Midwifery as an unevaluated intervention: a response to Liz Nightingale
I joined Facebook precisely because in an edition of Midwifery Matters quite a while ago it was mentioned that ARM had a Facebook page. In the event I've found it difficult to negotiate Facebook, and although I still have a page I visit it very seldom. However I was extremely interested in the article on midwifery as an unevaluated intervention. Liz Nightingale asked for comments. Here are mine. I am a retired midwife and the mother of two sons born in 1987 and 1991, both at home with independent midwives.
The whole concept of evaluating an intervention puts the phenomenon of childbirth and midwifery within a scientific context. I do not think that there can ever be such an evaluation, because childbirth is too multifarious and individual for the kind of quantification and comparison of variables which scientific analysis requires.
I think that there is a question of the philosophical context within which childbirth is understood. For example, if a woman's pregnancy has been normal and she is well nourished and healthy and the baby has been developing well, why is it assumed that labour is so intrinsically dangerous that the baby's heartbeat needs to be assessed every 15 minutes? Why is it not assumed that human beings have evolved to survive childbirth, and that if all has been normal thus far it is likely to continue to be normal? The NICE guidelines on normal labour as well as the all Wales pathway for normal birth are both making this assumption. When I was in labour my midwife, if I remember rightly, certainly did not check the fetal heart anything like that frequently in the first stage of labour. And the rationale for not doing so is to avoid unnecessary stress to the mother, since we know that stress hormones counteract the secretion of oxytocin.
When I was in labour I felt that I needed the support of a trusted midwife. There was one particular moment during my first labour when I was returning from the loo and I saw the midwife standing there and said to her 'I am frightened'. She replied with something which I found immensely helpful. She did not try to reassure me, she just said 'of course you are'. I knew that she had had three babies, and I felt at that moment as though something intangible passed from me to her, and I think that something was the rational, adult, midwife part of myself. To put it in neurological terms, my very human neocortex; I could become like a whelping bitch. And this is where, psycho-physiologically I think women need to be to labour successfully. But we are all different, and what is helpful to one woman may not be helpful to another.
So I think this intervention, midwifery, needs to be evaluated in a way which is not that of 'hard' science comparing quantified variables. I think it needs to be evaluated by each particular woman, qualitatively. And she may wish the midwife to be in a separate room, or outside round a fire. This is fine, as long as it is accepted that she takes full responsibility for her decision. In her book Reading Birth and Death Jo Murphy-Lawless describes a society in the high Andes where a woman giving birth to her first baby will have a more experienced woman with her, but after that it is accepted that she will give birth alone, although her husband will come to help her deliver the placenta. From my reading, in this society all women are expected to be able to palpate pregnant women and diagnose malpresentations, so that the woman can then seek medical advice. I do not think this society is primitive, rather very sophisticated.
In our society midwifery is still seen as a body of knowledge inferior to obstetrics, constantly compared to it. I should really like to see a clear description of midwifery knowledge which contains the biomedical (of course midwives need to know how to resuscitate both mothers and babies and control postpartum haemorrhage, and other necessary interventions) but which also articulates the rationale for those practices which are, for example, provided by independent midwives: homebirth; no routine assumption that vaginal examinations are necessary; breech birth, rather than obstetric vaginal breech extraction; homebirth after caesarean section... I think that all this needs social scientific discourse in addition to the biomedical, particularly anthropology and psychodynamics. It is in the psyche that interpretations are made which may heighten or lower stress.
Social science also explains the power of the institution over the process, and the way in which authoritarian and hierarchical relationships are oppressive to both staff and clients.
But I do not believe that the death of midwifery will ever be a good thing, although I do believe it might be imminent given what has happened to the Albany practice and in 2013 the requirement that all health professionals have indemnity insurance. Independent midwives, who I think provide the gold standard of care, may opt in to NHS trusts (or whatever exists at that time -- it is difficult to be sure given the intentions of the present government) but they will almost certainly need to adopt the protocols and procedures which are driven by fear, both of childbirth itself and of litigation.
There was once a time when I thought that I might be able to provide this articulation of midwifery discourse, but I am now too disabled by MS, my energy levels are low and my computer access is sporadic. Is there anybody who would be willing to do this? I should like to contribute as much as I am able. What I think I can provide is social scientific input. I also think I am quite good at producing well structured sentences. If so, contact me on firstname.lastname@example.org .