Psychoanalysis and Midwifery

A conference on psychoanalysis and midwifery was held at Guy's Hospital on December 11th 2004. This was the same day as the winter ARM meeting in Milton Keynes but nevertheless the conference was well attended: there were about 180 delegates. It was organised by the Freud Museum, with considerable input from Jessica James. This conference brings together two areas of special interest for me. It was a great pleasure to attend it. What follows is a subjective overview of the day describing in detail what particularly impressed me.

Psychoanalysis is a system of thought based on the theorising of Sigmund Freud. It is not generally well-regarded within academic psychology, which considers it unscientific, but I think it has a great deal to offer in the understanding of human beings. There is no space here to describe it adequately, but I regard it highly because it offers an explanation of human irrationality. The concept of the unconscious is crucial here. I do not believe that people are predominantly rational and I therefore do not consider it inappropriate that an explanation of human nature might be derived from an imaginative rather than a scientific method of thinking. I think psychoanalysis is particularly relevant to midwifery because one of its fundamental tenets is that early infant experience is particularly powerful in shaping the nature of a person's psyche. It seems to me to suggest by implication therefore that the nature of midwifery care can influence mental health.

Psychoanalytic thinking has also been applied to the way in which people function in institutions. The work of Tom Main and Isabel Menzies-Lyth is crucial here. I think that this work can explain a great deal of the resistance to change which Mavis Kirkham described in her paper.

Mavis Kirkham's talk was entitled Culture, coping and contradictions -- Midwifery in the NHS. It was a very clear and frank description of why midwives leave and how they stay in an environment which is becoming increasingly unhealthy. I understand that she is going to write at greater length about this, so I am not going to give it the space here which it merits.

I was very surprised to find myself intrigued by the substance of Michel Odent's talk. This was entitled 'Lessons from beliefs and rituals in the perinatal period'. He concentrated on physiology, describing how adrenaline counteracts the effect of oxytocin. Human women are also mammals and labouring mammals need security and warmth. Any perceived threat will elicit the production of adrenaline and this will interfere with the process of labour so that the animal can physically escape the threat. A physiological third stage involves an upsurge in oxytocin production greater than any other including that needed for the contractions of labour or involved in the most intense orgasm. He considers this upsurge in oxytocin to be crucial in creating the sensitive period after birth for intense mother/child attachment. It is obvious how an actively managed third stage interferes with this spontaneous upsurge but he also described how certain non industrial cultures have developed rituals and beliefs which interfere with this attachment. These include a taboo on the mother making eye contact with the child, 'smoking' the baby by passing it through the smoke of a fire and the taboo on giving the baby colostrum. These various rituals interfere with the mother/baby bond by keeping the mother and child separate at this time of critical sensitivity and he believes this serves an evolutionary purpose by attenuating the strength of what he describes as maternal protectiveness and aggression. He contrasted human mothers' docility with that of other mammals, even herbivorous mammals such as ewes, who, if their newborn young are threatened, will respond with lethal aggression. In humans he suggests this dilution of the maternal response enables a perversion of aggression such that domination over other people and nature becomes the norm. One of the reasons why this struck a chord with me was because, after the totally uninterfered with birth at home of my first child, I thought of various hospital practices which I had observed over the years, especially babies being given artificial milk without their mothers' knowledge or consent and I astounded myself by thinking that if anybody were to do this to my child I would kill them. I have long thought that the physiology of labour can provide a basis for a midwifery theory and practice, as opposed to be current theory and practice which is largely driven by obstetric concerns. I was gratified and interested to read some years ago that Umberto Eco had based a system of ethics on physiology. Any interference with normal physiological processes can be seen as abusive or worse: sleep deprivation can be the basis of torture. It seems to me that any intervention which disrupts the normal physiology of the process of childbirth must be justified in ethical terms.

Joan Raphael-Leff, a psychoanalyst well-known for her writings on the psychology of childbearing, described the broader context in which women have babies: the nature of the institutions as described by Ervine Goffman and Isabel Menzies-Lyth; the vulnerability of the labouring women. But she focused on the psychotherapeutic context. Without denying the reality of risk she described the primitive emotions such as awe and envy evoked by the power of the creativity of childbearing. She described more useful ways by which midwives could deal with the institution and the powerful emotions evoked by the work: staff support; a better focus on psychology during training; group and individual counselling; time, and a congenial ethos, for grieving and debriefing.

