Childbirth, the Crisis in Midwifery and Institutional Defences

My qualifications for giving the paper

My assumptions are unashamedly feminist, and there will therefore be references to politics.

In the best traditions of feminism, I shall start autobiographically.

What follows is intended to be speculative. I am not, and never have been, an academic psychologist. I studied social psychology at the LSE between 1971 and 1974 under the usual, often deluded, belief that I would learn something about people in general and myself in particular. In the event I did: that course was well endowed with theory which served my curiosity, including psychodynamic theory, the latter to an extent that I didn't realise was unusual until I did my masters, where I learnt that, at that time, most undergraduate courses in psychology gave one lecture on psychodynamic theory to the effect that Freud was unscientific and the subject need not therefore be further considered. I do not know what the status of psychodynamic thinking is in the current psychology establishment. To judge from correspondence in The Psychologist it is still regarded in some circles as unworthy of attention. I value it because it concerns itself with subjectivity and irrationality. I find it speaks more to my condition than academic psychology. I shall be looking in some detail at the concept of individual and institutional defences below.

I undertook a masters degree in psychopathology because I thought I might become a clinical psychologist. In the event I was repelled by the general tone of the course - this was the mid 70s - which was radically behaviourist. I realised that at that time clinical psychology was very much subservient to psychiatry and I had difficulties with both the medical model of mental illness and subservience. However the course introduced me to the research on neonatal and maternal behaviour in the context of childbirth and for reasons which are not relevant to this paper I became enthused to the point where I became a direct entry student midwife and worked as a midwife in the NHS in both hospital and the community for seven years. My motivation for this was complex and included the political - I wanted to work in a context which seemed relevant in feminist terms. But I also had a conviction that early experience was crucial to the development of the psyche, for good or ill, and that the experience of birth played a part in this. I had an idea that good midwifery could be a kind of preventative psychotherapy. I am still not sure to what extent this idea was naive.

During my time as a community midwife I discovered the concept of psychotherapy and realised that this was what I had inarticulately had in mind when I had wanted to be a clinical psychologist. I started training at a rather maverick institution and studied there for three years altogether, although my studies were interrupted by a diagnosis of multiple sclerosis and childbirth. I have subsequently obtained a diploma in counselling and have worked as a staff counsellor in the NHS and in private practice ever since. I have kept my links with the practices surrounding childbirth as a lay representative and ex-chair of the local Maternity Services Liaison Committee and an active member of the Association of Radical Midwives.

I have found the two disciplines of midwifery and psychology to be richly mutually influencing, and my practice as psychotherapist/counsellor has been deeply informed by the experience of being with women in labour. (I use a pragmatic distinction between psychotherapy and counselling. The latter is short term and focused and does not allow the same quality of therapeutic alliance to be developed and therefore I work with less, or a different, emphasis on transference and countertransference.)

I make no apology for the unacademic nature of this paper. I am interested in the pre-scientific soup of ideas and speculation, out of which hypotheses may emerge. I also believe that the human capacity for objectivity is overestimated. Alan Bennett quotes Kenneth Graham, author of Wind in the Willows:

'a theme, a thesis, is in most cases little more than a clothes line on which one pegs a string of ideas, quotations, allusions and so on, one's mental undergarments of all shapes and sizes, some possibly fairly new but most rather old and patched; and they dance and sway in the breeze and flap and flutter, or hang limp and lifeless; and some are ordinary enough, and some are of a private and intimate shape. And rather give the owner away, and show up his or her peculiarities. And owing to the invisible clothes line they seem to have some connection and continuity' (P 225).

The midwifery perspective and psycho-political concomitants

What I have to say is controversial and I take full responsibility for its idiosyncratic nature. I need to look a little at the history of midwifery, to illustrate what I mean by the term and to distinguish it from obstetric nursing.

Etymologically the word midwife means 'with woman'. I would argue that it is the oldest profession. I was taught as a student that the first reference to midwives in the western cultural tradition was in the book of Exodus in the Bible. The history of midwifery cannot be seen in isolation from the history of gender relations since the development of scientific thinking, and could be seen as an exemplar of the way in which women's roles and powers have altered and been redefined in that context with its concomitant development of technology and industrialisation.

