Obstetric and Midwifery Thinking
Either late in 1980 or early in 1981 I became a staff midwife at the Middlesex Hospital in Mortimer Street. It was a very small maternity department with three labour wards serving approximately 900 births a year. I was attracted by the small size and by the approachability of the senior sister. The rank of senior sister had been instituted there as part of the adoption of a policy of active management labour based on O'Driscoll's principles. I had considerable reservations about these before I started and in practice it seemed evident that they led to an unnecessarily high rate of all sorts of interventions. Concerned about this, I started noting statistics andI can still remember those for primip births for October 1983. 50% had normal deliveries in the sense that the babies were born vaginally without mechanical assistance. Normal in this context says nothing about induction, augmentation, artificial rupture of membranes, intravenous infusions, analgesia or anaesthesia, catheterisation or episiotomies. Of the remaining 50%, 30% were delivered by forceps and of the rest 9% had elective caesarean sections and 11% emergency sections. It seemed particularly inappropriate to be using this type of regime in a small and quiet department: we were aware that our smallness made us vulnerable to closure and for that reason used to offer any newly delivered mother the option of a ten day stay if she so wished to keep our bed occupancy figures up. It seemed particularly sad to me that a similar sense of leisure could not be applied to the labour ward.
This seemed a very different setting from that of the National Maternity Hospital in Dublin, which was a very busy department in a country where at that time contraception was illegal and the birth rate concomitantly high. It seemed axiomatic to me that O'Driscoll had developed his regime in order to cope with a bottleneck in the labour ward. I believe that O'Driscoll admits as much in the introduction to his book.
The statistics quoted above may seem not particularly unusual nowadays. There has been a large reduction in the incidence of normal, vaginal birth. A caesarean section rate for primips of 20 percent is nowadays almost modest. The current rate (2005) for first-time mothers in London is approximately 33%. I will describe below what seem to me to be some aspects of the reason behind this trend.
Before becoming a midwife I had studied psychology and while practising as a community midwife I started training as a psychotherapist. I had always been very aware of the social and psychological aspects of childbirth, but a deeper immersion in psychotherapeutic theory, especially psychodynamics, gave me a new perspective on aspects of obstetric practice. It became evident to me that this practice was driven not by science but by a desire to minimise uncertainty and unpredictability. This links in with Isabel Menzies-Lyth's analysis of nursing practice which, although carried out in the 1950s, I believe remains unsuperseded.
In the 1950s Isabel Menzies, as she then was, worked with a number of other psychoanalytically trained people from the Tavistock Clinic in London applying psychoanalytic principles of understanding to large organisations. She was approached by a London teaching hospital to investigate why they were unable to retain their nursing students. She observed the way that nurses, trained and untrained, worked and made a number of observations and conclusions.
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. Nursing fragments the care of the patient into discrete tasks; differentiates and distances nurse from patient by means of uniform and 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'. This all reduces anxiety by minimising the extent to which the nurse, as a whole person, encounters the patient, as a whole person. The nurse does not have to take on board empathetically the patient's frightening reality.
I should like to suggest that this distancing is still a major defensive response. It has been entrenched by moves within nursing to raise its professional status by raising its educational status. So student nurses are no longer full-time workers in a hospital, they are university students whose clinical experience is provided by less frequent placements. The day-to-day care which was once provided by student nurses is now provided by health care assistants. Health care assistants nowadays undertake a range of tasks which, when I was training, would not have been undertaken by nursing auxiliaries. One implication of this development is that the split between care and cure which used to be represented by the distinction between medicine and nursing is now represented by a distinction between the professionals, both medical and nursing, and those who are not professionally trained. It seems to me that within the framework described by Isabel Menzies-Lyth certain tasks are too menial to be considered by professionals. I conclude that their menial nature is anxiety provoking to professionals: to undertake these tasks is to breach the defence which professionalisation has provided. This professionalisation has succeeded in increasing distancing as a defence and rendering it even more impregnable.
Fragmentation reduces anxiety by enabling the nurse to fall back on the defence mechanisms of splitting and projection. Frightening aspects of my self, such as sexuality and aggression which psychoanalysis states are intrinsic to us all and, in the case of nursing, also mortality, are split off and attributed to another person. This means that I am less fearful for and of myself but the other person becomes proportionately more frightening. Those people who are the repository of projection tend to be those who are different in some way: racially or sexually or according to their social class, for example. Isabel Menzies-Lyth goes on further to claim that the hierarchical structure of large institutions supports and perpetuates these individual psychological patterns: the defensive structures of both the individual and the institution mesh. This meshing makes the strength of the defences almost impregnable.
