From MIDWIFERY MATTERS, Issue No.117
Margaret Jowitt
I HAVE LONG WANTED to write an article on ‘Woman's inhumanity to woman' but have shied away until now for fear of being seen as attacking midwives and failing to acknowledge all they have achieved over the years in the care they give to women, often under very difficult and alien circumstances when they are based in hospitals. I was prompted to put pen to paper at last because I could see a way of understanding this behaviour and understanding is the first steps towards counteracting it. I do have some suggestions to make as to how we can rehumanise maternity but first it is necessary to understand how it became inhumane in the first place.
A few months ago I came across a book The Bystander by Petrushka Clarkson and have been digesting it ever since. A bystander is someone who looks on but does nothing to intervene when seeing someone else being mistreated. Although Clarkson is a psychotherapist and hardly mentions healthcare outside psychotherapy, the book rang many bells for me and I felt that it could have been purpose written for midwifery. Much of this article is derived from it. However, I start with a little feminist philosophising, again prompted by Clarkson who writes:
Perhaps our world psyche has still not recovered from the millions of women tortured and burned not too long ago for ‘being different'. Truly those women were mysterious and powerful in a world where the options for normality were very small indeed. And great their punishment. And profound our loss. - Petruska Clarkson
I assume Clarkson is talking about the witch hunts of the counter Reformation and in the brave new world of North America, but her words relate powerfully to the treatment meted out today to any midwife who dares to be different and challenge the system, particularly independent midwives, but also maverick or even radical midwives working in hospitals. The legacy of the witch hunts in the USA is still a deep mistrust of midwives by doctors, and midwives still struggle for state recognition, despite excellent figures of normality, safety and maternal satisfaction (MANA). The American Medical Association is running scared and has recently passed Resolution 205 working towards outlawing home birth and birth in isolated midwifery units. The Resolution actually names a ‘witch' Ricki Lake, a media celebrity:
AMA Resolution 205
"Whereas, There has been much attention in the media by celebrities having home deliveries, with recent Today Show headings such as "Ricki Lake takes on baby birthing industry: Actress and former talk show host shares her at-home delivery in new film"; and
Whereas, An apparently uncomplicated pregnancy or delivery can quickly become very complicated in the setting of maternal hemorrhage, shoulder dystocia, eclampsia or other obstetric emergencies, necessitating the need for rigorous standards, appropriate oversight of obstetric providers, and the availability of emergency care, for the health of both the mother and the baby during a delivery; therefore be itRESOLVED, That our American Medical Association support the recent American College of Obstetricians and Gynecologists (ACOG) statement that "the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the American Academy of Pediatrics (AAP) and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers" (New HOD Policy); and be it further
RESOLVED, That our AMA develop model legislation in support of the concept that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the AAP and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers." (Directive to Take Action)
The American Medical Association, then, seems determined to keep women incarcerated in hospital. Why are they so afraid of small birth centres, independent midwives and home birth? Why are independent midwives such a threat to them? Is it not enough to skim a few off now and then with lawsuits alleging malpractice, in order to discourage others from joining their ranks? Independent midwives are indeed mysterious and powerful in a world where the options for normality are very small indeed, particularly in the United States, with its caesarean section rate of around 30%. It is patently obvious that the obstetric model does not work for women, although the doctors argue that it works for babies. In this issue we publish the response of the Midwives Association of North America (MANA) to Resolution 205. MANA claims that the doctors' fears are misplaced and that home birth and birth in stand-alone birth centres is no less safe than birth in large obstetric hospitals.
Maternity care is not much better in the UK. Our caesarean section rate is around 25% and, despite midwifery being mainstream, there are still witch hunts against any midwife who steps out of line. The length of time the Nursing and Midwifery Council takes to complete a case certainly leads to mental torture of a kind, and the end result might well be loss of registration and loss of livelihood. Faced with the prospect of an NMC investigation, many midwives give up completely and leave the profession without even a fight. Cases drag on for years, with months in between hearings.
At times the NMC seems to resemble an ecclesiastical court. These courts dealt with religious dissenters – there was an undue emphasis on character witnesses and reputation, discussions about who said what, when; who wrote what, where. Perhaps we should not be surprised; in some ways medicine is the new religion and the regulatory bodies are thus directly analogous to ecclesiastical courts. (Medicine, of course, places extreme value on bodily life on earth, whereas many religions are focused on eternal life in heaven.)
