Chapter - Birth and spirituality in Soo Downe (ed) Normal Childbirth: evidence and debate

Jennifer Hall MSc RN RM ADM
Midwifery Lecturer, University West of England, Bristol
Clinical Editor, The Practising Midwife

Meg Taylor BSc, MSc, SCM, Dip Couns
After studying psychology I became a direct entry midwife and worked for the NHS in both hospital and community. I then trained as a counsellor and have worked both in the NHS and privately. I am now retired due to secondary progressive MS.

Holistic care.

In recent years the aim to provide holistic care, to regard the individual as 'whole' and 'complete', has been part of midwifery and nursing culture. The implication of this is that a person is to be regarded as a combination of physical, emotional and spiritual aspects at least; (1, 2, 3) others suggest this should also include intellectual and social aspect as well (4). (Figure 1) However Goddard (5) has argued that this potential separation into parts may be in itself reductionist and conflicts with the need to care for people as a whole.

Davis-Floyd (6) suggests that the aim to give holistic care may be too great a challenge in institutions that are technologically orientated. Yet, at the ccurrent time in the UK the expectation that any care given will be holistic in orientation remains a part of midwives' Rules of Practice, with the assumption that the training of midwifery students will prepare them to have 'the ability to assess, plan, implement and evaluate care within a sphere of practice of a midwife to meet the physical, emotional, social, spiritual and educational needs of the mother and baby and the family' (7). The 'Requirements for Pre-registration Programmes'(8) states that within training courses for midwives 'the emphasis must be on the provision of holistic care for women and their families which respects their individual needs, contexts, cultures and choices.' This is further expanded in the competencies for entry to the register for midwives by stating that midwives must 'practise in a way which respects and promotes individuals' rights, interest, preferences, beliefs and cultures'This will include ensuring that women's labour is consistent with their religious and cultural beliefs and preferences and acknowledging the roles and relationships in families, dependent upon religious and cultural beliefs, preferences and experiences' (8).

The Midwives Alliance of North America (9) addresses this within their Core competencies for Midwifery practice by stating: 'D. Midwives understand that physical, emotional, psycho-social and spiritual factors synergistically comprise the health of individuals and affect the childbearing process.'

It is clear from these regulations for midwifery practice that spirituality is regarded as important for women and their families and subsequently for their carers. They carry assumptions that those who train midwives will know what spirituality and spiritual need is, how it can be assessed and implemented and how to teach it. (10)

An assumption must therefore be made that midwives will already be providing this care.

Throughout the last century over 1200 studies investigated the connection between religious belief and health (11). Many have shown a positive relationship between having religious faith and aspects of health, although the quality and methodology of some of the studies have been questioned. In recent years there has also been an increase in the number of books relating spirituality to different health disciplines (4, 12, 13, 14, 15, 16, 17). There is a clear indication from this literature that spiritual issues are thought to be of relevance in relation to health care. However the spiritual aspects of midwifery and childbirth are generally disregarded with the focus of care, education and research being applied to the physical, emotional and social issues experienced by women and midwives within the maternity services (14). This apparent lack of interest in spiritual care at the beginning of life is surprising considering the wealth of literature and understanding of spiritual need among those who give care to the dying. The purpose of this chapter is to explore some of the issues of spirituality and spiritual care in relation to the normality of childbirth and encourage discussion about how the focus of our practices may include these issues in the future.

What is the nature of spirituality?

In order to explore spiritual issues in relation to childbirth there needs to be an understanding of what they are. Many people assume that religious belief is necessary as a foundation for spirituality, and therefore that those without religious beliefs have no spiritual experiences or needs. This is reflected in the methods of assessment and history-taking where such questions are limited to finding out the religious denomination of the person, rather than taking time to assess the nature and depth of their belief (1, 19). In contrast Totton (20) suggests that spirituality and religious practice are quite different. He distinguishes the two by stating that spirituality always involves an enlightenment practice. By this he means 'one necessary feature is that an actual practice is involved: not just a theory or belief but a technique or a set of techniques, aimed at creating some sort of change in persons'. The shift that is attempted can be described and conceptualised in many ways. But perhaps all the practices I am considering might agree that it involves a radical lessening of anxiety: a profound relaxation which follows from a reappraisal of our situation as human beings. (131-2). This shift within a person can sometimes be tumultuous and has been labelled spiritual emergency (21, 22)

Totton's emphasis may be exclusive of those who are unwilling to engage in such practice. A more inclusive approach to spirituality may be one which focuses on each person's experience. If we are to regard each person in the terms of wholeness and completeness, as indicated by the principles of holistic care, there is potential for a spirit in all humans and the expression of this aspect of life may come in many forms. In establishing the links between the physical, emotional, and spiritual aspects of a person, McSherry (13) argues that 'spirituality pervades all dimensions of one's existence in a meaningful and intricate manner, whether there is a conscious awareness of this or not.' He further indicates that the spiritual dimension of a person's life exists even if the person's intellect or psychological abilities are not functioning. Dombeck (23) suggests that 'the spiritual issues in a person's life are at the core of all other issues' and as a consequence 'small changes in one's spirit can affect radical change in all aspects of one's life.' This is demonstrated in Swintons (4) model (see Figure 1 above), which illustrates the interdependence of five dimensions of the person and the spirit.

