By Nicky Leap
If you look up the word “power” in the dictionary, you’ll come across some definitions that fit well within the concept of the “skilled companion” described by Professor Lesley Page and other midwives who expound a “woman-centred”, “woman-led”, “with woman” approach to midwifery.
You will also find definitions of the word “power” that are more in keeping with the authoritarian approach to midwifery. Such definitions of “power” will trigger different reactions in all of us. Today I shall be attempting to look at different concepts and uses of power in relation to midwifery, paying particular attention to how we, as midwives, move forward in building woman-led services.
I would like to start by reminding everyone of the definition of a midwife that was adopted by the International Confederation of Midwives and International Confederation of Gynaecologists and Obstetricians in 1972 and ’73 following amendment of the World Health Organisation’s definition of a midwife:
The midwife must be able to give the necessary supervision, care and advice to women during pregnancy, labour and the post-partum period, to conduct deliveries on her own responsibility, and to care for the newborn and the infant.This care includes preventive measures, the detection of abnormal conditions in mother and child, the procurement of medical assistance and the execution of emergency measures in the absence of medical help.
She has an important task in health counselling and education, not only for the patients, but also within the family and the community.
The work should involve antenatal education and preparation for parenthood and extends to certain areas of gynaecology, family planning and child care. She may practise in hospitals, health units, under domiciliary conditions or in any other service.
That’s a fairly wide brief and in recent years some of us have attempted our own precis of the role of the midwife and it goes something like this:
The aim of the midwife is to facilitate the empowerment of women through their experiences of pregnancy, childbirth and parenting.
In fact, “empowerment” has become a bit of a “buzz word” in midwifery recently and maybe it’s time to look more closely at what that concept means in real terms.
I suggest that it’s impossible for midwives to enable women to feel empowered if midwives themselves are disempowered. I know that almost everywhere in the world midwives are feeling the need to guard their role from encroaching medicalisation and that in some places midwives feel that they have become little more than “obstetric nurses”, described by some as “doctors’ handmaidens”.
However, I suggest that there are strategies that we can adopt that will maximise the potential of any situation in enabling midwives and women to maintain and develop their power around childbirth.
These strategies have their roots in three main factors:
- Alliances with women
- Alliances with midwives
- Alliances with other practitioners
I shall talk firstly about alliances between midwives and women. The situations in New Zealand and Canada are fine examples of what can be achieved where midwives and women come together to attempt to change legislation and build woman-led midwifery services funded by the State.
Wherever midwives work we need to understand the importance of developing networking skills in our local communities. At one level this is part of the work we do all the time — putting women with particular needs or circumstances in touch with each other so that they can develop appropriate support networks.
We may also work at encouraging women to play a more prominent role in forming and joining campaign groups and in sitting on committees that make decision about funding and planning maternity services and related projects. This often means pursuing financial resources and creche facilities to enable those least likely to have access to performing such a role the opportunity to get involved.
At another level it means that midwives ourselves need to be on management committees of voluntary and statutory organisations in order to “have a finger on the pulse” of what is going on in our local areas. The midwife who is politically active keeps a watchful eye on local developments and builds a useful body of contacts at every level of intertwining hierachies: health workers, social workers, youth and community workers, teachers, government officers, members of support groups and voluntary organisations.
This sort of networking is about making our voices heard and not missing opportunities. Initially it’s daunting for many of us, this sitting on committees, but an approach of this kind is about all of us, midwives and the women we attend, building our confidence and skills at speaking out in places where the power lies in order to change things for childbearing women and their families.
In order for us all to move forward in planning and providing safe, woman centred maternity services, there needs to be good working relationships between all professionals involved, both purchasers and providers. We need to build mutual trust and respect and there needs to be recognition of our separate roles and how they complement each other. We need to establish equity between the three main lead professionals, midwives, obstetricians and GPs and move forward together. Good inter-professional relationships are vital for a safe and supportive service.
