The Professional Autonomy of Midwives: what is it?
The nature of science
I want to look at science because it informs medicine, and the misperception of science is one reason for the dominance ofmedicine over midwifery.
The Cochrane database indicates that the continuing medicalisation of childbirth is, according to medicine's own terms of reference, which are self-avowedly scientific, irrational. It is irrational because the evidence in general points to a midwifery approach as having better outcomes for the majority of women and babies. (By midwifery approach I mean here an approach which assumes that childbirth is an act for which women's bodies are capable on the whole without intervention: more about this below.) If rational thinking, which accepts that research findings should be the basis for action, really drove practice then modern methods of childbirth which are hospital based and highly interventionist would have fallen into disuse.
I believe that science is itself intrinsically unscientific, because it's human. Humans are capable of rationality in certain circumstances, but only in certain circumstances. I'll explain this belief further below. This might be seen as a limitation of human thought, but I see it as an advantage. We encompass far more than rationality.
Science is often seen as a process which is gradually uncovering the truth, as though the truth exists somehow as a solid thing out there, and science is progressively uncovering it. This was certainly a belief that I left school with, although I didn't know I held it until my first lecture at the LSE in 1971 on Logic and Scientific Method. I was quite shocked when the lecturer demolished this idea, stated that there could be no such thing as objective truth, and described science as a process which is constantly changing as thinking builds on what has gone before and as the circumstances of life allow new hypotheses to become thinkable. Truth is therefore not fixed, and science is a process of human creativity in association with constantly changing material circumstances.
Philosophy at the LSE at the time was dominated by the theories of Karl Popper who described what he thought scientific method was. One of his basic tenets is that science involves applying certain rules, which should be accepted as conventions in the same way that the rules of a game are accepted by its players. These rules are based on logic, deductive rather than inductive logic. Inductive logic assumes that personal experience allows one to make universal claims. For example, I might say on the basis of my experience that all ravens are black. But the existence of one albino raven will disprove this statement. Science therefore also requires a very precise use of language. It would be more scientific to say: most ravens are black, or ravens will be black if certain circumstances are met. So science involves accepting rules and clarity of language. It also involves formulating statements in a way which allows them to be tested. If a statement is supported this does not mean proof. Given the changing nature of science it is a temporary support for the underlying theory. A theory, if it is to be scientific, must be not provable, but falsifiable. Newton's theory of gravity was accepted as permanent scientific truth until Einstein's theory was shown to explain phenomena which were not known at the time of Newton because astronomical instruments were not sufficiently powerful.
So findings will change, and they will do so influenced by general world view, technological developments, politics and economics (and these anyway are in a complex systemic relationship of mutual influence).
Science has brought benefits. Its clarity and economy allow information to be taught very efficiently, so that succeeding generations know more than those that have gone before. There are obvious technological advances. Science also has its own aesthetic beauty and an implicit morality involving universality of ideas and information sharing which I believe to be of value. Another advantage of scientific thinking rests on the concept of control. It became thinkable that human beings could manipulate resources and control outcomes, and in material terms this approach was very successful. A sense of control leads to a sense of agency, increased self esteem and a reduction in anxiety. This makes for good mental health, so long as the sense of control does not become unbalanced. Some things are beyond human control.
Control can become a problem if science is used to over control and manipulate; when it encourages a state of disconnection from our context, ecologically, socially and spiritually. Knowledge may be divorced from its contextbecause of a pretence of objectivity. Science can be politically manipulated. Research on the structure of the atom, which was supposedly undertaken for the sake of pure knowledge, led to the bombs which were dropped on Hiroshima and Nagasaki. Is pure knowledge possible?
Science developed historically in a context. This context was a complex and interdependent mix of philosophy, technological development, politics and religion. The origins of modern scientific thinking are generally ascribed to Francis Bacon and Rene Descartes. They are specific to what is now not very accurately referred to as 'the west', and what distinguishes this science from, for example, the science of ancient China is its application to manipulate nature, which in turn was made possibleby the famous Cartesian split of mind and matter. Men of science perceived themselves as separate and different from that which they studied. This time of the development of scientific thinking was also the time of imperialist exploration by 'the west'. This is no coincidence. Imperial domination also involved the belief that those dominated were different and inferior.
There is sometimes a confusion of science and technology. Science allows the development of technology, but what is developed and the way it is applied is driven more I would say by politics and commerce. Although in my lifetime the direction of scientific research has also become more vulnerable to politics and commerce.