Burkhardt and Nagai-Jacobson (17) clarify that the root of the word spirit is the Latin word spiritus, meaning breath, and that the Greek word for breath, pneuma, is a reference to the soul. They state that 'The soul animates all that we are and do.' It is clear that this implies a need to understand considerable complexity in the relationship of spirituality to people's lives. It could be asked then how credible is it even to attempt to produce a definition which covers every belief, non-belief, religion, culture, gender, creed, ethnic group, social situation.

If we examine the studies on spiritual issues in relation to health care we see that the definitions contain many similar elements that could be associated with spirituality within a person and in the provision of spiritual care (14). (See Tables 1& 2) A question arises whether evidence of one of these elements is sufficient to define spirituality or whether a number of them have to be present in order for a person to be thought of as 'spiritual' (14). How anyone expresses spirituality will be affected by their social, cultural and historical background (24, 25). Tanyi (26) has provided one definition that aims to encompass every person in its framework: 'Spirituality is a personal search for meaning and purpose in life, which may or may not be related to religion. It entails connection to self-chosen or religious beliefs, values, and practices that give meaning to life, thereby inspiring and motivating individuals to achieve their optimal being. This connection brings faith, hope, peace, and empowerment. The results are joy, forgiveness of oneself and others, awareness and acceptance of hardship and mortality, a heightened sense of physical and emotional well-being and the ability to transcend beyond the infirmities of existence'.

This definition illustrates by its vagueness the problem of trying to create definitions in words that will be inclusive of everyone. It also does not adequately address the relation of spiritual issues to a person's bodily and emotional functioning.

Most studies into spirituality do not distinguish between men and women in the populations investigated (14). It is not known to what extent gender is relevant in shaping spirituality, though some women have argued that women's experiences have been viewed from a patriarchal perspective (27, 28). Gender stereotyping should, of course, be avoided (29). but some writers have attempted to suggest characteristics of spirituality that may be specifically applicable to women. (See Table 3) While intuitive knowledge has been suggested to be a specifically feminine trait (30,31,32,33,34,35) it is not exclusive to women and Swinton (4) states that 'intuition and feeling form a significant aspect of the ways in which human beings make sense of large parts of their experiences'. The culture of modern health care requires evidence based knowledge and intuition does not lend itself easily to quantification. There is a risk that the contrast of the unquantifiable with the medical paradigm may lead to further gender stereotyping with intuition written off as specifically feminine and evidence of women's difficulty in reasoning (36) .Women's spirituality may also be viewed in relation to the physical cycles which women experience and this may lead to women being more open to the 'intuitive, unplanned and nonrational, leaving room for the unexpected' (17). However rather than a deficit in reasoning which has to be compensated for, this could be seen as an advantage.

If we are to apply an awareness of spirituality to women and their families it is necessary to engage in a women-centred approach with each person treated as an individual and their needs and aspirations addressed accordingly (14). It may also be advisable to stop trying to research spirituality as a separate entity, and instead research people's lives as they are, recognising their complexity and seeing spirituality as part of the whole of their existence (23).

Spirituality and childbirth.

How can spirituality be placed within the context of normal childbirth and what are the implications for all those who are part of this experience? It is currently written in the Midwives' Rules that spiritual care should be provided (7) but it is not always included as a framework of care or within educational programmes (37). However historically midwives were involved in giving spiritual care to women during labour (38, 39, 40), and it has been suggested that they learnt to avoid drawing attention to their role in spiritual matters to ensure professional survival when the powerful Christian Church tried to maintain control. The role of being a midwife was seen as being influential and powerful (39).

A midwife's role has changed since the large scale move of birth into hospitals in the 1970's, and rising caesarean section rates worldwide reveal the extent to which birth has become entrenched in a biomedical model (6, 41, and 42). Furthermore the social structure in which women in the western world live has become far more complex. Technological developments have had a profound psychosocial impact on attitudes affecting women's perception of birth. The speed and range of new technologies have contributed to an intolerance of delay and a sense that much that was previously seen as beyond human control can and should be manipulable. To some extent it is now an 'instant' world, where the expectation is to have what is desired immediately, with as little waiting as possible. Instant access to information and communication via the internet and cable and satellite television has increased the amount of choice at the touch of a button. Such altered expectations have subsequently changed the expectations of the women who enter the maternity services. Their potential tolerance for 'waiting' whether for appointments or even the birth of a baby may be lowered; the expectation of a positive experience may be raised. The excessive use of technology to speed up all aspects of birth exacerbates a pre-existing tendency to separate carer and the person being cared for as the carer focuses more on the machine and this creates a distance (6). The ability of women to glean knowledge and information about their care is much increased and the expectation of the type of care they should receive is altered.