She also described ways in which the social and cultural context of childbirth had changed. Expectations have been raised around control and outcome. Women expect to bear children if they so desire and expect medical technology to meet this desire. However, when they become pregnant the reality of the physical nature of the event and the consequent real difference between, and often inequality of, the sexes frequently hits home. Regardless of overexcited journalistic claims about male reproduction, it is only women who bear children. Childbearing women are frequently shocked by experiences such as loss of dignity; a loss of physical integrity as they must share their body with another developing person; marginality when women used to pursuing a professional life find their new maternal concerns pushed to the side. This change happens within a social context where childbearing has become a comparative rarity. Families are comparatively small now. She showed a picture of a 19th-century family comprising around eight children and pointed out how the oldest girl, by the time she came to have her own children, would have experienced the complicated emotions evoked by a small baby a number of times as each successive younger sibling was born.

She described how a new mother, especially a first-time mother, as she relates with and discovers her baby also relates with and rediscovers her own baby self. This was an expression of a conclusion which I had come to when I was a new mother. I had concluded that in order for the mother to empathise with her non-verbal young baby she was, in effect, reliving her own babyhood. The nature of this experience will differ for each individual woman. Those women who have been traumatised or distorted by the experience will tend to perpetuate this in their upbringing of their babies.

Just as new mothers in this society do not often have the opportunity to encounter babies before their own first pregnancies, so midwives will not have had the opportunity to encounter the powerful arousing stimuli which childbearing women evoke. One of the psychotherapists in the audience made a comment about the inevitability of envy of the power and creativity of childbearing. Concepts such as this -- envy -- are the bread and butter of psychotherapeutic thinking but are still taboo within midwifery. This taboo status means that as a phenomenon its existence is denied, although from my perspective it is a powerful determinant of both institutional structures and individual responses. This denial can paradoxically lead to its continuing existence as a motivating force, stronger and more difficult to eradicate than if it were recognised and accepted.

Pat Hughes spoke about her research on the management of stillbirth. She trained first as a medical practitioner and then as a psychoanalyst and group analyst. I was broadly familiar with her research findings because a friend had heard her speak and we had discussed them but Pat gave some details here which I found particularly impressive. She said that thirty years ago, if a woman had a stillborn baby, the baby would be taken away and the body disposed of by the hospital because to see it would be considered too upsetting. Since then there has been a radical change: now if a woman has a stillborn baby she and her partner will be encouraged to see and hold the baby, to select mementos such as hand or footprints, to provide a funeral for the baby. The research was intended to find out whether this change brought about improved psychological outcomes: it was assumed that such improvements would be demonstrated.

Before she described the structure of her research she outlined the history of this change in practice. In the late sixties a paper was written by a psychoanalyst describing the in-depth therapy of two people. It is quite normal in psychoanalysis to base theory on in-depth work with a few or even one client, but it is not normal to base changes in healthcare practice on such small samples. The effect of this one paper has been very powerful and it is difficult to know to what extent this paper caused the change in attitudes or was a reflection of an underlying change. This change in practice was endorsed by the RCOG in 1985.

Three groups of women whose first baby was stillborn but who had subsequently had a live child were compared: those who had not seen their baby at all; those who had merely held their baby; and those who had held, taken mementos and organised a funeral for their babies. Each woman was assessed for anxiety, depression, and post-traumatic stress disorder and their subsequent child was also assessed at a year to see how well they were attached to their mother. There is a substantial body of theory around attachment and norms for healthy attachment have been accepted and criteria devised to measure this.

The sample was only 65 but the results were conclusive. Pat emphasised that grief and bereavement are not pathological. It is to be expected that women whose baby had been stillborn will be marked by this. But she considered the normal grief process in this context to be such that by six to nine months after the stillbirth the event would not be taking up most of the space in the woman's mind.