The scientific way of thinking is the dominant world view. It is dominant in the sense that most public discourse unthinkingly uses the basic assumptions of science and automatically assumes that these assumptions are universally shared and most highly valued. It is also dominant in that the effects of science and technology have had an indelible effect on the way that people live their lives, not only in the developed world, but also, given the global nature of applied science, in the third world. Because of this dominance science is taken for granted. Its basic concepts and the way it is applied are seldom questioned and when they are questioned the debate is easily manipulated so that the questioner is wrongfooted. Certain assumptions of science, of the value and possibility of achieving objectivity and reductionism for example, are used to imply that the scientific world-view is based in concrete reality and an attempt to question these assumptions is seen as unthinkable, mad or infantile. Dominance is an appropriate word given the way that science in alliance with politics has been used to justify and render efficient the colonisation of what is perceived as useful to the capitalist world.
For example, why, in the context of childbearing, is priority is given to the interventionist? Colin Tudge raises similar points in the context of animal husbandry, a context which has parallels with midwifery. (I notice a similar homeliness in the words 'husbandry' and 'midwifery'.) Tudge (2001) sees a government report of early 1972 as crucial. The report, by Lord Rothschild, advocated the promotion of science in agriculture 'in so far as it generates high technologies of the kind that can be seen to promote profit.' In terms of animal husbandry it set the context for it to become conceivable that herbivore cattle be fed dead animal remains. This of course led to BSE with its risk to people in the form of vCJD. Tudge goes on to say 'Increasingly scientific research is paid for by private enterprise, which in practice means big business. Big business promotes the kind of scientific research that will provide the kind of technologies that can underpin the most profitable modus operandi. The most profitable modus operandi in agriculture is industrial.' (P 26)
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 which funds the interventionist is prioritised. This is usually justified by a belief that this reduces mortality and morbidity. This belief is debatable (Tew 1998). But it alters what is conceived to be the normal in a way which encourages and legitimises further intervention. And intervention serves the purpose not only of generating profit but also of maintaining medical dominance over the process. Continuous electronic fetal monitoring has been shown to be counterproductive to the wellbeing of mother and child, but it has the advantage for some of being very profitable and keeping women compliant and still. The political implications of this are vast, seldom articulated because they are taken for granted, but not the focus of this article.
These politically and technologically based norms then become unthinkingly internalised. It is widely accepted as the basis for obstetric 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.
So science is inextricable in its application from the social and political.
An overemphasis on the value of science is generally referred to as scientism. And central to this misconception of science is the concept of reductionism, where greater value is ascribed to more basic explanations. So psychology, for example, may try to construct its concepts in terms of the biological sciences, in a belief that they have more credibility. Medicine as a discipline has difficulty dealing with the universal and powerful phenomenon of the placebo because it tends to overemphasise the physiological and play down psychological and social aspects of illness.
The limits of science
1) The limits of RCTs.
Controlled trials work very well when testing isolated variables. This means that what is being tested needs to be capable of being broken down into discrete entities which can then be subjected to different conditions, and outcomes need to be measurable. My son did an experiment at school recently which tested the elasticity of different materials. So to be sure that it was the nature of the material which related to the degree of elasticity, care needed to be taken that the different materials were all subjected to the same conditions when they were tested.
In human populations randomisation is a way of ensuring that different social variables such as class are equally distributed in the different experimental groups. This is another way of trying to eliminate bias. Randomised controlled trials in medicine or midwifery are usually used to compare two different treatments. Randomisation is an attempt to make sure that the two groups are as similar as possible. If people elect to be in certain groups then there is the bias of self selection. With RCTs any differences in outcome between the two groups should be due to differences in the treatments being tested. There are sophisticated statistical tests to demonstrate whether any differences between the groups are statistically significant, or whether they are of a size that may just as well be due to chance. Even if a result is statistically significant it may in reality be due to chance or to other overlooked factors. RCTs are not concerned with individuals, they are concerned with groups: they cannot account for individual variation because of the nature of the statistical tests which the data undergo..
There are obvious limitations to this approach. It only works for comparatively simple phenomena: a drug of a certain dosage versus a placebo, for example. It is my experience as a refugee from psychology to midwifery that this scientific approach is inadequate for understanding or communicating human experience. We are too complex to be analysable in a way that makes controlled testing realistic. As a psychology student at a time when psychology as a discipline was trying very hard to acquire the prestige and status of 'hard' science I didn't recognise humanity in very much I was taught. It was important at that time in the discipline that human behaviour be quantified, and this in itself distorted totally whatever it was under examination. I have a philosophical problem with the intrinsic reductionism of the necessity to analyse. And it may be the individual differences which give more information about the phenomenon under consideration.
It is obvious how, in midwifery, the phenomenon of labour can be seen as something too complex to be analysed in this way. It involves the physical, the psychological, the social, the sexual and the spiritual. Anything which attempts to observe and measure what is going on runs the risk of distorting a very delicate and subtly balanced process.