It has been suggested by some psychologists that one of the major psychological tasks of pregnancy is to first identify with and then distinguish oneself from the baby (43). Some modern technological developments, such as mobile phones and text messaging, may impact on this by reducing one's ability to tolerate separation and delayed gratification. The sociological issues raised here may reflect a culture of fear that pervades society and the lack of trust in us and in each other (44). A concomitant fear of natural processes will impact on women's attitudes to giving birth. The concept of this fear and the associated risk women experience when coming to give birth is explored later but it is enough to say now that understanding the background culture women are coming from is helpful when we reflect on how difficult it may be to introduce the concept of spirituality. It will need a major change of philosophical approach to birth by women, by midwives and other carers in order to encourage the recognition of spiritual need. However, if we are to accept that birth is a normal, natural physiological process and that a woman needs to be cared for in a holistic, woman-centred way we must recognise her personal understanding of her spiritual needs and aspirations. If we address the elements identified in Tables 1&2 it is possible to see how these may be applied to the care of pregnant women.

Effect of Spirituality on mothers.

Birth is a powerful, meaningful event for women whether they have a normal birth or not. Richards (45) highlights birth as being 'one of the most powerful forces on earth and certainly the most powerful that can occupy a human body.' If women spend the time telling their birth stories they often do so in the language and framework of a spiritual experience (46,47) and they use terms such as 'holiness' and 'miraculous' (15,28). The reality of experiencing pregnancy and motherhood may provide the opportunity for discovering personal significance and growth which may in turn be regarded as a spiritual event (15, 47,48,49,50,51,52,53,54,55,56). It is suggested that for those with a religious belief the birth experience may bring them closer to the Higher Being they believe in. For example Baumiller (57), states: 'Bringing a new person into the world for whom one has responsibility must cause a great feeling of closeness with God and the infinite love that is co-creating a human being whose destiny is in God's and her hands.'

Do all women have a spiritual experience during birth and some not recognise it? Does this require a 'normal', natural birth and if women have a totally 'normal' experience will they always have a spiritual experience? Can women who have an inherently technologically managed birth still regard it as an opportunity for spiritual growth? Birth as an event is full of symbolism and ritual behaviours (24, 58, 59, 60), and has the potential to be life changing. The implication from this is that a woman cannot go back. In many cultures birth is regarded as a rite of passage, a time when a woman moves from one social state to another. She may also move from one spiritual state into a state of greater awareness (15). However a number of individual issues may influence the meanings a woman gains from her childbirth experience. For example these could be culture, age, parity, personal experience and religious faith or spiritual beliefs (54).

These factors may impact on a woman in a small or great way depending on her social situation. The depth and richness of this experience will be dependent on her background and previous life challenges as well as her beliefs.

The development of a search for meaning and purpose in life appears to be a significant element within a person's spiritual experience. In Klassen's (15) study of religious women in America who gave birth at home she established that they gave meaning to home as the place of birth, their bodies as the basis of new life and their pain as the trigger of physical and spiritual power (p216).

Pain as a spiritual experience.

These particular women chose to give birth at home away from the technological environment of hospital and were generally willing to experience the pain as a source of growth. The pain co-existed with a sense of pleasure in feeling the sensations and power of the birth, and the satisfaction of being able to endure the labour. Elsewhere the pain of childbirth has been described in the terms of being positive and 'normal' (61). Some women perceive the pain as bringing a greater closeness with their new baby or giving them more strength to cope with their new role as mother (62). For those women with a religious belief the sense of openness may lead to a greater closeness to their God (14). The inability to escape from the power of the pain has been described as being 'useable' leading 'beyond the limits of the experience itself' (51). Taylor (56) takes this further by relating it to the closeness of the experience to the boundaries of death: 'To give birth one needs to go through the pain of labour, to survive the darkness and the fear, which is the fear of death. To go through this easiest requires acceptance, an opening to the experience, which is also an opening of the cervix.'

If the meaning of the pain is as intense and deep as this it is perhaps not surprising that some are fearful of experiencing such opening of themselves and seek to have the pain removed from them by analgesic or anaesthetic means. There is a delicate balance between pain relief interfering with the natural process of labour and the relief of enabling a woman to regain her personal level of control.

In order to be so wide open in the emotional and spiritual sense as well as physically, to be so totally vulnerable, a woman requires a place of safety. It means she needs to feel safe within her physical environment and with the people with her if she is to be able to truly let go of who she is and open herself up to what she will become. Odent (63) describes this as a 'period when the mother behaves as if she is 'on another planet' cutting herself off from our everyday world and going on a sort of inner trip.' To be able to establish such a change in a level of consciousness requires the women to trust the carers who are with her and for the carers to understand that this is part of the process of a normal labour. There is a paradox here in that women need to have sufficient control of their own labour to be able to feel safe enough to lose total control. Some women, in order to ensure a place of safety when they do not entirely trust their caregivers find methods of putting themselves in situations where they can avoid 'being interfered with' by the midwives, for example in a birthing pool where they can float away from the side (64). The degree of safety will be enhanced if the woman and her caregivers have had an opportunity to build up a relationship with each other before the event but it will be hindered if the birth attendant does not have knowledge of the 'normal' physiological processes of birth or tries to control the situation to meet her own needs (6, 63). There needs to be an understanding of the rhythms and breathing patterns women experience within a normal physiological labour and a 'letting go' of power and control to the woman's body. For some of the women in Klassen's (15) study this control was experienced as submission of themselves into the hands of a Higher Power in relation to their belief. Thus some women's decisions regarding care in labour may be directed by their religious beliefs. These decisions could include refusal of analgesia, or interference in the timing of labour such as by induction, or through refusing operative delivery or blood transfusion (24, 65).