In particular the history of midwifery has been shaped by the development of medicine as a profession, the development of technology and tools within medicine and the scientific concept - often implied - of control of nature. It has been marked by a diminishing area of expertise and a complex and ambivalent relationship to nursing and professionalisation as that word has been defined within nursing.

Jean Donnison outlines in detail the way in which midwifery became subservient to obstetrics. This originally coincided with the development of the obstetric forceps. The socially subservient position of women, their lower educational status and the access men had to the language of science account for the relentless ease with which this process has continued since the eighteenth century. Ornella Moscucci describes how this development links with social change, and especially industrialisation and urbanisation. Yet for much of this time the man midwives and obstetricians had much higher mortality rates than their less educated and often illiterate female counterparts. Women who gave birth in hospital before the transmission of infection was understood had particularly high mortality rates as they were vaginally examined by doctors who were also examining the sick and performing post-mortems without washing their hands. It was the better off women who suffered this: poor women gave birth at home with their traditional attendants, and it came to be believed that this higher mortality rate was a reflection of the greater refinement of women of greater wealth. A belief that is still influential today. The professionalisation of midwifery in the 20th century arguably further served the development of medical control over the process. Heagerty shows how the regulation of midwifery under the Midwives' Act 1902 was intended to control and curtail the practice of lay midwives to the benefit of better educated women whose aim of professionalising midwifery they saw as relying on subservience and adherence to the power of doctors. Nevertheless domiciliary midwives in this country had considerable autonomy of practice, although varying degrees of understanding of the idea of client centeredness, until the 1974 reorganisation of the NHS which brought such midwives under the aegis of the NHS rather than the local authority.

I am interested in the idea of deriving a set of midwifery based values and assumptions. These have rarely been explicitly articulated, partly because the subject matter of midwifery is easily conflated with that of nursing and obstetrics. It is a truism of radical midwifery that these disciplines are distinct. All three have different histories and different fields of expertise. Blurring the distinctions between them could be seen to have benefited both nursing and medicine to the detriment of midwifery.

While historically in this country, midwifery has been seen almost as a postgraduate branch of nursing, midwives used to be professionally distinct; they had a separate professional body, formalised rules of practice and, in theory at least, sufficient professional autonomy that, provided all remained normal, a midwife could supervise the entire process without reference to a doctor. To this end she was authorised to prescribe certain drugs, including controlled drugs. With the development of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting, midwifery came under the same professional body as nursing, and it can be argued that the specific needs of midwifery have been lost in the numerical disadvantage midwives have on that body. Nurses now have some of the obligations and privileges which used to distinguish midwifery, such as the right to prescribe in certain contexts and the need to demonstrate continuing professional development. But the continuing medicalisation of the process of childbirth has led to the erosion of midwives' autonomy of practice, an erosion that the UKCC has been unable to combat, partly I maintain, because of the blurring of professional boundaries between nurses and midwives. Increasing medicalisation obviously benefits medicine in that the area of medical control becomes larger. And the traditional relationship between medicine and nursing has always been one of the subservience of the latter to the former.

Louise Silverton, who articulates a difference in approach between midwifery and medicine, quotes Ann Oakley:

(Oakley 1989)

So far this is clichéd feminist orthodoxy. But the process of childbirth is unusual in a medical context in that a database exists containing all relevant research findings. It is not an exaggeration to say that the undoubted tenor of these findings supports a midwifery rather than a medical model of childbirth as measured in terms of a safe outcome for both mother and child. (Chalmers et al 1989). The Cochrane database indicates that the continuing medical hegemony over childbirth is, according to medicine's own terms of reference, which are ostensibly scientific, irrational.

Basic midwifery assumptions that I infer include the idea that midwives are custodians of the normal. That gestation and birth are events for which women's bodies are designed and that they can be accomplished for the vast majority without medical intervention. That there is a process to be trusted - a newborn baby, for example, if left untouched will 'swim' up its mother's body and find the breast; if mothers and babies are left uninterrupted they demonstrate an almost universal pattern of interaction, of mutual gazing, the mother touching and smelling the baby, talking to it in a tone which is instinctively chosen and for which the neonatal ear is most attuned (Klaus et al 1974). That, just as women's bodies are designed to gestate and give birth, so they are designed to lactate, and that breastfeeding confers many and complex benefits on the baby and on the development of the relationship between mother and baby. That the relationship between a mother and her baby - and therefore child - has a strength which is greater than other relationships, because it is physically based.

