Is Midwifery Dying?
I was writing a book called Psychodynamics and Midwives. My computer crashed, taking all I had written with it. I had been told to put work on to back-up disc, but I am comparatively new to computers and didn't believe they were so fragile. I know better now.
I didn't know what to do about it. Starting again from scratch seems a huge task and it is possible to find out about psychodynamic theorising around childbirth from other sources. But I did think my experience and background gave me a particular slant. When I read Joan Raphael-Leff, for example, or other theorists, they always seem to me to omit the political and institutional structures in which the process and care-giving take place, and those structures I believe have considerable influence over the physical nature of the experience. They seem to take it for granted, for example, that birth takes place in hospital, that antenatal care includes a gamut of screening tests, that the person in authority over the process is a doctor.
Although I am no longer practising as a midwife and have not done so for a long time, there is a sense in which I believe I have internalised a set of midwifery values, and the basis of these values is the bare physiological basis of childbirth. All women give birth physiologically in the same way and there is a psychological aspect of that which I believe is also basic. But there is a wealth of cultural encrustation laid over this basis, and western childbirth is as encultured as any other. I had wanted to make this clear and to try to separate out the basic from the cultural.
These midwifery values are seldom clearly articulated and are not easy to articulate. In 1999 I wrote: "Midwifery knowledge is not systematised, it is intuitive and cannot be made to fit easily the paradigms of male institutions". There are historical and political reasons for this, but I also think that this difficulty reflects the nature of the phenomenon of childbirth. 'Every Birth It Comes Different' was the title of a book recounting women's experiences of birth: midwifery knowledge, I believe, accommodates these differences and allows for a wide range of experience. It is not easy to distil a wide range into easily transmissible facts.
In this context I had intended to give space to describing the nature and history of scientific thinking, I wanted to demystify science as an endeavour and to justify midwives giving their attention to the 'unscientific' in these evidence-based days. The institutions, assumptions and values of science are also culture bound. I had also intended to outline the psychodynamic analysis of institutions along the lines of Menzies-Lyth and Obholzer, because it seems to me that this explains so much about the conscious and unconscious pressures midwives and women experience in the context of western childbirth.
And I still think that this is valid and interesting. But I also feel that it is fiddling while Rome burns. I think midwifery may be dying.
Midwifery and Feminism
I became a midwife because I was a feminist. I thought that childbirth was a feminist issue because it was an event unique to women which took place in circumstances which were defined by male dominated institutions. It seemed evident to me that such a uniquely female event should be defined and controlled by women. As time has gone on my thinking has gone further and I now believe that the control and distortion of childbirth by male dominated institutions serves a purpose which keeps all women suppressed. It is a process analogous to the fact of the existence of rape, described by Susan Brownmiller, or the way that women's sexual behaviour is defined and restricted by male norms. Childbirth and sexuality are basic and physical. If the physical is distorted, people's sense of self on a deep level is confused or denied. This is a basic principle of oppression.
The Beginning of the End
In detail the issues in the mid 1970s seemed clear. The NHS reorganisation of 1974 brought domiciliary midwives under the authority of the NHS hierarchy rather than local authority bureaucracy and they thereby lost authority and autonomy: the Peel Report had advocated 100% hospitalisation of birth; technological advances in obstetrics, most notably the reliable administration of artificial oxytocin by intravenous infusion, meant that women's bodies were being manipulated to suit the timetables of their care-givers.
Within hospitals through-shaves and enemas were unquestioned routines, episiotomy was recommended for all primigravidas and any woman who'd had a previous episiotomy, birth took place in the lithotomy position, babies were routinely kept in nurseries, breast feeding was scheduled four hourly for restricted lengths of time according to the age of the baby, and breastfed babies were bottle fed by staff without the mother's knowledge or consent.
It was evident that this, and more, needed to be changed. And some of this, with the exception of the continuing non-existence of an autonomous and authoritative community midwifery service, has improved.
What constitutes good midwifery care?
