, and expense. Yet there is no sign of any reduction, at least in the south of England, especially London. I believe that some are carried out because the women prefer them. I believe that some are carried out because the professionals prefer them: they avoid unpredictability for the professionals as well, they can be timed. I predict that if the dates and times of caesarean sections are examined it will be discovered that they tend to occur before late afternoon or late evening, especially on Fridays. It is also very likely that they relate to the possibility of litigation. This is a social not a biomedical phenomenon. It is interesting that the fear of litigation leads to the more complex and risky intervention. Perhaps women should sue for unnecessary damage to their abdomens.
Maybe there are occasions when professionals know better. But it may also be that professionals do not know as much about their subject as they should. Ultrasonography and other technological devices have caused a reduction in the skills of palpation and auscultation on the part of both midwives and obstetricians. I do not believe that midwives or women need as much technology as is habitually used. I think that technology benefits obstetricians because it increases the rate of unnecessary interventions. This teaches women and midwives that obstetricians are more important than they are. Early scans, for example, used to indicate low-lying placentas thus increasing anxiety about placenta praevia when it was inevitable that the placenta would have been low-lying at this stage because the uterus was not sufficiently large. (I am assuming that this no longer occurs. I was in the interesting position of practising at a time when continuous electronic fetal monitoring and ultrasound were being introduced, so I know the situation before they were habitually used and I know the misconceptions that accompanied their introduction.) Of course technology also benefits the profits of the companies manufacturing the technology. Low tech does not make money.
It is to the benefit of the medical profession if obstetricians are prominent. And it is to their benefit if unnecessary anxieties are created, because they then need to be assuaged. It is to the benefit of anaesthetists if women have epidural anaesthesia: it raises their status by making them seem indispensable. It may not be to the benefit of the woman or the baby, since epidural anaesthesia tends to lead to operative deliveries and these increase the risk load for both mothers and babies. The medical profession has, I believe, an unhealthy relationship with both the pharmaceutical industry and the various technological industries. That which creates profits is not necessarily what either women or midwives need.
There is something unspoken in the above which is very seldom articulated and this something concerns power relationships. The medical profession is more powerful than midwives who seem so lacking in comparative power that I have found it impossible to use the word 'profession' here. Medicine, together with law, is probably the most prestigious profession. It is understandable, though not creditable, if midwives compensate for their lack of relative professional power by being over officious with their clients, if not actively bullying them. This set of power relations is one reason why women do not get what they need and I would maintain that midwives will not get what they need until they ally themselves with their clients, rather than the medical profession.
Perhaps what I am saying is that what women and midwives really need is a change in the psycho-political, a real recognition and taking on board of the findings demonstrated by those social psychological studies after the Second World War. If this were to happen, and there is no evidence that it ever will because it has not thus far in any sphere, there would not be any hierarchical distinctions between childbearing women, midwives and obstetricians because members of each group would have the confidence and courage to express themselves assertively to each other and sufficient mutual respect to listen to each other. This would be a revolutionary change in social, psychological and political well-being.