The witch hunts were predominantly conducted by men against women. If a woman healed by hands or herbs it must be the work of the devil – it couldn't be a God-given power – and she must be burnt at the stake to keep other women knowing their place and obedient. Returning to the USA, briefly, Ricki Lake's wonderful home birth must have been a fluke (magic, luck) it would be dangerous for other women to follow suit. Why?
Why should men want to conduct a war against women and what is it about midwives that makes them especially vulnerable? Marsden Wagner suggested at an ARM meeting during the 2004 retreat that men's wish to control childbirth comes from their deep fear of women; women as mothers and women as midwives. Do they fear the power that women's bodies have over their own bodies and is this fear heightened by seeing the awesome power of women's bodies in childbirth? One theologian has it that men fear women because they bleed but do not die. Are men also afraid of women's other body fluids – tears and milk? Tears, because they feel powerless in the face of female emotion and milk because it reminds them that they were once helpless infants? Is it the fear of the power of women's bodies that makes men so eager to control, constrain and confine them during birth? Is it just too primeval a power to contemplate? Jo Murphy Lawless in her book, Reading Birth and Death: A history of obstetric thinking, has talked of obstetricians and their fear of birth being linked to the fear of death. Does the fear of women come from some sort of jealousy? In French orgasm is known as the ‘little death'. Birth can be orgasmic too but it leads to life.
Reverting to the theme of medicine and religion, are not both medicine and religion methods of dealing with fear of death and fear of women? Religion herds people into churches and medicine herds women into hospital for birth. (Note how the American Medical Association's Resolution 205 is explicit about the appropriate building for birth.) The very buildings are often so huge that they themselves have an effect on people's behaviour. In such a large place the individual becomes insignificant – unless their significance is heightened by wearing clothes which single them out as priests. In large buildings people are more controllable, less likely to step out of line, more likely to follow the rules; defying the authority of priest or doctor is likely to be taken as a sign of mental disturbance. Is it not significant that in both churches and hospitals the high priests have their own spaces – the vestry and the consulting room whereas the acolytes have to make do with communal spaces, the robing room and the staff room?
But medicine also herds midwives into hospital, where they also can be controlled far more easily. From my reading of the history of the midwifery profession in the UK, midwives lost their professional status and their professional autonomy when the community midwifery service was taken over by the NHS from the local authorities in mid 1970s (Donnison, 1977). The downgrading of midwifery continued in 1979 when the Central Midwives Board was replaced by the UKCC. The UKCC subsumed midwifery into nursing very effectively at a time when nurses had far less autonomy than some have nowadays. Both these political events took place in the 1970s and it is perhaps significant that the Association of Radical Midwives was formed in 1976. ARM was founded by students who, maybe because they were outsiders, were able to see what was happening to midwifery. Just ten years after the formation of the UKCC the home birth rate had plummeted to under 1%. The control of women was all but complete. The witch hunts resumed to ensure that things stayed that way. Jilly Rosser was brought up before the UKCC because she transferred a client to hospital in her own car, "She had it coming to her because she's a feminist," said a leading obstetrician at a private party (personal communication, Lindsay 2008). Wendy Savage, a woman centred obstetrician, fought a long and bitter battle about both place and style of birth, which she won on paper by her reinstatement but which ultimately failed to reverse the trend towards factory birth (Savage 2007).
(I do wonder whether the hospitalisation of mothers and midwives was the establishment's reaction to feminism? If women were getting unruly in the home and in the workplace and in politics, was it not better for the powers that be to take control of them for birth – the root source of their power over men? And I wonder whether this is the reason for the demise of feminism, and why women mostly have had to transform themselves into honorary men in order to ascend the ladders of power in society. Respect for women as mothers has plummeted as their value is measured only in their earning power. The status of once highly respected professions such as teaching, the priesthood and politics, has dropped now that women play a fuller part. As Allison Ewing points out in her article in this issue, the current social class classifications rank management as the high status positions – even a doctor has less status unless he is in management.)