Place of birth.

For some the only sacred, safe space where they can truly let themselves go is their own home - for others a safer environment will be a hospital. For either there will be a need for privacy and security within the environment (63). The environment will need to be 'right' in order for the woman to be able to feel free to practice the ceremonies for labour related to her religious or spiritual beliefs. This may not be easy in hospital. For those couples of Jewish faith within Sered's (59) study the ceremonies were carried out before going into hospital, which shows how there are difficulties connected with institutional acceptance of religious ritual, even in the US, a society that is more self-avowedly religious than the UK. Religious ritual which women in labour may wish to use to convey faith may include chanting, music, prayer, use of candles, and specific care of personal hygiene or ritual hand washing. However such women may find that they will encounter barriers to their use within hospital settings (14). Some women in Klassen's (15) study said they felt 'the religious aspects of the birth were best respected in the home'. How they then observed these practices were personal to them. In Kahn's (52) unequivocal view a spiritual experience of birth in a hospital environment is not possible. However it has also been suggested that women can 'prepare' their own space spiritually within a hospital setting when they enter the room or by 'absent visualization' techniques if they have been able to visit the labour rooms before the birth (66).

Risk and safety.

The choices that women make for their labour will be related to their concepts of risk and safety and their level of fear (15, 46, 50, 67, 68, 69, and 70). Furedi (44) states that: 'The term risk refers to the probability of damage, injury, illness, death or other misfortune associate with hazard. Hazards are generally defined to mean a threat to people and what they value.' For women coming to labour there is a definite threat to their integrity physically and emotionally and to the value they place within themselves and their unborn child. Being on the borders of life and death, they take the risk of not knowing whether they will survive intact. The reality of the pain and the raw power of the birthing process lay women bare, place them in touch with their real selves. Yet for each person involved in the birth process, woman, partner, midwife, medical team, their sense of risk and safety will be individual to them and may be different from the others who are there. This can lead to stress and conflict within the woman if she senses she is not being supported in her views. If a woman regards the technological environment of a hospital as safer, then that is the better option psychologically for her, however much midwives may prefer the different sense of safety that a home birth offers. It is to be recognized that those with religious faith may have concepts of risk and fear that are embedded in trust in a Higher Power (15), but this will also be dependent on their personal levels of fear and anxiety.

Some theorists consider that the Western world is currently entrenched in fear (44). Fear is a normal, human reaction, available for the safety and protection of our selves. To be fearful in dangerous situations is sensible and normal. But fear that becomes all encompassing and all enveloping may lead to emotional and physical paralysis in people's lives. The alleviation of fear could also be regarded as a spiritual need, given the potential for fear to prevent an individual from reaching personal fulfillment, from finding meaning and purpose within a situation, of preventing connecting relationships, of taking away hope. Watson (22) defines spiritual emergency as: 'critical, experientially difficult stages of profound psychological transformation involving one's entire being.' According to this definition birth could be regarded as a potential spiritual emergency as there is a 'positive potential' for change: conversely it is an opportunity for devastation. Within women the fear of pain and childbirth is very common. This should not be surprising as the event is unknown and unpredictable. However, Richards (45) states that this fear is further perpetuated through the effect of cultural, religious, gender and societal influences. Psychiatrists have recently defined a pathological condition of tokophobia. (71) There are currently inconsistent results from studies aiming to investigate whether the increase in caesarean levels in recent years may be related to women's fear (72, 73, and 74).

The evidence surrounding fear in labour is currently limited but what is available is showing that it may prevent labour from starting, increase the amount of pain experienced and lead to higher rates of operative deliveries, especially emergency caesarean section. In addition there would seem to be a greater chance of preterm or postterm delivery, restriction in growth of the baby or asphyxia at birth (75, 76, 77, 78, 79, 80, and 81).

If the aim is to increase the chance that women will birth normally it is clear there is a need to address the concept of fear both within individuals and culturally within the western world. Potentially midwives may address these fears by providing known carers and developing effective communication including effective listening, in particular asking the right questions. They could help the woman find meaning and purpose in the situation by further helping her to understand where her fears are coming from and to face them. They could provide an opportunity to pray or find support from her religion if this is what she wants.

The last point is demonstrated in Klassen's study (15) where the women were able to turn to resources beyond themselves or within their religious community to enable their journey. There is a need for women to address their fears before they get to the point of being in labour, perhaps before they even embark on pregnancy. Midwives and other professionals need to be aware of the possibility of fear and provide opportunities for women to talk about what is worrying them and to acknowledge this as part of the process of providing care.