2) The limits of rationality
A problem I have with Popper is he way he values the scientific above all other modes of understanding. I am particularly interested in the way that hypotheses are generated, and I see this process as not primarily rational: it involves imagination and unconscious processes. I value disciplines such as psychoanalysis which are concerned with these processes but which Popper derided. Although it must be said that part of his derision is justifiable because psychoanalysis tried to mitigate its sense of inferiority by claiming a scientific status it does not have. I regard it as an imaginative discourse which can explain a lot on that level. This does not mean it has no value: science does not have a monopoly on value.
I believe that human beings are not intrinsically or even mostly rational. Rationality belongs to the neo cortex and developed comparatively late in evolution, just as it develops comparatively late in individual development. (I do not think that individual development mirrors that of evolution.) According to the psychoanalytic thinking described above mental activity involves a constant background of 'primary processes', which is a kind of stream of consciousness - often a stream of unconsciousness - involving distortions and condensations and weird associations. When individuals are under stress they revert to primitive thought patterns, a good example of which is splitting and projection whereby negative characteristics are denied in oneself and attributed to an outgroup. Rational thought needs background security because secondary process thinking is secondary in the sense that it needs to develop out of primary process thinking, it is a comparatively recent and precarious development in both the species and in individuals, and there is always the possibility of regression - more than possibility - in times of stress. Scientific rationality and objectivity are only possible in humans to a limited extent. According to psychodynamic theory, which can be seen as a theory of the irrational, much cognitive endeavour is an imaginative attempt to create a way of being in the world which minimises uncertainty. This may distort reality. Scientists are as human in this as the rest of us.
Tudge states 'Science at any one time gives the impression that its explanations are complete; that everything pertinent has been taken into account. Scientists often speak as if this were the case' (P 27). It is current scientific orthodoxy, for example, that the origins of the universe lie in a split second: the big bang. This, which is only a theory which cannot be demonstrated, is spoken of as fact. Jeremy Narby writes of scientific theses on the origin of life: 'Any certitude on this question is a matter of faith' (P 161): these claims are themselves irrational and therefore unscientific. As we saw above they are in contradiction of the tenets of scientific method, which precludes certainty and fixity. This desire for certainty is understandable, but understanding it lies within a discourse of understanding which may be psychological or religious, but is not scientific.
In midwifery the search for certainty and predictability is found in the use of policies, procedures and 'guidelines' which attempt to make the characteristics of individual women meet some spurious norm, antenatally, in labour and postnatally.
Alan Bennett in a quotation from Kenneth Graham, author of Wind in the Willows describes how the personal is to be found throughout the apparently objective: '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).
Science and pseudo-science
Some disciplines claim a scientific status they are not entitled to according to Popper's criteria. I mentioned psychoanalysis above. But medicine also is a pseudo-science. It includes practices which are intrinsically irrational, and which serve social or political purposes. Some even work because they are irrational either using the placebo effect or by developing a sense of trust in the process or caregiver. Medicine would not see examination and fostering of the placebo effect as within its remit: not 'hard' science. But I think that midwives could very fruitfully investigate the role of the midwife as intrinsically a placebo.
Controversially: there are some things I will not believe, even if the evidence seems unassailable. I do not believe in the Big Bang theory of the origin of the universe. It offends me philosophically in its presumption that something has somehow come out of nothing. So anything I believe has to accord with my personal philosophy, and that is woven through with political assumptions and various other types of belief. So I judge the basis for my beliefs on whether what is stated accords with an underlying world view which, for me, includes the scientific but is not limited to it.
I want to give some value to the non-scientific as well as the scientific. Processes of irrationality can be so fruitful. It could be argued that processes of irrationality are intrinsic to science insofar as they provide the breeding ground for theory and hypothesis. Unscientific myths and popular beliefs have value. They provide a context within which the woman and her attendants can give meaning to the complex process of bringing a child into the world: a process which involves far more than the physical. The baby is to be born and bred in the context of these myths and popular beliefs and myth and popular beliefs still inform the process. They are just different ones: that birth is safer if the woman is separated from her home environment and introduced to strangers; that birth is difficult and painful and can only be accomplished with medical assistance and pharmacological pain relief, for example. A midwife confirms the belief structure into which babies are born, and nowadays that belief structure is pseudoscientific. Then and now it includes superstition. Obstetrics also includes superstition: that ARM at three centimetres dilatation enhances labour is one example. If the non-scientific can be valued there will be less temptation to create pseudo-sciences. Psychology and medicine could incorporate the unscientific aspects which are so intrinsic to their functioning. There are implications here for midwifery. Do not ape the pseudo-scientific. Central to midwifery is intuition, which is by definition not amenable to rational analysis.
A Specific Midwifery Knowledge?