If midwives are to be powerful and effective we also need to come together in order to build trust, to support each other and to break down the rigid hierarchies which stop us moving forward together. This means meeting our colleagues regularly for skill sharing sessions, to look at research findings and mull over how they tie in with our experiences — such opportunities for reflective practice must take place in an environment where we feel safe enough to say:
- I’m not sure if what I did the other day was entirely appropriate. What would you have done?
- Have you ever come across this situation?
- Do you know if anyone has written about this?
- How do these particular research findings fit with our experience of such situations?
- What do you think might have been going on in that situation?
- I think I could have handled that confrontation differently. What do you think?
Such dialogue has possibly always been an important source of midwifery learning. We should not underestimate how much we learn from each other by story telling. We must document and build a respected midwifery knowledge based on stretching the boundaries of what is known to be normal and safe.
We cannot build that midwifery knowledge if we ignore our needs for education. In some quarters it’s fashionable to knock education in institutions of learning as being divorced from practice and therefore invalid. I suggest that education is about building our confidence in challenging orthodoxy; it’s about questioning our attitudes and learning to place the experience of childbirth within the wider social context of women’s lives. It can also be about fostering better inter-professional understanding.
Such an inter-disciplinary approach can be seen in a recent all party Government Health Report in Britain, now commonly referred to as the “Winterton Report”. Politicians took evidence from women, midwives, obstetricians, GPs and Government officials. They studied research findings and visited various units in the UK and elsewhere in Europe.
They highlighted the fact that women are asking for the 4 “C”s — choice, control and continuity of carer. One of the conclusions of this group was as follows:
We conclude that there is a strong desire among women for the provision of continuity of care and carer throughout pregnancy and childbirth, and that the majority of them regard midwives as the group best placed and equipped to provide this.
The recommendations of the Winterton Committee were that:
- There should be full utilisation of midwives’ skills
- There should be improved financial benefits for young pregnant women
- The duplication of services caused by “shared care” should be abandoned
- There should be improvement in neonatal services
- The closure of small maternity units should cease
- Birth in hospital can no longer be justified on grounds of safety
- There should be the development of midwifery managed units
- There should be improved continuity and community based care
- There should be an urgent review of the training needs of Senior House Officers
- Maternity Services Liaison committees composed of users and providers of services should be strengthened.
The report called for a change in attitude towards childbirth and advocated putting women and their families centre stage. The medical model of care was described as inappropriate and the report stated clearly that there should be more recognition of midwives’ skills.
The response of the Government was to ask Baroness Cumberlege, one of the Ministers for Health to set up a task force to review maternity services and to make recommendations. The Expert Group composed of representatives of user groups and professionals published its report, “Changing Childbirth”, last year.
Each chapter in “Changing Childbirth” ends with an objective and an action plan for both the purchasers of services, the health authorities, and the providers of services.
The Expert Group identified ten key indicators of success. They were specifically chosen as being feasible and achievable within a five year period and as you will see have great significance for midwives. These were as follows:
Within 5 years:
- All women should be entitled to carry their own notes.
- Every woman should know one midwife who ensures continuity of her midwifery care — the named midwife.
- At least 30% of women should have the midwife as the lead professional.
- Every woman should know the lead professional who has a key role in the planning and provision of her care.
- At least 75% of women should know the person who cares for them during their delivery.
- Midwives should have direct access to some beds in all maternity units.
- At least 30% of women delivered in a maternity unit should be admitted under the management of the midwife.
- The total number of antenatal visits from women with uncomplicated pregnancies should have been reviewed in the light of the available evidence and the guidelines from the Royal College of Obstetricians and Gynaecologists.
- All front-line ambulances should have a paramedic able to support the midwife who needs to transfer a woman to hospital in an emergency.
- All women should have access to information about the services available in their locality.
Baroness Cumberlege and the Expert Group visited our midwifery group practice and their proposals commend the model which the six of us have been developing over the last five years in independent practice.