These basic assumptions are rarely articulated because of the extent to which this is countercultural: doctors have long ago lost any expertise in or experience of normal birth; now midwives are similarly losing it. And the complexity of industrial society is incompatible with them. I am conscious that my unequivocal statement about breastfeeding is made in a society where the majority of mothers do not breastfeed their babies for longer than six weeks, a belief that some women's bodies simply cannot perform this physical function is socially sanctioned and statutory maternity leave is at odds with the state's medical advice that babies need nothing nutritionally except milk for the first six months. To advocate breastfeeding, and a midwife's education is clear that she should, is to advocate the countercultural and to put many women in an intolerable double bind. The norms which operate to make breastfeeding more difficult clearly imply that the baby's wellbeing is not socially paramount. It is my contention, following Winnicott, (Winnicott 1956) that the mothers of newborn babies are in a unique condition, which he calls primary maternal preoccupation, and that until the baby is capable psychologically of tolerating separation, the wellbeing of the mother and the baby are intertwined. Which is to say that these social norms are detrimental to women too.

There is an unspoken assumption that the physiological processes of childbearing and breastfeeding are all right for women in the third world, but that we cannot easily accomplish then in the west because we are somehow too advanced. This assumption mirrors that of the well-to-do women of the seventeenth, eighteenth and nineteenth centuries who similarly justified their disproportionate sufferings in childbirth. It is as racist as that was classist.

Another reason why midwifery assumptions are rarely articulated has to do with the fact that both historically and at the present midwifery is rooted in the practice of a group of people who were of low social status, dealing with a client group which was of similarly low status and with an event which was to some extent taboo: women dealing with an entirely female phenomenon: childbirth.

It is partly also because midwifery involves processes which are subtle and difficult to articulate. One is the process of being with. I remember thinking, in the context of a conversation about current local practices and developing midwives confidence in attending homebirths, that if any woman were suddenly to start to give birth, I could be of use to her as I am, years out of formal practice and with no equipment. So I started to think about what this might mean; what would I be offering a woman in these circumstances? My knowledge of the process per se means that I have faith that babies will come; my experience means that I have some techniques for coping with emergency, even without equipment. But mostly it's confidence and the ability to stay with a woman without trying to alleviate her pain, but knowing that the pain can be transmuted, expressed, survived. It is a being with very similar to that of being with the dying (or a client in psychotherapy). One that accepts that this is a process which will change the participant for ever, which may involve pain for the participant and impotence for the attendant. And one where the participant may not be capable of communicating verbally, and certainly not capable of communicating politely. So it requires the ability to understand and communicate on this level. This is hard to articulate because it is nonverbal, but it is a commonplace skill; one which every carer of very young children possesses.

All this links with low status and taboo. It is low status because both the nonverbal and the taboo are low status. Childbirth is taboo because it involves the sexual organs (and is a process itself arguably intrinsically sexual, see Southern 1994), and taboo bodily substances. I maintain that there are other aspects which amplify this taboo nature of childbirth and therefore midwifery, and which further distinguish midwifery from nursing. In 1996 I referred to the four dangers: sex, death, madness and love. Sex I have mentioned. Death is more uncommon in midwifery than nursing, obstetric interventions are aimed at preventing death, and it therefore is more easily split off and denied. Madness is an issue because the normal and desirable psychological state which new mothers experience involves a state where the boundaries of the self are fluid and levels of empathy between mother and baby are high. Midwives are constantly in contact with this state, and therefore are themselves either in a state of empathy with it, or not. To maintain the latter is a struggle. Fluid boundaries to the self evoke a condition which in orthodox psychiatry and psychoanalysis is called psychosis. Psychoanalysis differs from orthodox psychiatry in that it regards this state not as pathological and therefore only experienced by the sick, but a normal developmental stage belonging to early infancy and therefore one which we have all experienced and can touch on again. Love in a sense should go without saying. I have mentioned above the strength of the mother-child relationship: the commonplace word for this is love. Dealing professionally with all this evokes strong feelings, which may not be conscious, and which, like midwifery values and assumptions, are not articulated.