It may be argued that midwifery and nursing are two distinct disciplines. I agree that they are and that they present a different set of anxieties. Pathology and death are comparatively rare in midwifery. Yet I maintain that the defensive structures are as well entrenched and immovable in midwifery as in nursing. Some years ago I was providing support to a friend who was having a medically induced termination of pregnancy at 16 weeks in the same hospital of which I was chair of the Maternity Services Liaison Committee. I was well aware of the shortcomings of the maternity department and I was struck by how the nurses on the gynaecology ward seemed much more pleasant and generous and altogether less anxious than their midwifery colleagues even though they were dealing with an event much more intrinsically unpleasant than the welcome birth of a new baby. I think in fact that this distinction is telling. The anxieties intrinsic to midwifery include envy of creativity and sexuality. These can be as challenging as the vagaries of nursing particularly to those whose own experiences either of childbearing or of childhood have been disappointing or traumatic.
The findings of the Cochrane database on childbirth on the whole support a midwifery rather than obstetric approach if outcomes are measured in terms not just of mortality but also in terms of morbidity, psychological trauma and quality of experience. Yet there is no indication that this is being taken on board widely in practice. Continuing irrational and counter-productive interventions include: continuous electronic fetal monitoring; routine induction at a certain gestation; aggressive intervention in cases of pre-labour rupture of membranes, including vaginal examination; time limits on the various stages of labour regardless of the condition of mother or fetus; the use of epidural anaesthesia for women who have previously had a caesarean section and are now intending to give birth vaginally. All of these interventions have their own well-documented risks both intrinsic and iatrogenic.
However in the process of reading Jo Murphy-Lawless's Reading Birth and Death I realised that I had made a number of fundamental misassumptions. I assumed that O'Driscoll had based his interventions on the need to respond to a problematic situation: that of the bottle neck in the labour ward at the National Maternity Hospital, Dublin and that these interventions were only possible because a reliable technology existed in the form of an intravenous infusion of syntocinon. This may be questionable practice on a number of levels but it at least has the benefit of logical consistency. But reading Jo Murphy-Lawless it is evident that the urge on the part of obstetricians to intervene and reduce the length of time of labour was not logical: it predates any reliable technology. Her book describes how, in the eighteenth century, completely arbitrarily, a time limit of fourteen hours was decided upon and that the steps taken to accelerate labour included manual dilatation of the cervix followed by the use of forceps before the head had even entered the pelvis. The resulting lacerations at a time before the understanding of the transmission of infection were almost inevitably lethal. The thinking behind this was based on a number of ideologically driven views of women including that women were intrinsically fragile and in need of rescuing from the equally intrinsically dangerous process of childbirth. The means of rescue led to a spiral: more deaths entrenched further the belief that childbirth was dangerous and deepened the conviction that more (lethal) interventions were required.
One point which Jo Murphy-Lawless makes is that this high death rate was beneficial to medical science because of the extent to which it provided material for dissection. She does not suggest that these women were knowingly killed. But it seems to me she is suggesting a considerable depth of irony.
One psychological effect of these lethal interventions was to reduce anxiety by eradicating the uncertainty around time intrinsic to uninterfered with labour. It could be argued that most modern obstetric and midwifery interventions exist to eliminate uncertainty. These uncertainties include: am I pregnant? How long will the pregnancy last? How will I know labour has begun? Will I be able to bear the pain? Will I survive? Will the baby be okay? Yet the interventions which are supposed to eliminate this anxiety all involve the risk of further physical complication, albeit not in terms as lethal as those of the 18th century. The ability to tolerate uncertainty is necessary if midwives are to support women without unnecessary interventions. It is an ability which is fostered in psychotherapy training but not generally in midwifery training. It is an ability which is discouraged both by current obstetric practice with its tendency to perform unnecessary interventions and by the trend among certain women to choose elective caesarean section.