But the results of this study were consistently the opposite of those expected. Those women who had not seen their baby were less anxious, depressed and had experienced less PTSD; their next babies were attached better. Those women who had held their babies but nothing more were intermediate on all these indices. And those women who had fully adhered to the recommendations and had more involvement with their babies were consistently worse and their subsequent children were more insecure. One change which did have noticeably good effects was the recommendation not to conceive within a year. Conception within this time led to poorer outcomes. Family support related to improved outcomes; counselling was found to be neutral and attending support groups was found to contribute to negative results.

Pat described the social context for this change. By the 1970s maternal and perinatal mortality and morbidity were much improved. She attributed this to reliable and safe blood transfusions, the introduction of antibiotics and the monitoring and control of BP in pregnancy. Also in the 1970s there was the recommendation of the Peel Report that all births should take place in hospital and the consumer backlash against this. At that time home birth was a feminist issue.

The results of her research were widely publicised in the media and misinterpreted as a recommendation that parents should not hold their stillborn babies. She and her research team received abusive letters and e-mails. Of the feedback she received 95% of the parents who had seen and held their babies were glad to have done so. A return to previous practices seems unthinkable.

When I was discussing these results with my friend we wondered whether reluctant parents were being encouraged to see and hold their babies by over rigid staff. It would seem that this was not so: the parents did not feel coerced. I also wondered whether, just as there seems to be a sensitive period after giving birth for the development of attachment, women who feel that their baby might not survive cut-off in order precisely to avoid feeling this attachment. Pat suggested that one explanation for the poor outcomes might be that the currently recommended practice encourages mothers to become attached to their dead babies in the same way as they would to their living ones by avoiding this protective cutting off mechanism. Attendance at peer support groups might well further encourage this. In the context of this conference this struck me as a very reasonable hypothesis. Within the last few years there have been articles in the Psychologist and the Guardian suggesting that disaster counselling soon after sudden and disastrous events such as the Lockerbie bombing or the recent tsunami can exacerbate distress. I think Pat Hughes's findings demonstrate something analogous. In these contexts there would seem to be a necessity for some kind of interim state of psychological withdrawal. It is as if the psyche needs to experience some kind of protective shock. Psychological descriptions of the grief process describe a state of numbing. This study would suggest that this numbing is ultimately therapeutic. Psychoanalysis has a concept of cathexis which means, essentially, psychological investment or attachment. The process of childbearing would seem intrinsically to involve a unique form of cathexis. But with death there needs to be a gradual process of decathexis. The present practice around stillbirth would seem to undermine this.

I was also particularly impressed by the way in which the mother's state of mind influenced the degree and quality of attachment of the next child. This would seem to be evidence of the powerful nature of the experience of childbirth. The strength and resilience of a child's attachment to its mother influences its psychological and social development. It would seem that this particular practice is unsound from this point of view. I would suggest that other practices, many of which are so deeply accepted that they are not even seen as options, may be similarly unsound. I'm thinking about the institutionalisation of childbirth; the overuse of induction of labour; the high incidence of artificial feeding of young babies and many others.

Jessica James works in Hackney, Inner London, with expectant and new parents. She has also trained as a group analyst and works at the Anna Freud Centre as a parent/infant psychotherapist. She presented a very interesting paper which graphically showed the parallel processes operating between mothers and babies, between midwives looking after labouring women and women in labour and between childbirth educators and their clients. She started by showing a film of an experienced mother changing the nappy of her twelve day-old son. The baby was distressed, his arms flailing and his cries high-pitched. As she was changing him the mother was comparatively brusque and matter-of-fact. After she had finished changing him she lifted him, gazed at him and as her tone modified to one which was more soothing he gradually quietened, making eye contact with his mother and imitating the movements of her mouth. Jessica asked us to imagine what the baby was feeling, what the mother was feeling and to think about what we had been feeling as we watched it. I found it a very powerful film. At the height of the baby's distress I was repetitively and silently uttering the reassuring noises which I would have made in real life. I was moved to tears by the resolution and good communication between mother and child. I was not capable of thought.