These basic assumptions are rarely articulated because they are intimately to do with women's business.

Midwifery assumptions imply a value system which sees health as involving connection with nature and therefore which accommodates death. Jeanne Achterberg, writing about shamanic healing could also be writing about midwifery 'in contemporary Western medicine, life's natural passages are viewed as deficiency diseases that require medical attention. Newborn babies, about-to-be mothers, menopausal women, and people who are simply experiencing old age are hospitalised and medicated as if pathology were present...Growth rituals in our society have been turned over to the health care system; thus the natural maturation and fruition of human condition are regarded as sicknesses, and in need of intervention.' She goes on 'The function of any society's health system is ultimately tied to the philosophical convictions that the members hold regarding the purpose of life itself. For the shamanic cultures, that purpose is spiritual development. Health is being in harmony with the world view...health is not the absence of feeling; no more is it the absence of pain' (P19). This value system is not the dominant one in health care, or in society generally.

What passes for midwifery in Britain is, I would argue, on the whole obstetric nursing, where those who support a woman in pregnancy and childbirth do so according to instructions, norms and protocols devised by obstetricians, rather than on their own expertise in the process of normal childbirth.

Midwifery therefore deals with women's business. In feminist terms to accept midwifery values and assumptions implies, for me, essentialism.

Feminist essentialism is generally seen as problematic because to suggest that the undeniable physical differences between men and women equate also with psychological differences is associated with an implied assumption that these differences are polarised, unalterable and immutably linked to the undeniable social oppression of women. This can be comparatively easily refuted. More serious is the suggestion, well expressed by Sara Schneiderman (1999), that too great an emphasis on essentialism can lead to an underestimate of the power of social and cultural difference.

Childbirth is a phenomenon which is intrinsically female and the mother-child relationship is powerful in terms of shaping the psyche of the child according to psychodynamic assumptions. There are some feminists who see these assumptions as providing the basis for oppression, and given the isolation of new mothers within the context of the nuclear family in industrialised societies, this is understandable. But it can be seen as either oppressive or liberating. Dinnerstein, for example, used her understanding of the psychological power of mothering to argue for greater equality of the sexes in rearing very young babies. My response to this suggestion, however, is always to ask about how the baby is to be fed. Assumptions about the value of breast milk must lead to further assumptions about the inevitability of greater female involvement. This is seen as oppressive to women, but I would argue that to prevent the mother of a young child from having an intense involvement is itself oppressive. It denies the physiology of the event. Umberto Eco (1994) persuasively uses physiology as the basis of an ethical system. In a New Statesman interview he was asked 'If there are only preferences and no truths, what basis can we find for a definition of what is universally intolerable?' He replied: 'On respect for the body. One could construct a whole ethic based on respect for the body and its functions' (P 15). He goes on to list the basic physiological functions of the body, though not including childbirth, and shows how torture and 'all types of racism and exclusion are, in the end, ways of denying the body of another.' According to this logic then, any intervention which causes a deviation from the normal physiology of childbirth would need to be justified.

More specifically feminist, Anita Phillips writes 'Women menstruate, give birth to babies, breastfeed, are on the receiving end of the reproductive process in a way that men are not. These biological, nurturing processes require courage, patience and generosity, but there is little recognition of this. The most fundamental aspects of human life are the least visible, as if the entire culture were dominated by some communal vision of a sterile masculine ideal, some bronze statue of a military man' (P 51).

Anita Phillips is arguing for a feminism which can accommodate 'a woman's different (sometimes contradictory) facets' (P 51). Childbearing is a facet which public expressions of feminism seem to overlook, and which is basic to many women's experience. Elsewhere she states 'Whenever feminism promotes female assertion and achievement it unavoidably denies another side to life' (P 51). It is easier, publicly as a feminist, to assert that women should be allowed to serve with men in the front line of combat that to say that women's physiological and psychological needs around childbearing should be fully taken on board by a society which claims to accord women equality.

To some extent this is because childbearing is seen as the province of the conservative or reactionary. There is no logical or political reason why this should be. The acceptance of midwifery assumptions and values could provide the basis for a radical feminist critique: the status quo, the dominance of obstetrics and obstetric nursing, could be seen as the literal embodiment of male norms.