I would like to suggest that what would be helpful in looking to the future of maternity services is what others of us might call a “paradigm shift” and what others of us might call a “different mind-set”. Instead of thinking in terms of the “named midwife” working in a “team” who take responsibility for a defined group of women deemed to be at “low risk”, we should arguably be thinking in terms of the “named woman”. What I am talking about is continuity of carer and maximising safety — caseload practice where one midwife takes responsibility for the midwifery care of a woman or women whom she gets to know.
Midwifery care follows the woman throughout her pregnancy, labour and the postnatal period regardless of where the woman gives birth, regardless of whether or not she is deemed to be “at risk” and regardless of who she chooses to be her “lead professional”. All women need midwives. Women who are labelled as “high risk” are arguably more in need of continuity of carer than those who sail through on the wings of prosperity and good health.
I suggest that we think in terms of midwifery practices and move away from the concept of team midwifery. Apart from the danger of the hierarchical notion of the team we all know of examples of reorganisation in the name of team midwifery where women are being cared for by as many as 20 team midwives.
I am talking about midwives in midwifery group practices seeing themselves as autonomous practitioners with caseloads. I believe that this is the way forward for the majority of midwives but that they should receive public funding for working in this way. Midwives should receive a per capita payment for each woman for whom we guarantee to provide flexible tailor-made continuity of care.
This may mean that we choose to work in pairs, linked to other pairs, or in midwifery practices of up to 8 midwives, in order to provide cover or support. However, each midwife should be responsible for named women. The number of women she chooses to be responsible for will vary from year to year depending on her other commitments. For example, a midwife might choose a smaller case load in any of the following situations:
- If she is doing a course or wants to study
- If she has increased family commitments
- If she is doing research
- If she needs time to lecture or write
- In order to carry out her duties as a manager or teacher
- If she wants to work part-time.
A flexible caseload system has benefits for both women and their midwives. A two-way relationship of trust can be developed where midwives and women come to know each other. Furthermore, for women this can mean more control and confidence. Care can be tailored to meet the woman’s individual needs and situation. Midwives may have the benefits of enhanced job satisfaction and staff retention. Midwives with case loads will be able to maintain and develop a wide range of clinical skills. With the establishment of community based care the midwife will be well placed to listen and respond to the needs of women.
We need to find ways of making ourselves visible and available in the community. This means being involved in local groups and becoming experts at networking.
Over the years the six of us working independently in S.E. London have developed excellent working relationships with, notably, Guys Hospital and Kings College Hospital. There are certain obstetricians to whom we choose to turn if a woman wants to book with us whose medical or obstetric history warrants careful liaison over screening, monitoring and the most suitable place for birth to take place. On the whole, if a problem arises, we would like to refer directly to a sympathetic obstetrician or paediatrician but occasionally there are certain situations where we might liaise with supportive GPs. Midwives also need to have direct access to laboratory facilities. Working relationships between midwives themselves improve dramatically when we have the option to chose with whom we work.
I recognise that not all midwives will be in a situation to take on a case load, particularly those who have inflexible child care arrangements. There will always be the need for a strong core group of midwives working shifts and running the important facilities in hospital. This will include midwives with particular expertise in certain fields whom those of us who are community based can refer to when necessary.
The South East London Midwifery Group Practice has recently become the first midwifery group practice composed of self-employed midwives to be given an NHS contract. We have secured enough funding to last us for six months during which time we have to go to tender and compete with other health service providers for a longer term contract with per capita funding from the NHS.
Hopefully we shall be able to prove that our model is safe, cost-effective and satisfying for midwives and the women for whom we provide care. Our main aim is to pilot a model that can be replicated throughout the country.
Certainly our statistics for the years that we have been working as independent midwives are encouraging. Looking at 506 births, 45% of them women having first babies, and over 25% of the women over 35, the following statistics have emerged:
- 69 of the 506 women planned to have their babies in hospital although 13 of them ended up deciding to stay at home to give birth.
- 437 women planned to give birth at home. Of these women 69 (16%) ended up giving birth in hospital, giving a total home birth rate of 75%.
