From MIDWIFERY MATTERS, Issue No.114 - Autumn 2007
Margaret Jowitt
Less than 50% of women now have a normal delivery (defined as one "without induction, without the use of instruments, not by caesarean section and without general, spinal or epidural anaesthetic before of during delivery." The spontaneous delivery rate, at 64.9%, is at an all time low, and while elective caesareans are very slightly down, there has been an increase in emergency caesareans, forceps, inductions and epidurals (source: NHS Maternity Statistics 2005-2006, Information Centre, www.ic.nhs.uk).
At all stages up to birth itself mothers are being told that their body doesn't work properly - it doesn't even know when to start - you won't be able to cope with the pain, you can't push hard enough, you'll have to have a Ventouse/forceps/caesarean, whatever, and so on and so forth and then suddenly once the baby is born and the danger of litigation is past they are thrust out into the wide world and left to get on with it; postnatal stays are getting shorter and shorter. The system has no time for anyone, no time to wait for labour to start naturally, no time for it to become established, no time to wait for progress, no time to help mothers breastfeed - no time for the midwife to grab a quick cup of tea, let alone time to sit with a new mum. How have we allowed such a System to develop?
The following passage comes from a book, an account of the Stanford Prison Experiment, The Lucifer Effect, by Philip Zimbardo, a social psychologist. Zimbardo took 18 students, divided them arbitrarily into prisoners and guards and put them together into a makeshift prison and recorded what happened. The experiment had to be abandoned well before the end of the planned fortnight - guards and prisoners alike quickly took on their roles the former becoming increasingly brutal, the latter rapidly losing their sense of identity. Both were becoming dehumanised. The SPE as it is known is a classic experiment in social psychology and shows the incredible power of the situation over the behaviour of individuals. You or I could find ourselves behaving like that in similar circumstances. Of course, it has absolutely nothing to do with midwifery - or has it? See if Zimbardo's reflections ring any bells for you:
Systems provide the institutional support, authority, and resources that allow Situations to operate as they do. System Power involves authorization or institutionalized permission to behave in prescribed ways or to forbid and punish actions that are contrary to them. It provides the "higher authority" that gives validation to playing new roles, following new rules, and taking actions that would ordinarily be constrained by pre-existing laws, norms, morals and ethics. Such validation usually comes cloaked in the mantle of ideology.... The programs, policies, and standard operating procedures that are developed to support an ideology become an essential component of the System. The System's procedures are considered reasonable and appropriate as the ideology comes to be accepted as sacred.
The sacred ideology in the case of obstetrics is, of course, that birth is an inherently dangerous event that can safely be managed only by a consultant obstetrician in the context of a highly technical environment with trained technicians following standardised protocols directly under his power. Such ideology gives carte blanche to treat women almost any way you want, despite the rhetoric of choice.
Scientific apologists such as Richard Dawkins and obstetricians such as Sara Paterson Brown and Nicholas Fisk might argue that it is inappropriate to use religious language in the context of medicine - 'sacred ideologies' are belief systems; modern medicine has nothing to do with belief but everything to do with science, they would say. I would say that science, particularly medical science, has its own belief systems which are just as capable of dehumanising patients and health care professionals as Zimbardo's artificial prison experiment.
In contrast midwifery is not afraid to state the importance of the belief - for both mothers and professionals - that most women's bodies most of the time are capable of giving birth safely. Midwifery acknowledges the importance of interaction between mind and body but however much scientific evidence is produced to support this belief the medical System is still sceptical.
What was all the more shocking about the Stanford Prison Experiment was that, despite knowing that it was only an experiment and that theoretically they could leave at any time, prisoners found themselves totally unable to exercise their right to leave when appearing before pseudo parole boards. This rings more bells for the maternity services. There is a rhetoric of choice but it seems virtually impossible for most women and many midwives to go against the dictates of the 'standard operating procedure' of the maternity System. Midwives and women have to resort to subterfuge to get round the System.
Many of these subterfuges concern time: women manipulate their LMP day to avoid induction nine months later; midwives are 'woolly' about deciding when labour starts, in order to avoid CTG monitoring; they avoid recording the time of onset of second stage to give women a bit more time to give birth and avoid an operative delivery.
Midwives are forced into trying to subvert the System to give their clients the best possible care and mothers who know what is best for them and their babies learn how to manipulate the System to get what they need. Will we ever manage to change the System itself?
In order to do away with this institutionalised System of childbirth we need to do away with these vast inhuman and inhumane institutions. One mother, one midwife would go some way towards keeping the mother out of the institution and the institution out of the midwife. The NHS Community Midwifery Model is all there ready and waiting for implementation. Now that Blair control freakery is in the past will Gordon Brown be more willing?
Margaret Jowitt
This article was originally published in Midwifery Matters ISSUE 114 Autumn 2007
AH updated 15 June 2001