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. And obstetrics of course is more powerful: it is the dominant discourse, it is allied with powerful technological and profit making interests. 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 it is important that a midwife knows broad based theory, her work is or should be with the individual, and any individual may deviate from norms. Midwifery guidelines may therefore need to be based on much broader principles. For example instead of the (spurious) norm that labour should progress at the rate of 1 cm per hour, a more productive approach for midwives is to assume that as long as the condition of mother and baby is all right there is no need to intervene. And if this assumption only applies, or applies best, in conditions where the woman feels safe and can regress, then midwives need to be researching what those conditions are and promoting them.
The effect that the application of scientism has had on childbirth is apparent in the endemic overmedicalisation of hospital practice.
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. To accept these time limits on the physiological process of birth is to render further intervention inevitable.
It seems a basic midwifery tenet that the vast majority of women are capable of giving birth without any intervention. The human body has evolved to do this. What midwives, then and now, need to be able to do is to provide unobtrusive observation of the process while giving a high level of psychological, emotional and where appropriate spiritual support and to intervene in an emergency on the few occasions when they are called upon to do so. In a modern context this intervention would involve calling upon the specialist skills of an obstetrician.
There are relevant issues for midwives which RCTs cannot illuminate:in Mavis Kirkham's book The Midwife-Mother Relationship she describes skills for relationship, and talks about the qualities a midwife needs to bring to being with a woman in childbirth. What can foster these? What can impede them? Midwives may define the word safety quite differently from obstetricians. Midwives need to understand the power of the macro-politics and the micro-psychodynamic. This needs a different discourse from the biomedical and different allegiances.
Most midwifery texts, however much they might wish it otherwise, exist very much within the medico-nursing framework and much of the intuitive nature of midwifery is omitted. But it is hard to articulate the intuitive, and methods for developing it owe little to science.
I believe that midwifery must encompass qualities which are not amenable to research because they are not measurable, such as this intuition and the quality of care a midwife feels and expresses to a woman. I think it would be a terrible pity if midwifery took on the values of science to the extent that it lost the unquantifiable: midwifery would be destroyed.To quote myself in Labour and Sexuality (Southern 1994):
'The language of science is the language of public discourse, what Ursula le Guin calls the father tongue. In her attempt to describe the mother tongue, the language that women use in the private and domestic sphere she wrote:
We are told in words and not in words, we are told by their deafness,
by their stone ears, that our experience of life, the life experience of
women is not acceptable to men, therefore not valuable to society,
to humanity. We are valued by men only as an element of their
experience...anything we may say, anything we may do, is recognised
only if said or done in their service.
One thing we incontestably do is have babies. So we have babies as
the male priests, lawmakers and doctors tell us to have them, when
and how to have them, how often and how to have them; so that
is all under control. But we are not to talk about having them because
that is not part of the experience of men.
... (As midwives) we need research and well referenced articles, but we also need to understand and speak the mother tongue; that is the language our clients speak. As midwives maybe we can forge a unique dialect of it for ourselves.'
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 confersmany 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 arguably 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.
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), 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. But I think midwifery would be healthier if it were to learn to accommodate death: Jeanne Achterberg: 'First and foremost, avoiding death is not the purpose for the practice of medicine in the shamanic traditions' (P 17). I don't know if it comes across as callous to say that there will never be a zero maternal or perinatal mortality rate and that in the impossible and illusory search for this women and midwives have both lost power.
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 maintain that the mother-child relationship is the strongest there is: 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.
In my view midwifery assumptions imply a value system which sees health as involving connection with nature andtherefore 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 would be the value system on which midwifery knowledge is based?
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. Scientism and pseudo-science bear some responsibility for this.
- Achterberg J: Imagery in Healing: shamanism and modern medicine. Shambala, Boston Massachusetts, 1985.
- Kirkham M.: The Midwife-Mother Relationship. Macmillan 2000? 2001?
- Narby J: The Cosmic Serpent. Jeremy Tarcher/Putnam, New York. 1998.
- Silverton L.: The Art and Science of Midwifery. Prentice Hall International (UK) Ltd, Hemel Hempstead, Hertfordshire. 1993.
- Southern M.: Labour and Sexuality. Midwifery Matters No 61, Summer 1994 pp 5-7.
- Taylor M.: An Ex-Midwife's Reflections on Supervision from a Psychotherapeutic Viewpoint in Kirkham M. (ed) Supervision of Midwives. Books for Midwives Press, Hale, Cheshire, 1996.
- Tudge C.: Bring Back Common Sense. New Statesman 29th January 2001.
- Winnicott D.W. Primary Maternal Preoccupation in Winnicott D.W. Through Paediatrics to Psychoanalysis. Hogarth Press, London, 1956.