- A third of our clients are on benefits and many are grappling with all the socio-economic pressures of inner city deprivation and inequalities in health.
- with 87% of women having spontaneous vaginal births and a caesarean section rate of 6.7%;with a 1% episiotomy rate for births at home, 7% for those in hospital including instrumental deliveries;
- with 74% of women having no pharmaceutical analgesia in labour;
- and with breastfeeding rates on discharge at 28 days postnatal standing at 96.4%;
- we feel confident that continuity of midwifery carer can play a vital role in decreasing perinatal mortality and morbidity and that midwives are a cost-effective proposition.
The overall philosophy of the Midwifery Group Practice is set out in our proposal for the Midwifery Group Practice to be funded by the NHS:
- Midwifery care is a trusting partnership of equals between the woman and her carers
- Pregnancy and childbirth are seen as a normal part of a woman’s life within her social context
- Each woman is entitled to get to know the midwives caring for her throughout her pregnancy and childbirth regardless of recognised risk factors, complications or place of birth
- Women should be enabled to give birth to healthy babies in a normal, safe and satisfying way in the place of their choice
- Each pregnant woman books with two midwives who will undertake all her midwifery care
- The midwife follows the woman thereby enabling care both at home and in hospital to take place, appropriate to the woman’s needs and choices.
There are eight midwives in the practice — six full-time equivalents as there are two job-sharers — and along with our practice manager we have formed a legal partnership. Between us we intend to take on the midwifery care of 200 women a year but each woman will book with just two midwives who will provide all her care, whether she books for birth at home or whether she chooses or needs to have her baby in hospital.
When we are not on annual leave, we are on call 24 hours a day and are available by means of message pagers. In order to avoid burn-out we shall be taking three months holiday a year and will be paying ourselves an annual income of £25,000 for those working full-time. This salary is compatible with that of an NHS community midwife who receives extra payments for being on call during unsociable hours.
In our practice we have chosen to target certain groups who are often denied choice or who have particular socio-economic factors in their lives that have been identified as placing them and their babies more “at risk”. We are therefore developing a positive discrimination access policy for women in the following groups and will reserve a quota of 75% of bookings for them:
- Women from Vietnam and other minority ethnic groups
- Women who live in specific local housing estates
- Women with housing difficulties
- Women on income support
- Women who are unsupported
- Women under the age of 18 and over the age of 38
- Women with mental health difficulties
- Women with previous pregnancy or childbirth bereavements
- Women who are lesbians
- Women with disabilities
- Women who are referred by GPs and other health professionals as being in particular need of continuity of midwifery carer
- Women who are HIV positive
- Women who have had previous low birth weight babies
- Women who have a history of substance abuse.
Our objectives in this project are two-fold. Firstly for the women they are:
- To ensure, as far as possible, the birth of a mature, live, healthy infant.
- To prepare the woman for labour, birth and the care and feeding of her child.
- To provide women and their partners with information about choices concerning the care given during pregnancy, labour and the postnatal period.
- To enable the woman and her partner to be equally responsible with the midwife and medical practitioners for her physical health and emotional wellbeing, before, during and after pregnancy.
- To provide continuity of care for women with two named midwives, who will remain responsible for the midwifery care throughout pregnancy, labour and the postnatal period (to 28 days).
- To detect conditions which may endanger or affect the future health of the mother or baby and to refer the woman to the relevant practitioner.
- To ensure that the birth of the baby is as emotionally satisfying as possible for the mother and also a pleasurable experience for the whole family.
- To encourage women to evaluate care given during pregnancy, labour and the puerperium and to make changes accordingly.
For the midwives our objectives are:
- To enable midwives to take full responsibility for midwifery care for named women.
- To enable midwives to listen to and respect the needs of women.
- To foster mutual trust and respect between midwives and the women in their care.
- To foster mutual trust and respect between midwives and other practitioners.
- To enable midwives to design their own working practice.
- To enable midwives to choose the size of their case load.
- To enable midwives to manage their own time appropriate to individual commitments.