How might midwives better be able to resource themselves? I found the autumn 2005 edition of Midwifery Matters very rich. It emphasised how important it is to ensure that one is sufficiently resourced: I cannot give if I am running on empty. Musing about this I was reminded of the two cultures of addition and subtraction as described by Rebecca West in her book Black Lamb and Grey Falcon. This is a huge book of over 1000 pages describing a visit she made to Yugoslavia in 1937. Yugoslavia was a complex country, the intersection of Catholicism, Orthodox Christianity and Islam. This complexity contributed to its devastating fragmentation in the latter quarter of the 20th century; a fragmentation which is continuing today. Rebecca West was politically sophisticated and knew that her visit to Yugoslavia was occurring in the context of the development of fascism in Europe. Everything she observed and learnt she perceived in this context. She believed that fascism needed to be opposed militarily but was concerned that such opposition might lead to democracies being contaminated by a totalitarian mindset. She loved the Slavic culture that she found herself in; she believed that it embodied what she described as a culture of addition and that this culture must be a foundation for an effective opposition to fascism which would avoid such contamination.
It may seem far-fetched to link this with the situation of midwifery within the NHS but such a link seems pertinent to me. I believe the culture of addition is the basis for ensuring that practitioners feel resourced and that the culture of subtraction is the basis not only for totalitarian mindsets but of the deep rooted resistance within institutions to treating service users as autonomous -- in other words to real woman centred care.
In terms of the support of childbearing women this means opening up to and accepting the anxiety rather than trying to eliminate it. I learned as a psychotherapist that reassurance does not reassure. If a woman, anxious about the pain of labour, is told by her midwife 'don't worry, we'll take care of that' there is an implicit suggestion that she needs an armoury of analgesia and anaesthesia to have the pain taken away and that she needs professional support and complex technology. This is a suggestion based on the culture of subtraction. Compare it with my experience in my first labour. At one point I said to my midwife 'I'm afraid' and she did not try to take this away but responded simply 'of course'. The implicit assumption here, to my mind, was that I was undertaking something huge, something irrevocably life changing, something worthy of fear but the calmness of her tone and demeanour told me it was something which I was well able to survive. This was a response born of the culture of addition.
How might midwifery training be amended to facilitate this? I think it is necessary that midwives have faith in the process. This may not be so easy to acquire in a context where the dominant discipline, that of obstetrics, has itself no faith in the process and where midwives and students may find it quite hard to witness the process of birth without intervention. However there are, I think, sufficient contexts in which this is happening and sufficient articulate witnesses, Soo Downe for example, to amend this. But it will be necessary that midwifery as a discipline is clear that a major part of its raison d'etre is to support the physiological process. The reason for this emphasis needs to be clearly stated.
Physiology is important because, as case holding and independent midwives will attest, the physiology of labour is a complex and subtle process which is vulnerable to being interfered with but if uninterfered with is profoundly powerful. And as the research of Klaus and Kennell (more old research which I think has not been superseded) demonstrates it is the basis for good quality mother-child relationships. And good quality mother-child relationships are the basis not only for mental health but influence the nature of neurological development in the cerebral cortex. The work of Bessel A. van der Kolk and Alan N. Schore is an example.
I think that midwifery also needs to get a sense of itself as doing something profoundly important for individual mothers and babies, for their relationships, for the subsequent mental health of the child, and for society. To return to Isabel Menzies- Lyth, I re-read her research on children in long stay wards at the Royal National Orthopaedic Hospital. I re-read this because I remembered it concerned the staff, especially nursery nurses, being required to support mothers and children differently and I wondered whether there might be some parallels. In the event I found a number of parallels with midwifery. What was glaringly relevant was that the nursery nurses were being required to provide long-term continuity of care and emotional support for both the children and their families. In this case it was for children who were long stay orthopaedic patients rather than childbearing women but in both cases such care was the basis of psychological well-being. Unlike the situation with midwifery she accorded serious attention to the nature of the change she was requiring staff to make -- on P 114 she used the word 'courageous' and I notice that the whole research took four years (P 153). In other words I think what was important was that the staff felt they were being asked to make a big change but that it was for a commensurately worthwhile cause. There was also some explicit education about the nature of emotion (P 184) although she does not describe in detail what form this education took.
On P 187 she wrote 'their (the nursery nurses) initial training and experience had not usually prepared them for such work, nor had they chosen a profession in which they would ordinarily be expected to do it. It is much to their credit, therefore, that they were willing to undertake it and became very competent in carrying it out. This work involved, as did that with the children, being in close touch with and working with distress without denial, false reassurance or evasions but with respect, understanding and tolerance. It required a good deal of wisdom and understanding of the complexities of feelings.'