In a recent edition of the New Statesman Rebecca Abrams stated that feminism and motherhood are antithetical. To accept this is to imply that the needs of mothers and children are necessarily opposed. This adversarial approach informs modern maternity care: the needs of fetus and baby are seen as opposed to those of the mother; the needs of the woman as opposed to those of her caregivers. I do not believe this need be so, and the fact that it seems so self-evident is a measure of how anti-feminist are the values of transglobal capitalism.

What would the psychology of childbirth look like if it were based on midwifery assumptions? There would be an acknowledgement of the power of the experience and the bond. To acknowledge this fully would not necessarily relegate women to a position subordinate in social or political terms, but it would be a recognition of difference. The intensity of primary maternal preoccupation must gradually attenuate for the social and psychological benefit of both mothers and babies. There would be a further recognition that the process is best served by midwives, that is to say by an attitude and approach which is based on trust in the process. In turn this would not be to abdicate skilled observation and intervention, but it would imply a considerably reduced rate of intervention (and all interventions have concomitant risks). It would imply also a valuing of aspects of the phenomenon other than and in addition to the scientific, the incorporation of those words on the right side of Louise Silverton's list.

The recent political context and the crisis in midwifery

At the moment, in southern England at least, there is a staff shortage crisis in midwifery such that one-to-one midwifery care in labour, homebirth or even access to the hospital where a woman is booked for delivery, cannot be guaranteed. This follows on from an initiative of the last, Conservative, government called Changing Childbirth which was supposed to increase the choice and control of the woman over the process of birth, including the place of birth, and the professional autonomy of midwives. This initiative was implemented in a way which has become familiar, of pump-priming money awarded to projects in a piecemeal and temporary fashion, on the apparent theoretical basis that excellence would be recognised and further money somehow forthcoming. It is my contention that this initiative, which was ostensibly based on the type of midwifery assumptions articulated above, was accepted for the political end of reducing the power and influence of the medical profession; a reduction that was necessary from the standpoint of monetarist ideology since medical assumptions, just as midwifery ones, are not based on, and probably run counter to, economic considerations.

Changing Childbirth did not work and I maintain that this failure has a complex cause involving both the political and the psychological.

Many of the initial projects folded for lack of money. There was a foreseeable resistance on the part of many doctors which was not adequately addressed. Some attempts to improve continuity of care had the opposite effect. Rates of medical intervention rose. Midwife numbers fell.

Norms regarding childbirth have changed. This change reflects both the technological and the political. Many interventions happen simply because they are technically possible. The reliable induction of labour using artificial oxytocics simply was not possible before the mid 1970s, for example. But this raises political questions about why research prioritises and funds the interventionist. This is usually justified by a belief that this reduces mortality and morbidity. This belief is debatable (Tew 1998). But its enactment then alters what is believed to be the normal in a way which encourages and legitimises further intervention. And intervention serves the purpose of maintaining medical dominance over the process, the political implications of which are vast, seldom articulated because they are taken for granted, but not the focus of this paper.

These politically and technologically based norms then become unthinkingly internalised. It is widely accepted as the basis for protocols determining responses to women in labour that the normal rate of progress is cervical dilatation of one centimetre an hour. But this norm was first articulated by Kieran O'Driscoll in circumstances which were specific to his situation. As chief obstetrician in a busy Dublin maternity hospital he thought it necessary to devise a workable schedule for interventions such that women gave birth within twelve hours. These circumstances do not necessarily apply elsewhere and arguably should not apply anywhere.

As an example of how obstetric norms dominate thinking about childbirth Louise Silverton, in her textbook for midwives, distinguishes midwifery and medical approaches, for example, to norms in labour, but she omits to say that midwifery approaches are simply not acceptable generally. She compares the idea that labour is normal unless shown to be otherwise with the medical idea that labour is normal only in retrospect. But when discussing the length of the second stage of labour she uncritically quotes obstetric norms: two hours for a primipara with no more than one hour of active pushing and forty five minutes for a multipara. She does not question whether these norms are appropriate or what a range of the normal might be, or what criteria may be used to work with an understanding that labour is intrinsically normal - such as the condition of fetus, mother and midwife.