She then described a vignette of a woman in labour. She has been coping well with her contractions, mobilising, breathing through them. Her partner has been attentive and helpful. The midwife performs a VE. This requires the women to lie on the bed, to come out of the self absorbed trance she had been in. Her partner becomes an observer rather than a participant. The midwife becomes much more active, concentrating on her findings. While she can report progress it is not as much progress as all had hoped. She needs to go off shift soon. She speaks to the mother in such a way as to emphasise the fact that progress has been made. She speaks to the partner to assure him that his contribution has been very helpful. She leaves the couple with a sense that they have the resources within themselves to see them through the rest of the labour in her absence. Jessica then went on to describe the work she does with expectant couples as analogous to the work of the mother and the midwife in the previous two descriptions. She used concepts derived from the work of Winnicott to illustrate the processes involved, particularly the concepts of disruption, repair and scaffolding. She also referred to the basic psychoanalytic concepts of transference and countertransference.

Winnicott was a British psychoanalyst who, I think, has particular relevance to midwives. Unlike many other psychoanalysts at the time he was neither a neurologist nor a psychiatrist but a paediatrician. This means that he was not dealing with psychopathology but with sick children in ordinary family settings. His theoretical focus, in my understanding, highlights this. He is well known for saying that there is no such thing as a baby meaning that a baby cannot survive outside the context of a caring relationship. He is also well known for the phrase 'good enough mothering'. By this he means that perfection is neither possible nor desirable. All babies will experience disruption and all good enough mothers will provide repair. They will create a 'scaffolding' within which the emotional repair can take place. In fact babies need this contrast to learn resilience. Jessica was suggesting that midwives can not only provide a similar scaffolding for childbearing women but that the quality of the scaffolding can influence the resilience of the woman's response to her experiences. I would suggest that the nature of this scaffolding can actually affect the physical course of the labour. Moreover it can provide a model of the way in which especially a first-time mother can later provide care for her baby.

Transference is a concept derived quite early in Freud's thinking. It is used to describe the way in which any relationship will evoke each person's idiosyncratic style of relating which, in turn, is learnt as a child relating to its parents. In psychodynamic psychotherapy the therapist will consciously use this as a major part of the work. Transference can distort relationships. For example, a parent discussing his child's progress with a teacher may find himself responding to the teacher in the same way that he did when he was at school: he may be over deferential or rebellious. Relationships with authority figures tend particularly to evoke transference. Psychotherapists' structures are designed to enhance transference, and their training equips them to deal with it. All midwives will experience transference. And their training gives them no equipment to deal with this at all. For midwives the transference will probably be particularly coloured by the client's relationship with her own mother.

Countertransference refers to the way in which the professional, psychotherapist or midwife, experiences the equivalent. This will affect their style of relating to their clients. All midwives will have a range of attitudes to childbearing which will influence the way in which they deal with their clients. When Joan Raphael-Leff referred to midwifery training involving a better psychological input I would assume that this must involve a quite deep understanding of transference and countertransference.

Carol Bates, according to the information we were given, devised a course for qualified midwives at University College Hospital, London, which focused on psychological processes and integrated infant observation seminars into the curriculum. This sounds extremely interesting and very pertinent to the conference. I would have liked to have learnt what led her to conclude that infant observation would be of benefit to midwives, because this was a conclusion which I made during the course of the conference. I would also have liked to have learnt how midwives found this. Mavis Kirkham found, in one of her studies, that midwives experienced clinical supervision not as helpful but as onerous. Unfortunately I missed the substance of Carol's talk as I had been having some problems with the wheelchair accessible lavatories. What I did hear was a subjective assertion of the necessity for a more psychological approach to midwifery education and practice but without a very coherent basis for this assertion.

Conclusions

Psychoanalysis can offer concepts which explain aspects of a midwife's work and which allow her to process disturbing emotions which may be aroused. It is also possible that a greater socio-psychological insight informed by the concepts of psychoanalysis may enable midwives to practice in a way that reduces the tendency of mothers to repeat the inadequacies of their own child-rearing and to allow midwives to leave behind those unhelpful past influences which may distort their practice.