So where is the problem? To start with, while midwives may wish to take the credit for these changes, I think on the whole they were led by women, and many midwives were resistant. I also think that the very improvements - and this is certainly not a plea for a return to the good old days - have muddied the issues and there is a combination of a certain degree of complacency about the extent and nature of the improvements with a serious shortage of midwives.
This has led to what seems to me to be a double level of crisis: a question of simple lack of resources and another question of what constitutes good midwifery care.
(Where the word midwifery appears in italics there is an implied comparison with obstetric nursing.) These two can be separated out, and they also influence each other.
Shortage of Midwives in Labour...
The issue of the shortage of midwives is quite simple. My local labour ward has shut a number of times recently because of staff shortage. It can no longer guarantee a home birth service. It is my observation, certainly in London, that there are not enough midwives practising to ensure that women get one-to-one obstetric nursing care in labour, let alone one-to-one care from someone who is known to the woman and has her trust.
It may be that normal labour is not such a high risk activity that it requires one-to-one care by a skilled and qualified professional. Or it may be that cardiotocography is being used as a midwife substitute. Or both. In which case the delivery of maternity care needs a radical reappraisal, and one which also appraises the level of medical care. But it is not just low risk women who are not getting one-to-one care in labour. Our local unit has a staff shortfall of 17%. I am told that in other units in London the figure is 30%.
Women booked for home birth cannot be guaranteed a midwife: they may have to come in to the hospital so that they can share a midwife with other women on the labour ward.
... and afterwards
Neither are there enough midwives to provide a basic postnatal service for women in hospitals such that high-dependency women get the level of care they need; all women should have access to skilled and sensitive help with breastfeeding when they need it, and all new mothers should receive the consideration that their condition deserves. But there are not even the basic resources to ensure that bloodstained bed linen is changed. The inadequate kind of service that the system delivered routinely when I was practising has come to seem in some ways luxurious.
As a community midwife I was keen to use my discretion in the frequency of my postnatal visits, so that I could be flexible to the clients' needs. But it now seems that research findings are being used to justify a pattern of care which is driven really by the need to cut costs.
I am suspicious of guidelines because they often come to be seen as rules and there now seems to be a 'rule' that women don't need daily postnatal visits. Some might, even if there's nothing wrong: they might just need that level of reassurance. In any case, whether under the old system of unthinking routine or the new system where research findings are applied selectively when they save money, the idea of midwives' judgement and autonomy doesn't seem to apply.
Shortage? What Shortage?
Towards the end of last year Gisela Stuart, the government's spokesperson on health was denying that there was a shortage of midwives. When people have their reality denied they feel mad. Yet I stuck by my perceptions.
The basic shortage of midwives means that strategy cannot be considered. Part of that strategy must surely be a consideration of what constitutes good midwifery care. While I believe that the expressed aims of Changing Childbirth are laudable, I also believe that it did for radical midwifery what Jane Jakeman believes new Labour has done for political thinking in South Wales:
With new Labour, the passion has gone out of politics for the Welsh: the socialism that fired their blood is seen as defeated from within. Welsh socialism was created by the miners' unions with a vision of a mutually supportive society. This vision remained intact, even after Thatcher's destruction of the mines... But the Cardiffians realise that... this version has been effectively castrated into a milk-and-water alliance with capitalism that is unlikely to deliver social benefits (New Statesman, 4.10.99).
This language feels almost embarrassingly passé, yet South Wales (and not only South Wales) could surely benefit from a mutually supportive society. So we have had Changing Childbirth and we have had a simultaneous doubling of the number of maternity units where the caesarean section rate is over 20% (ENB Audit 1998-99), and a midwife shortage such that the concept of continuity of carer is a hollow joke. (In addition locally few of the Changing Childbirth criteria are genuinely met: the named midwife, for example, may be named at booking and never met again.)
In the example from South Wales the despair results from the fact that there is no channel or language for opposition. The ostensible opposition to capitalism has allied itself with business. And in Changing Childbirth ostensibly radical midwifery co-operated with obstetrics to provide cosmetic change. Yet the fact that some real improvements have occurred (women no longer give birth in lithotomy, shaved, etc.) makes it hard to be clear about what has not improved.