Most midwives are women, and as such have either given birth or have the potential to do so. They are therefore vulnerable to the same fears around childbirth as their clients. Also, as women, they carry cultural fears: all of us have grown and developed in the body of a woman and experienced women as mothers at a time when we have been vulnerable in earliest infancy. According to psychoanalytic theory this makes women the object of powerful unconscious feelings, both positive and negative. In the industrialised world childbirth takes place in a biomedical context, and in those countries where midwifery exists, it does so within a hierarchy where the medical is seen as dominant. Although good quality midwifery care may be powerful in terms of optimising the best outcome for mother and baby physically, emotionally and spiritually, midwifery expertise is less powerful institutionally. It is notable that the power of midwifery care is becoming recognised increasingly in research, yet the rate of caesarean birth continues to increase.

If women are to approach birth from a perspective of spirituality that requires them to be open and accepting of uncertainty, they will demand a level of support from their birth attendants that can accommodate this. It is possible that this may be painful and difficult for some midwives because uncertainty is hard to tolerate. It is also possible that women who choose to go through labour without analgesia or anaesthesia may express themselves uninhibitedly and this may have uncomfortable connotations, including the sexual. It may be too alien to their caregivers' own experiences and they would prefer to 'intervene before it exposes their own vulnerability as women' (82).

Relationships and spirituality.

Creating and forming relationships is valuable in itself; for a pregnant woman it could subsequently become an important aspect of her spiritual journey. By the time she has reached labour she will have had the time of pregnancy, of being challenged by the concept of having a new person growing inside her. This is described as a 'mysterious union' where the woman and her unborn baby are as one, but two separate human beings (50). Rubin (49) argues that the child cannot be independent from the way the mother is or how she behaves. Her own boundaries of where she ends and the baby begins may have been confused, merged together within her psyche. She may also have experienced the mystery of giving love to an unborn child and perceiving love received in return. Rubin's (49) study of women's maternal experience suggests a woman demonstrates the action of her giving of herself by the act of birth through letting go of her 'physical, mental and social self', with the aim of giving a child to her partner first, then after to the rest of her family and subsequently to society. A different study examining the experiences of women of Jewish faith demonstrated that many women felt that it was the development of their relationship with their new baby which gave them a spiritual experience rather than the process of the labour (59). There is some limited evidence suggesting that a mother's negative perception and inability to integrate the experience psychologically may lead to difficulties with early attachment with her new baby (83). The intensity and power and empowering of experiencing normal birth may have a positive effect on the relationship with her child. The sense of her having 'gone through something' together, of having been in touch with the creation of birth may subsequently increase the depth of the relationship. Odent (63) has explored this further by his description of oxytocin as the 'hormone of love' and the 'fetus ejection reflex' where women who are able to be upright in labour will have an adrenaline rush prior to birth which induces the infant to be more alert at birth thus encouraging eye contact and mutual bonding. This is a physical manifestation of the psychological and spiritual aspects of the love relationship, indicating the depth of the intertwining of all parts of a human being and the need for wholeness for this relationship to develop.

Being able to form relationships that are 'connecting' within their intensity has been indicated as particularly spiritually significant to women (32). These may be made through relationship with God or 'Ultimate Other' or in more secular terms a sense of self, in connection with history and the future, nature or other people (32) During birth women may wish to establish some or all of these connections as part of their spiritual experience. Some women have written of their identification with other women's experiences as they give birth, describing being on a continuum with all women who have given birth before and will do after (43,46,47,51,52,55,84). The relationship with a woman's own mother may also be significant here and it may be within a spiritual context that a woman may need to make contact with her own mother around birth (14). Baumillar (57) states that there is a particular bond that develops because of the sharing of knowledge about the birthing experience: 'A woman's mother often becomes an even more special person in a daughter's life because now they too know'. Conversely, the birth may have a detrimental effect of revealing hidden negative feelings towards the grandmother (43, 51, 85, 86). Further difficulties may arise where a woman has two perceived mothers, for instance in cases of adoption (43, 53). It may only be speculated how this effect could be applicable to women born as a result of infertility treatments (14). Hampton's (53) study of the birth experiences of twenty adoptees identified these women as lacking a sense of 'belonging', which resulted in the need for a majority to search for their natural mother during pregnancy or shortly after birth. Those who were able to find her before the birth were helped by the knowledge, while those who did not felt disadvantaged. This implies that for women being able to connect with their natural mothers is significant to the birthing experience, psychologically and spiritually (14).

Some women experience a greater depth of spiritual connection during childbirth, as indicated above (15, 56) whether this arises from engagement with institutional religion or personal belief. Such connection may be encouraged purposefully, through the practice of ritual or prayer to an attempt actively to deepen contact with their belief. Others may find this occurs through no effort of their own: rather that the process of letting go allows a connection to be made at a deep level.

It has been highlighted previously that childbirth may be viewed as a transformative time for women that they will never retract. Within a study of women's self-development (87) many participants identified childbirth as the most important learning experience in their lives and linked the creative nature of birth with an increased depth of understanding of women's creative abilities. An investigation of the development of maternal identity (49) establishes that: '...childbearing requires an exchange of a known self in a known world for an unknown self in an unknown world'. The act of birth may thus be seen as a peak experience in women's lives (50) with the survival of pain seen as part of the process of achieving the appropriate depth of self-knowledge. Such depth of connection with her self in childbirth may be a key aspect of a woman's spiritual growth as it establishes the person she really is and places her in a totally vulnerable and open position.