Caesarean section rates have been rising. Enkin et al state 'The caesarean section rate varies considerably from about 5 per cent to over 20 percent of all deliveries. The optimal rate is not known, but from national data available, little improvement in outcome appears to occur when the rate rises above about 7 per cent'. It is becoming increasingly common in British maternity units for the rate to exceed twenty percent. In fact, during the years when Changing Childbirth was being implemented the number of such units doubled (Taylor 2000). Enkin et al continue 'The extent to which obstetricians differ in the use of this major operation to deliver babes suggests that the obstetrical community is uncertain as to when caesarean section is indicated. It also suggests that other factors, such as he socio-economic status of the woman, the influence of malpractice litigation, women's expectations, financial considerations, and convenience may sometimes be more important than obstetrical factors in determining the decision to operate' (P 256-257).

The changing role of women in the work place which has followed on from the deindustrialisation in Britain has had an inevitable impact on patterns of mothering, including rates of breastfeeding, which have been declining in recent years. This has a further impact on assumptions about the mothering of little babies, downgrading the phenomenon of childbirth as an event of psychological importance. This change is mirrored in changes to the law regarding maternity leave.

All this coincided with the managerial revolution in the NHS, which had the effect also of downgrading the concept of clinical judgement.

The above touches on the political aspects of the failure of Changing Childbirth and the crisis in midwifery. The psychological aspects of this involve the psychoanalytic concept of the defence mechanism.

Personal and institutional defences

Charles Rycroft, outlining the three bases of Freudian thinking gave as the first basis the concept of unconscious processes which 'obey different grammatical rules from those of conscious thinking, ... anyone knowing these rules can translate primary process statements into the language of waking thought' (Rycroft 1985 Pp 60-61). He goes on 'secondly... the ego uses defences to prevent itself becoming aware of certain unconscious mental processes' (P61). Freud's description of these defence mechanisms was developed and amplified by Melanie Klein.

It is fitting that a paper concerned with childbirth should use concepts developed by Klein because she based her thinking on what she inferred were the psychological processes of tiny babies. There are logical objections to the way that both Freud and Klein used the assumption that adult 'pathology' can be equated with infant thought processes. However I find the usefulness of Klein's concepts in illustrating individual, group and larger political processes to be invaluable and have come to accept the validity of the psychoanalytic concept of development and regression more and more as I have got older.

Melanie Klein was a woman in a man's world, and a nursery school teacher in a context where most of her peers were psychiatrists or neurologists. I think this accounts for her unnecessary use of the jargon of pathology to describe what are normal developmental stages. She describes two positions, the paranoid-schizoid and the depressive. Her use of the word 'position' indicates that these are not developmental stages which one leaves behind, but positions which are visited and revisited normally. The paranoid-schizoid position is based on the premise that reality for a very young baby is intense and immediate, that before memory develops experience is divided into extremes. For a hungry baby, for example, hunger is all there has ever been and all there ever will be. Then, when the child is satisfied, blissful satiety is all there has ever been and all there ever will be. As the child experiences more, these extremes develop into the realisation that the source of both the hellish deprivation and the blissful satisfaction is the same: the mother. This realisation is the depressive position. The depressive position is uncomfortable. In Klein's view the baby experiences guilt, as s/he realises that the person s/he has hated is the same person s/he has loved. To protect against this discomfort one takes refuge in the mechanisms of splitting and projection.

I regard these processes as common and fundamental to day to day thought. However I am not sure to what extent they are currency in psychological discourse. I was interested to note that Erwin Staub's analysis of the psychology underlying atrocities such as political massacre and genocide made no mention of these processes (Staub 1989). They are the processes that fuel the style of discourse of the tabloid, and often the broadsheet, press; whenever outgroups are defined and characterised by the qualities which we all possess but would rather we didn't; whenever one regards difference with unthinking and reflex fear.

These defences operate not only individually but also, maybe especially, in institutions. In 1959 Isabel Menzies-Lyth first published the paper in which she made clear how these defences operate in the context of nursing, both institutionally and individually. Indeed, the individual and the institution develop a style of defence which serves to enhance the impregnability of both.