It is part of ARM's traditional rhetoric to compare midwifery and obstetric nursing, and I think I am really only beginning to understand what this comparison means. I believe that with the refusal of the Royal College of Midwives to insure independent midwives, and the consequent reduction in their numbers and their visibility, we have lost the clearest example of what good midwifery care means in practice.
Unthinking hospital care has become the norm, not just in the sense that it is the commonest, because only a tiny minority of women ever had the care of independent midwives, but in the sense of providing the criteria for measurement. And most hospital care is obstetric nursing because it is obstetrician led and obstetrician defined. And however much a midwife may want to practise midwifery, she cannot at times of shortage. If she is required to look after more than one woman in labour, for example, she can do little more than keep an eye on the machine, write down the observations and report to the doctor. Midwifery care requires time, and that is becoming a luxury.
Intervention has become the Norm
As intervention has become a statistical norm, so midwifery skills are lost. And intervention has become the norm. It is generally accepted that the 'normal' rate of cervical dilatation is 1 cm per hour. It has been forgotten that this norm was developed as a suitable criterion for workable intervention in a busy Dublin maternity unit. In the 1970s, women were being induced for the sake of nine to five convenience. Now they are being accelerated to disguise staff shortage.
One difference between the 1970s and now is that when it was publicly revealed that women were having their labours manipulated for the convenience of the caregivers, there was public condemnation. Now intervention is so much the norm that we are forced to argue the value of allowing physiology to take its course, not the value of the intervention. This is in spite of the fact that most research supports an uninterrupted physiological approach.
And the power relationships between obstetricians and midwives have not changed. Midwives are not regarded as partners in care of equal worth with a different knowledge and skill base, but as nurses to meet defined protocols. And I'm not sure to what extent, in spite of the rhetoric, power relationships between health professionals and clients have improved. But we can't say this because we have had Changing Childbirth. The language is passé.
The language of money of course is not passé. Obstetric nursing is cheaper than midwifery. Active management of labour and caesarean section are more cost effective than waiting for a woman's physiology to accomplish the task in its own time. The more care can be fragmented and parts hived off to care assistants the cheaper it will be. The concept of the doula, however much it may represent the woman's choice of birth attendant and a privileging of the female, also represents splitting off part of a midwife's role - that of emotional support.
Does obstetric nurse + doula = midwife?
A practising midwife friend of mine said that all they can do is run to put out fires, and this keeps them all, including the managers, so busy and exhausted that they cannot devise a strategy for preventing the fires. Yet the rhetoric is still of woman centred care, continuity of carer, midwife-led care. It seems to me that there is not enough basic quantity to think in terms of quality. This cannot be admitted because it will cost money. And a real qualitative change would require the revolution in midwifery practice which Changing Childbirth implied but never spelt out, and never properly supported on an institutional level.
Did Changing Childbirth Raise the Caesarean Rate?
When there is scarcity or shortage things get pared down to basics. So even thinking about articulating psycho-dynamic ideas to midwives seems a little mad, when there aren't enough midwives to do basic observations, never mind give emotional support. But I think I have got to refer to Isabel Menzies-Lyth. I have to do this to justify a mad thought which is:
it is not coincidental that, just as midwives had apparent institutional back-up to practise with autonomy in the NHS, the rate of caesarean section rose hugely and midwife numbers began to fall.
Separating Patient from Person
Isabel Menzies-Lyth did her basic work on the psychology of nursing in the 1950s. I believe that her work still holds - and not just for nurses. She described the way in which the anxieties which are intrinsic to nursing - or any kind of caring probably - show themselves in aspects of the way care is delivered. The nurses find the anxiety intolerable, yet cannot articulate its existence, and the delivery of care is shaped such that it alleviates the nurse's anxiety by fragmenting any possible relationship between her as a person and the patient as a person. Hence task allocation, depersonalisation through uniform, referral up the hierarchy and other such tactics.