The January 2005 edition of The Psychologist, which is the bulletin of the British Psychological Society, contains an article by Keith Nichols in which he is examining the lack of impact which 30 years of health psychology has had on the experience of hospital patients. In this article he states that hospital patients experience a total lack of psychological care. By this he means not specialist input from psychologists or psychotherapists but a delivery of appropriate care by nurses, doctors and other therapists which recognises the basic humanity of the patient in the bed. The Psychologist, as an organ of academic psychology, does not tend to use the language of psychoanalysis, so this article does not look at the concept of resistance. Keith Nichols was surprised and dismayed. I was not surprised because I am familiar with the concept of resistance but am also dismayed. Over the last 25 years I have observed the way in which nursing and midwifery have failed to implement on a large scale any attempt to approach patients or clients with decent psychological care. Attempts at total patient care or primary nursing have been subverted by the concept of 'skill mix' which decrees that it is not economic for trained staff to administer basic care. During the time when Changing Childbirth -- a regime designed to further individual choice and raise the status of midwives -- was being implemented the number of maternity units where the caesarean section rate was 25% or higher doubled. Isabel Menzies-Lyth described the cause of this deep psychological resistance in the 1950s. In one of the discussions a midwife from the Albany practice asked why the Albany practice was still the only such practice in the NHS: not only a case holding practice but one where, because the midwives are self-employed, they have true autonomy. This concept of resistance partly explains why.

One phrase used more than once at this conference was the medicalisation of childbirth. I haven't heard this phrase for quite a long time. But if midwifery is to evolve in a way that fully takes on the insights of psychoanalysis, that delivers truly women centred, ethical care then medicalisation must be left behind. This is a huge undertaking. It involves confronting not only individual and institutional defences but also a deeply entrenched power bloc. The answer to this question about the Albany practice involves not only psychoanalysis but also politics.

During the course of the day the discussion focused at one point on independent midwifery as offering a template for good care. A deep split between obstetrics and midwifery especially involving different concepts of risk was described. The possibility of the NHS contracting independent midwives was mooted. One possible problem involved in independent midwives' contracting into the NHS involves contract law: in this instance the NHS would be the client and the independent midwife the contractor. Under health and safety legislation the client has responsibility to ensure that the contractor follows 'safe' practice and it is possible that what makes independent midwives' practice distinctive might be curtailed by trust policies and procedures. In this case, it might be better if independent midwives could arrange to be funded by the NHS under some sort of grant. This was not mentioned during the conference but was pointed out to me by my partner who is a health and safety practitioner. It is an example of the way in which fundamental and broad structures are changed to maintain a status quo which perpetuates defensive practice. This metamorphosis of such structures is one aspect of the way in which resistance manifests.

In their article publicising the conference Ivan Ward and Kalu Singh wrote 'it is shocking to realise that no society or culture has ever regarded the way it treats its mothers-to-be as an index of its moral integrity or enlightened values. It may be that the time is right to bring maternity into the heart of our thinking and political debate and to argue for the unconditional, free provision of social and psychological support for the mother and child, from conception and birth through to infancy and early childhood.' They also refer to the loss of a psychological and spiritual dimension in the understanding of maternity governed by a 'crude biologism' which sees the body as a machine. This loss has replaced 'the idea of birth as an interconnected process (with) the idea of birth as a bio-medical event'. Within the last decade or so New Zealand has radically revamped its maternity services so that now the money follows the woman who is free to choose case holding midwifery if she wishes. Midwifery training in New Zealand now accommodates this alternative of autonomous practice. But New Zealand has an advantage which we, in Britain, do not. The Maori community is still in touch with an ethos of childbirth which expresses social and spiritual values. And they were sufficiently politically enlightened and articulate to describe how the medicalisation of childbirth violates these values. There is no such coherent and articulate community in Britain. I fear that tokophobia is too endemic now for something analogous to happen here. It is possible that psychoanalysis and midwifery together could forge the basis of a similarly strong articulation of such an ethos here. What I should like to have come from this conference was a clear articulation of the basic theoretical principles of both disciplines as a grounding for this. It would have been good if a basic structure was designed to begin this with the intention of creating a strategy to bring about change such that the well-being of childbearing women and their babies becomes paramount.