Some women may experience a connection with the earth and nature during pregnancy (47, 88, 89), or a desire to spend time outside in labour, to feel sand or grass under her feet or to smell nature through flowers or woody odours (46). Others may be particularly drawn to water, either to be close to, swim in or to labour or give birth in (63). Odent (63) highlights the 'mysterious power of water on the birth process' and states 'Water, as a symbol, helps humans to feel secure in a great variety of circumstances.' Such a desire for security may be another indication of the spiritual nature of the whole process.

A woman's relationship with her partner will also be of significance during the birth process. It is appropriate to suggest that those who are present at births may also be affected spiritually by the experience. Many men describe the wonder of the beauty and creation and may feel a spiritual experience themselves despite being an 'outsider' (46). There is evidence that some women develop a new connecting relationship with their partner during the birth as they change from being a couple to a family (55). It is important for the woman to feel that the birth supporters will also enhance her birth experience and not detract from it. Both Gaskin (46) and Klassen (15) give examples of how unwelcome people present at the birth can prevent a woman from giving birth effectively. It is a challenge to midwives to be able to recognise if someone's presence or interference is effectively causing a blockage in the woman's ability to 'flow' in labour. This may be difficult without having formed a relationship with the woman prior to the labour. There have been continued discussions whether men should be totally excluded from birth rooms due to the 'feminine' nature of the act. Certainly there are cultures where it is not normal for a man to be present, where it is the excusive role of women within the society. Where it is the social norm for male partners to be present it is feasible to expect that the birth may be a spiritual experience for them as well as the women. However, it is to be recognised that they will be carrying their own perceptions of risk and fear within the situation and if this is at a different level to the women there may be resulting conflict. How much he trusts the other carers within the situation and how much he trusts the woman's body to be able to give birth will have an influence on his own understanding and fear within the situation. His own concepts of value and worth will also be important as well as the strength of his love and care towards his partner.

Within some religious communities there may be particular responsibilities for prayer or ritual that the man will carry within the time that birth is taking place (24). This may be easier to enact within the home setting, as Sered's (59) study identified. Consequently he may not be allowed to be present and it will be important for the midwife to understand the religious rules associated with birth by which the family live.

There has been little investigation of the spiritual effect of other children being present at the birth but it is evident that children are able to have a simple acceptance of life and are able to view birth as a normal, natural process. There seems no reason to exclude children if the parents wish them to be there.

From the perspective of the unborn infant it is a challenge to ask: when does she have a spirit? Is this present right from the moment of conception, is it 'received' or does it 'develop' and when does this occur in pregnancy, or does it not happen until the baby is actually born? Different religions have different beliefs on this. Such questions are philosophical. Some have suggested that certain dreams in pregnancy are evidence of the child's spiritual potential, in particular dreams of white birds or light (66, 90, 91). However it is also suggested that for this to occur the mother has to accord spiritual meanings to such dreams from within a spiritually aware frame of reference (52). There is evidence to suggest that the mother will make some form of connecting relationship with her unborn baby during the pregnancy (47, 48, 90, 92, 93). However those women whose pregnancies carry some uncertainty or are thought to be at risk may try not to get too attached emotionally until such a time as the perceived threat to the pregnancy has passed (94). This may even be avoided until the baby is successfully born and is perceived to be well. The boundaries between mother and baby are intertwined and fluid and at times it is hard to discern where each ends and begins. There is obviously a dependence of the child upon the mother during pregnancy and for some time after the birth but there is also the complex need to recognize the infant as a separate being. If we are to understand that the unborn baby has a separate spirit from the mother it is possible the child would be able to try and form a connecting relationship with the mother and dreams may again be the channel for this, but this is obviously speculative.

The possibility that the child in utero has a spirit leads to a further supposition that it is possible the child will encounter a spiritual experience by going through the birth. Bergenheim (95), a Swedish midwife, goes further by stating that some infants may experience a spiritual emergency following birth and require special care to deal with their distress. She suggests that 'spiritual bonding' includes giving physical contact, eye contact and talking to the child.

It is essential for the carers at the birth to treat the infant with love, respect, care and gentleness. There has been much made of the potential danger physically of normal birth to the infant and yet little made of the potential danger to the emotional and spiritual side of a child by being pulled out mechanically or being cut off from the mother too soon. It has been speculated that this has a detrimental effect on people later on in life (21, 90).

Spiritual Distress.

Though this book is focused on normal childbirth and we are looking at spirituality within this context it is important to raise issues of what occurs if women's spiritual integrity is impaired. A diagnosis of spiritual distress may be given on such occasions (96). For example if a woman who is spiritually aware is cared for within a rigid maternity system that does not recognise her need and is intent on thwarting her she may become spiritually distressed. The result will be that she will shut herself down emotionally and spiritually in order to protect herself from further hurt and damage. This consequently may affect her ability to labour and give birth and may subsequently lead to difficulty in relationship with the child. It may be that much of postnatal depression is as a result of such unmet expectation. (97, 98, 99). A recent challenging paper describes women experiencing out-of body experiences during labour (100): this dissociation could be evidence of such distress.