Isabel Menzies-Lyth maintains that the institution will develop systems and structures which reinforce the nurse's individual defensive style unless the emotional load of the task is recognised and catered for. Defensive nursing is recognised to be detrimental to patients, either by actually impacting on their physical wellbeing, or by denying them agency. There have been attempts to improve the situation. I remember as staff counsellor in one health district dealing with the anxiety of a student nurse on her care of the elderly secondment who was expected to provide total patient care to someone who subsequently died. She had become fond of him, and her total care extended to laying him out. Holistic care makes the experience emotionally easier for the patient and harder for the professional.
Facilitating Holistic Midwifery
If we ask midwives to practise holistically, or in a woman-centred way we are asking something analogously hard. If they are to do so they need resourcing materially and emotionally. They also need political support because they are doing something quite revolutionary. If they practise midwifery rather than obstetric nursing they are practising feminism. They are a female dominated profession working with a female client group taking decisions without reference to men or to male dominated structures. This is very challenging to the status quo of the hospital system. I want to repeat that I think it is no coincidence that Changing Childbirth, which embodied radical midwifery in theory if not in practice, was accompanied by institutional changes in medical decision-making and midwifery management.
So I can actually be quite clear about what has not improved:
- Women are receiving care which continues to be fragmented, does not attend to their emotional needs and is debatably inappropriate in the way it attends to their physical needs;
- There are economic and psychological reasons for this, and when economics and psychology support one another it is hard to break their dominance;
- It is in the interest of the political and institutional status quo for this state of affairs to continue;
- One relevant aspect of the political status quo is the continuing dominance of obstetrics over midwifery and this mirrors the continuing dominance of men over women;
- Language which uses words like 'power', 'oppression', 'dominance' has been defined as overemotional, immature, out of touch with the monolith which is political reality since the Berlin wall came down. People who disagree with this consensus are thus silenced;
- Women are giving birth not just in circumstances which are less than optimal emotionally. Some women are giving birth in circumstances which are dangerous.
If this situation does not improve midwifery as a body of skills and knowledge will cease to exist and women will further lose any sense that childbirth is a normal physiological function which their bodies are well able to accomplish without medical help. It is possible that midwifery by definition must be unpalatable to the status quo. It is possible that the death of midwifery would be welcomed, even encouraged.
The anger of the tone reflects my angry new understanding of the delivery of health care as a person with secondary progressive multiple sclerosis. It seems that I am slowly losing the use of my legs, and I am convinced I would have done so sooner if I had not had access to good quality neurophysiotherapy. I have had such access because I am well informed and assertive. It is my contention that many, if not most, people with MS are worse than they need to be because the need for good rehabilitation medicine is not adequately recognised or funded. The chronic is less sexy than the acute. These parallel decisions about resourcing in the maternity services: the midwife who sits for hours with a woman in labour seems to be dispensable. The doctor who, excitingly, intervenes surgically is not. Yet surgery might be prevented with good emotional care. And instead of providing more midwives and such care, which costs money obviously in the short term (although it probably saves money overall by cutting down morbidity) the nature of surgical intervention is redefined so that it becomes the norm.
- Joan Raphael-Leff (1991). Psychological Processes of Childbearing, Chapman and Hall, London.
- Meg Taylor (1999). 'The death of midwifery? AIMS Journal, 11, 1, Spring 1999.
- Hackney Reading Centre (1980). Every Birth It Comes Different. Centerprise, London.
- Isabel Menzies-Lyth (1988). Containing Anxiety in Institutions, Free Association Books, London.
- Anton Obholzer and Vega Zagier Roberts (eds) (1994). The Unconscious as Work, Routledge, London.
- Susan Brownmiller (1976). Against Our Will: men, women and rape, Penguin, London.
- Midwifery Officers of the English National Board for Nursing. Midwifery and Health Visiting (1999). Midwifery Practice: identifying the developments and the difference, ENB, London.
- Nursing Times, (1999). 'Minister denies midwifery crisis', October 6, 95, 40.
- Midwifery Matters ISSUE 84 Spring 2000