- To enhance job satisfaction.
- To improve the retention of midwives in midwifery practice.
- To maintain and develop a wide range of midwifery skills.
- To provide a supportive learning environment for student midwives and other practitioners.
Probably all of us midwives know what it’s like to feel like “a bit of a square peg in a round hole”. Some of us will have had a taste of independence and autonomy. Others of us will be struggling to avoid being denigrated to the role of “obstetric nurse”.
However, we can all work at developing an empowering model that places the woman centre stage. We can all develop our listening skills and can work at developing a quietly supportive role. We can take a back seat, ensuring that the people the woman has chosen to be there for her are the ones who carry out the key support. They after all are the people who will be there in the long term, not us. We can develop our role as a “safety net” — and be aware that usually “the less we do, the more we give”.
We have to reject the sort of power that is associated with words like “control”, “manage”, “supervise” and “conduct”, using words like “patient” when we are referring to a woman undergoing the normal physiological process of having a baby. Such words are the language of “confinement” and getting rid of them from our vocabulary can be a good starting point for shifting power from birth attendants to women.
Each time we are tempted to say something like “I had a nice delivery last night” we need to stop and remember that it’s the woman who delivers the baby, not us. This is not always easy. It may not stretch us too much to substitute the noun “birth” for “confinement” and “delivery” but sometimes the “doing” words are harder. Some of us try to talk about “attending” women as a substitute for delivering but the oft used phrase of “catching babies” does have a rather sporty, gung ho ring to it and at times might sound as though we are trivialising the process. At the moment I’m trying out talking about the midwife “receiving” the baby.
If we work on “receiving” babies then it is a relatively easy step to move away from the idea of picking the baby up and giving it to the woman or placing it on her abdomen. For the woman a crucial part of the act of giving birth is picking the baby up. Apart from the fact that this puts her in an ideal position to deliver her placenta, it allows the woman control of the act of giving birth. You will know that often women don’t want to pick their babies up immediately, they need time to recover from a process which often feels as though it is nothing to do with having a baby. Women say things like — “Oh, it’s a baby!” and — “Is it mine? Is it really mine?”
The midwife who is powerful will work on optimising physiology in labour. She will respect the extraordinary intricacy of all those interacting hormonal cascades, surging polypeptide chains triggering feedback mechanisms in a swirling dance of purpose between the woman and her unborn baby.
The more we study such biology, the more respect we can have for the extraordinary nature of birth. We don’t have to remember detail, but studying and beginning to understand even a small part of the mechanisms involved can increase our sense of wonder and encourage us to work hard at avoiding disturbances, be it in the form of light, sound, touch, smell or sometimes our very presence. These are powerful midwifery skills and nowhere is the midwife more challenged to employ them than when she has to attend a woman who has chosen to give birth in an institution, particularly where she and the woman have not met before.
I shall finish by quoting some of the midwives who worked in the first half of this century in Britain. When asked what they thought were the most important qualities for a midwife to possess, these were some of their responses:
I think you need some common sense. You need to find a way to get on with people and not be too bossy. And you’ve got to be able to instill confidence.
Kindness for one thing. You have to be in sympathy with the woman. And patience and love of the job.
You’ve got to be capable of working on your own in adverse circumstances, make up your mind, and carry it through. And if you’ve made a mistake, you can’t afford to put your head in the sand and say “How awful!” You have to learn by your mistakes. This I think is what it is all about.
And finally, back to the concept of “the skilled companion”:
Practical down-to-earth knowledge is important, but it’s having the right attitude that’s important, too. You have to be their friend. If you can befriend a mother and get her on a level with you, there’s an understanding and you’re both far better off. I think the midwife in her own mind should remember that the mother is important to her. She, the midwife, is not the most important person. She isn’t. The mother is the most important person.
The message from all these old midwives is clear. Midwives, let us use our power wisely to kindle the power that belongs to childbearing women.
This paper was presented at the Future Birth 94 Conference, Australia, May 1994 for Associates in Childbirth Education.