Conversely, Smucker (96) suggests that the experience of spiritual distress may bring a person into a deeper relationship with God and in Shamanic practice value is given to a time of spiritual conflict to allow a point of growth to be reached (21). There is also much literature about the ultimate spiritual value of 'the dark night off the soul'. A negative experience of pregnancy or birth may allow the same for a woman (101). There is much work to be done to establish which women will find the experience of spiritual distress a time of growth or of devastation.

Midwives and spiritual issues.

Earlier in the chapter we indicated that there is a place for investigating spiritual matters within midwifery care simply because, as a requirement of the Midwives' Rules and Code of Conduct, there is an expectation that it will be explored in training. However, it is also clear from issues already outlined in relation to the woman's experience of birth that midwives should be aware of the role spirituality plays in normal birth. Table 2 indicates the elements of spiritual care identified from studies related to spirituality (14). It is apparent that many of these could be qualities inherent within midwifery practice. However, over time midwives have lost a lot of knowledge and skill through acquiescing in the over-use of technology in normal birth. A number of questions arise. What aspect of midwifery skills and knowledge it is which makes midwifery care different or spiritual? What is it that is different about some midwives that the care they give is regarded as special or 'better' despite the fact they are undertaking the same actions or procedures as others? (14) Is it possible that this is a spiritual link that is missing? Is it possible that midwives have lost the skills of the art of midwifery and no longer believe that women's bodies are made to give birth?

Intuition.

Carlsson et al (102) suggest there is a type of 'tacit knowledge' which 'lies beyond rational understanding of patient situations' and that 'experienced nurses who are asked to explain their decisions about patient care often cannot articulate the reasons satisfactorily or scientifically.' For midwives this kind of knowledge may be intrinsic within them and they may not know it is present. Is it something that is so embedded in the nature of the work of midwifery that it cannot be extracted? This could indicate that a certain type of person who carries such characteristics will be drawn towards the job; perhaps it should be recognised that this is a quality required in midwives and should be an indication for selection for midwifery training.

Within the current fragmented and over technological nature of the maternity services the chances are that someone possessing these characteristics could be suppressed, although many good midwives exist and circumstances may allow her to grow into it. But the fact that students are qualifying without seeing many truly physiological births means that they may be losing such intuitive skills very early on or not being allowed to develop them. Before the technocratic age midwives relied more heavily upon their senses to recognise and understand the process of normal birth. (103). They also relied more on their ability to use intuition as a tool for recognising subtle changes within the process. The skill of intuition has been derided in an age of scientific knowledge yet it has been viewed as a major part of giving spiritual care (35, 46, 104,105). In order for intuitive care to occur it may be necessary for a relationship to have been formed. The midwife needs to be aware of her own self and limitations and to be able to trust her instincts and those of the women she is caring for. Clarke & Wheeler (106) also suggest that the carer should feel confident in the knowledge that she is being cared for herself which indicates a certain level of security in her self and relationships (14). Such skills may be inherent, but may also develop over time with experience. It is suggested such skills may be enhanced or encouraged through education (3,107). It is apparent that women recognise when midwives are practicing intuitively and that these skills are important to women (108,109). Woman's confidence appears to be reduced where there is a perceived lack of intuitive care (108).

Support.

There has been a great deal of research carried out in relation to the provision of support to women during labour. The evidence demonstrates the benefit of continuous support in labour (110) and this benefit may be enhanced if a relationship has been formed prior to labour during the antenatal period (111). This relationship gives an opportunity to develop 'connecting' qualities, as indicated above. Women have specified that their preference is to be cared for by someone with whom they been able to develop a relationship of trust and care (109,110,112, 113), one of 'professional intimacy' where a woman is allowed 'space' to be herself which also allows for 'connection' (109). The ability to form this type of relationship may affect the midwife as well. Sandall's (114) study comparing different schemes of midwifery practice shows that providing 'continuity of carer is as important to midwives as it is to women' and that a scheme promoting the development of a trusting one-to-one relationship with one midwife provides the greater satisfaction, as midwives experience the opportunity in this method of working to develop a 'meaningful relationship' with women (113, 114). However it is also noteworthy that the provision of a one-to-one relationship is of no worth if the midwife is also 'distant' from the woman. It appears to be significant that there is a quality of 'presence' within a powerful caring relationship. Osterman and Schwartz-Barcott (115) established four images of 'presence' from the nursing literature. These are: literally just being present when the nurse is physically in the room with another, but is totally self-absorbed, and therefore not available to the other; partial presence when the nurse is physically present but is intent on putting all her energy on a task instead of the other person; full presence when the nurse is physically and psychologically present and each patient interaction is 'personalized'; transcendent presence, which is described as 'spiritual' presence and said to come from a 'spiritual source initiated by centring'. In this last case the presence of the carer is felt as peaceful, comforting and harmonious. The ability to care appears to be boundless and she is able to recognise a 'oneness' or unity with the person being cared for.