This quotation appealed to me because I saw a parallel with midwives caring for women in labour, or in any case with childbearing women's intense feelings. The difference is that midwives are supposed to have been trained to deal with this. I don't think midwives are trained to deal with this. However much their theoretical education may seem to deal with it there seems to be still the split between theory and practice and midwives, when confronted with practice which is uncaring, based on the values of the production line and not evidence based, either internalise the values implicit in it, leave, go into education, go independent or into one of the few case loading practices.
The current situation has wide social implications. In his book Promoting Equality Neil Thompson refers to the book Limits to Medicine by Ivan Illich. This book was originally published in the seventies. In it Ivan Illich introduces the concept of social iatrogenesis. Thompson defines this as 'the ways in which the social organisation of healthcare becomes a causal factor in the experience of ill health'(P102). And he quotes Illich:
'It (social iatrogenesis) obtains when medical bureaucracy creates ill health by increasing stress, by multiplying disabling dependence, by generating new painful needs, by lowering the levels of tolerance of discomfort or pain, by reducing the leeway that people are wont to concede to an individual when he suffers, and by abolishing even the right to self-care.
Social iatrogenesis is at work when healthcare is turned into a standardised item, a staple; when all suffering is hospitalised and homes become inhospitable to birth, sickness and death; when the language in which people could experience their bodies is turned into bureaucratic gobbledygook; or when suffering, mourning, and healing outside the patient role are labelled a form of deviance.' (P 49.)
Thompson distinguishes iatrogenic illness which is experienced by an individual from social iatrogenesis which affects what he describes as the 'macro level'. In terms of the maternity services this relates to such phenomena as the concentration of childbearing women into large centralised maternity units; the blanket imposition of policies such as routine induction at a certain gestation; the general culture in which women defer to those they consider more expert rather than trust the validity of their own experience. Obstetric social iatrogenesis has helped to create a society where many women are terrified of giving birth vaginally, where caesarean section is considered a reasonable alternative. In other words women have so little faith in the ability of their bodies to function in the way for which they evolved that they prefer to have their abdomens and wombs cut open; they consider the consequent comparatively high risks of infection and wound morbidity negligible in comparison to their fantasies of what might happen if they give birth normally. They do not consider at all the increased risk of their own deaths and the increased possibility that their baby might be lacerated by the scalpel and the inevitability that their baby's initiation of respiration must take place without the helpful stimulus of vaginal compression followed by the sudden release of emergence.
I would suggest that the current rate of caesarean section is an example of social iatrogenesis as are other unnecessary obstetric interventions. The extent to which they alleviate the individual anxiety of health professionals is unrecognised but I would maintain that the persistence of these procedures is testament to the power of this. One major social effect is regarding the way that childbirth is generally perceived and that these perceptions represent fantasy rather than reality. Many women are choosing a major operative procedure because they have internalised a sense of fragility and inadequacy comparable to that which drove the lethal interventions of the 18th century. These perceptions, now as then, are inaccurate and ironic given the current safety of childbirth in terms of both maternal and infant mortality.
I think that it is necessary to make very clear the ideological and social biases which influence medical practice. This is necessary if the power balance is to change between obstetrics and midwifery. This is an overtly feminist undertaking. I see it as contributing to the foundation of a clear exposition of midwifery knowledge.
- O'Driscoll K. and Meagher D.: The Active Management of Labour. W.B.Saunders Company Ltd, London, 1980.
- Menzies-Lyth I.: Containing Anxiety in Institutions, Selected Essays, Volume 1. Free Association Books, London. 1988.
- Kennell J.H., Jerauld R., Wolfe H., Chesler D., Kreger N., McAlpine W., Steffa M. & Klaus M.: Maternal Behaviour one year after early and extended post partum contact. Developmental Medicine and Child Neurology, 16 pp 172-179.
- Thompson N.: Promoting Equality: challenging discrimination and oppression. Palgrave Macmillan, Basingstoke. 2003.
- Illich I.: Limits to Medicine. Penguin, Harmondsworth. 1977.
- Midwifery Matters, Autumn 2005.
- Rebecca West: Black Lamb and Grey Falcon. Macmillan & co, London, 1955.