Menzies-Lyth was asked by a nurse training school to investigate the high drop-out rate of student nurses. She described how the task of nursing involves high levels of anxiety: the nurse must deal intimately with bodily processes, illness is her raison d'etre, and death is always a possibility. This understandably evokes anxiety in the professionals involved in care of the sick, the patients themselves, and their relatives. In order to make the level of anxiety manageable nurses organise their care in a way which minimises the depth of involvement they have with their patients. And their individual defences are mirrored and reinforced by rigid and hierarchical institutional structures. The processes of splitting and projection are fundamental to this. (Menzies-Lyth's task was focused on nurses, but it is not hard to extrapolate her findings to other professions. What she described is by no means unique to nurses.)

So nursing fragments the care of the patient into discrete tasks; differentiates and distances nurse from patient by means of uniform, modes of address; encourages detachment and denial of feelings; eliminates the need for reflection and decision making by ritualising tasks; attempts to underplay the reality of the situation by 'collusive social redistribution of responsibility and irresponsibility'. (I think this last is particularly important. It includes unnecessary referral upwards in the hierarchy, which in midwifery describes the way in which midwives are reluctant to take responsibility for what ought to be well within their range of expertise. There is a huge discrepancy between what midwives are legally entitled to do in the support of childbearing women and what they actually do in practice. They are encouraged in this role limitation by obstetricians who want to maintain their control over the process.) These defensive strategies and the others she describes are inimical to good patient care, in some cases because they are clearly physically detrimental, but in all cases because they deny the patient's sense of self. Most patients play along: they don't want to trouble the doctor and the nurses are so busy. I would argue that it is better for the mental health of all concerned if this were not so.

During my involvement with the NHS there have been a number of attempts to remedy this fragmentation of care by introducing total patient care and primary nursing, for example. Changing Childbirth was one such initiative in midwifery. On the whole these attempts have not succeeded. Of late the managerial revolution in the NHS has judged primary nursing to be inefficient and has introduced the concept of 'skill-mix', which is task fragmentation by another name. Efficiency - cost-effectiveness - is the major criterion. Clinical judgement, medical, nursing and midwifery, has been affected, downgraded, by the introduction of general management.

It has always been hard to eradicate these defensive strategies and structures because, while they may be inimical to patient wellbeing, they are not inimical to the psychological comfort of the staff. And since the introduction of general management that psychological impetus has been further reinforced by economics. I wrote elsewhere with reference to midwifery (Taylor 2000) 'women are receiving care which continues to be fragmented, does not attend to their emotional needs and is debatably appropriate for their physical needs. There are psychological and economic reasons for this, and when economics and psychology support one another it is hard to break their dominance' (P 6). In the same article I suggested that it was no coincidence that during the introduction of Changing Childbirth the number of units where the caesarean section rate was more that twenty percent more than doubled.

Conclusions

To some extent Changing Childbirth failed because in its emphasis on continuity of care, greater choice and control for the women and increased autonomy for midwives it undermined too profoundly both individual and institutional defensive structures. If any such change is to be effective it must allow for the psychological reality of the task and accommodate the inevitable anxiety differently.

The subtitle of Jean Donnison's book is 'A history of inter-professional rivalries and women's rights.' Marsden Wagner (1999) shows how irrationality, in the sense of a wilful refusal to accept evidence, is keeping the medical model of childbirth dominant. The inter-professional rivalries are rarely articulated but, I maintain, still exist and still shape woman's experiences of childbirth to the detriment of the physical, psychological and social health of themselves and their babies. The rivalries have a political dimension and a psychological dimension, and I maintain that the continuing undervaluing of midwifery assumptions has a spiritual dimension. Isabel Menzies-Lyth described a concept of disavowed knowledge. In this context this disavowed knowledge must involve a sense that childbearing women are getting suboptimal care for reasons which are to the benefit of the caregivers. (I think this situation is probably true for all aspects of health and social care.) The disavowed knowledge has to be acknowledged and accepted if lasting change is to occur.

Throughout this paper I have referred to that which is rarely articulated. Women's business is not part of public discourse. To some extent I quite like this. But the covert nature of midwifery knowledge is, I believe, putting women's wellbeing at risk. I think it is important that women continue to believe that they can give birth of their own power.