Others have seen a spiritually healing power within the concept of presence (101). Burkhardt (116) describes a need for the carer consciously to let go of the anxieties of the person she has left to be fully aware and present for the person that she next encounters. She highlights elsewhere that the skills of being 'present' can and should be developed and indicates how carers can enhance these skills (17). Within midwifery the concept of presence carries considerable meaning and significance as it has been shown how valuable the supportive presence of a midwife is to women, and how it may benefit their future role as mothers (111, 117,118). If the relationship between midwife and woman is to have a beneficial and healing value it is argued there should be qualities such as authenticity of being, conscience, commitment, presence, compassion, empathy and empowerment (119).

Such concepts of relationship that border on being loving in their intensity may be regarded as spiritual in nature. However there are complex issues to be addressed regarding the ability to develop such powerful relationships. The midwife obviously has her own life experiences and these will have an impact on how able she is to respond to others. She may feel the need to protect her own personal boundaries within a situation in a way that will subsequently affect her ability to be 'present'. She may also feel unable to give the kind of care she wishes to within an institution that suppresses spirituality. In order to give out to others she will need to feel personal safety and trust within the situation. If for any reason she feels fearful or vulnerable it will affect her ability to care and respond appropriately. As stated above, midwives as women in society may already be living in a framework of fear that will give her an intolerance of risk that may conflict with that of the mother. The following factors indicate potential reasons why a midwife may carry fear: lack of experience or support, bullying, her own birth experiences, the threat of litigation, previous difficult births she has attended or a lack of trust in women's bodies.

Those midwives who fear the power of labour or the openness of women may be challenged by women who wish to 'let go' of themselves and give birth and may want to suppress the labour as a consequence. There needs to be overt recognition of the impact which the fear of the threat of litigation has on midwives' practice and the boundaries placed by rigid protocols. In order to reduce the fear that midwives have we may need to change the culture in which we practise. For example we need to ensure that students' training is appropriate and that both students and newly qualified midwives are adequately supported; where midwives are lacking experience in normal birth this should be recognised and the opportunity provided for 'shadowing'. There should be the facilities for debriefing both previous birth experiences and midwifery experiences. There must be recognition of the potential for a blame culture to exist within maternity units and measures taken to eradicate this. There should also be recognition of potential difficulties in situations where midwives are spiritually aware and are caring for women who are also spiritually aware but hold different viewpoints. The potential may be for conflict or growth and it may be appropriate for care to be handed to someone else if the relationship is proving detrimental. Alternatively, if a spiritually aware midwife cares for any mother there is the possibility that she will enable or facilitate a woman to the extent of bringing her into a place of spiritual awareness.

Practical Considerations.

There may be some ways in which a midwife can enhance the spiritual quality of birth. Place of birth is relevant: there is a contrast between the cold, clinical, bright hospital environment and the warmth and comfortable atmosphere created within most homes. There has been much effort in recent years to 'soften' hospitals, providing curtains and soft furnishings, provision of televisions and music and in some places water-birthing facilities. This is superficial and ineffective without an accompanying change in philosophy and attitude. There are also situations where women giving birth at home have experienced midwives trying to convert their home into a hospital room (120). It is clear there is more to birth than just the place (121). The aim should be to facilitate an atmosphere of calm and serenity. Certain environmental props may be helpful: softer lighting, and quiet or chosen music seem to be appropriate for some women. Some women appreciate the use of candles, but these may be impractical in a hospital setting due to the perceived risk of fire. Some women also welcome the aroma of particular substances to enhance their spiritual receptivity. Outside the therapeutic use of aromas some women may use a particular scent or flowers or incense within their homes during labour. Others may participate in ritual whether of an orthodox religious nature or not; some may use chanting, singing or prayer as a way to cope through the pain of labour. In a woman's home the midwife is a guest, and unless some obvious harm is being done to the mother or baby, there should be no question of interference with such practises. The key fact is to respect the individual beliefs and values of the woman and her partner (24,122). Midwives should never impose their own beliefs.

Conclusions.

The aim of this chapter has been to raise issues of spirituality in childbirth, to provide a basis for reflection about ways in which women's experiences might be affected and to suggest ways in which midwives might introduce spiritual awareness into their care. A holistic approach is fundamental, both towards the childbearing woman and her family and the way in which midwives' practice is configured within the broader social context of health care provision. But spirituality cannot be forced: inauthentic spirituality is a contradiction in terms. And as Quinn (123) has pointed out there is no point in tagging on such practices to a system that is inherently flawed. As Furedi (44) has written: 'A journey that is self-consciously about safety is very different to one that is about exploration and discovery. A safe journey attempts to avoid the unexpected - since the unexpected is more than likely to be dangerous.' As a society we currently believe birth is dangerous and go out of our way to attempt to avoid the unexpected at all costs. There needs to be an examination of the whole system of care as it is currently presented and a radical change of philosophy away from a technological one to one where women are seen to be able to give birth without intervention. This will have implications for training and practice, both of which will need to give greater priority to self awareness. Midwives should start to take note of what they do and how they are when caring for women in labour and to identify places in themselves where they are not at peace, or fearful, and find ways to deal with themselves first. Karll (124) writes 'creating a birth of love and trust could influence an entire lifetime. Every birth contains the potential to make a difference. As midwives, this can be our highest offering...'

Midwives have the power to make a difference for birthing women and one aspect of this has to be through recognising the spirit.

Unfortunately the illustrations cannot be reproduced here.