Herding midwives into hospital under the NHS and equating them with nurses in the UKCC was an extremely effective way of controlling midwives as individuals and the profession of midwifery as a whole. They could now be managed within the male hierarchical structure of hospitals but, more to the point, they would now be managed by each other. I doubt whether the establishment was aware of this mechanism but despite the paper victories of Jilly Rosser and Wendy Savage the message of what would happen to deviant women was well learned: it is best to keep your head down and stay out of trouble. There was enormous support from ‘ordinary’ women for both Wendy Savage and Jilly Rosser but women failed to stop the tide largely because the viciousness of the attack served as an effective warning to other health professionals.
The simple expedient of herding midwives into hospitals de-individualises them. Their uniform makes them one of a crowd, the larger the group, the more insignificant they become. Being one of a crowd reduces their autonomy; a hospital could not function effectively if each midwife worked as a consultant, basing her practice on her own personal style. She does not ‘own’ her women and must hand over care at shift changes, so there must be some consistency imposed from above to enable her colleagues to take over care when required. Working in hospital, midwives must be managed by protocols and guidelines and the most effective way to enforce these is by peer pressure and, if this fails, by making an example of midwives who step out of line. If management makes an example of an individual midwife, will the other midwives stand up for her or will they become bystanders and watch from the sidelines? Will the other midwives close ranks against her for fear of being tarred with the same brush, or will they say to themselves, "There but for the grace of God go I," and offer support privately or publicly; or will they keep their heads down and say nothing. If the latter, the power of the group will be even stronger and the capacity for empowerment and change reduced further.
Management can work on the principle of ‘divide and rule’, reinforcing the behaviour of midwives who fit the system it wants to perpetuate and making an example of midwives whose practice deviates from that desired. Independent midwives must be taken to the NMC because management has no other means of control over them.
What has this to do with bystanding? The larger the group, the more tempting it is to adopt bystanding behaviour. Clarkson entitles an appendix to her book: ‘Bystanding: A block to empowerment’. I believe that midwives are disempowered by the system and by each other. When working in a large organisation, it is tempting to keep one’s head down and get on with the work and not get involved in local politics. Clarkson gives 12 ways that people justify their reluctance to get involved. Of these four seem to me to be particularly telling for midwives. The first two involving active harm and the second two, passivity in the face of unkind behaviour.
1. I’m just following orders.
The first excuse justifies unkind treatment of women. There are protocols and guidelines to be followed by midwives, particularly in large hospitals. It is easiest to abide by the rules, to be inflexible, to insist on an admission trace, unnecessary VEs, a managed third stage. This rigid following of orders can be summarised for midwives as, "It’s more than my job’s worth." Clarkson writes:
This bystanding pattern may be characterised by its convenient obedience to authority to avoid difficult moral or ethical decisions. These protagonists claim to lack the authority to intervene, ignoring the basic fact of their autonomy as human beings, and the many ways in which they do have power to change the outcome of a situation.
Clarkson is not writing about midwives, she is not even writing about healthcare, she is writing about everyday situations. The moral and ethical dilemma faced by midwives concerns maternal consent and choice. Women are naturally inclined towards obedience, the midwife, obedience to protocols (look what happens to her if she has to justify not following guidelines), the mother obedience to the midwife. How many times does a woman say "Well’ I’d rather not have ….. but if you think it necessary…." And of course in midwifery and obstetrics you can always wave the shroud. It is so easy to get women to comply, so difficult to support them when they would prefer to go against hospital guidelines.
2. They brought it on themselves.
The second justifies unkind treatment of other midwives who do try to change the system. The likely response to a midwife who wants to go the extra mile in supporting a woman is: "Who does she think she is?" If the midwife concerned has a less than optimum outcome she will find it hard to justify not following guidelines and will get little or no support from her more obedient colleagues. There may be midwives who do not join in the active bullying of women and of each other who may say to themselves:
3. My contribution won’t make a difference.
Radical midwives know that their contribution does make a difference – even if only to one woman who experiences kindness instead of perfunctory care. Radical midwives can chip away at the culture and lead by example.
4. I don’t want to rock the boat.
If all was well within our maternity system there would be no need to rock the boat. The trouble is that hospitals are like ocean liners and it takes more than one person to rock the boat and anyway the person rocking the boat is likely to be thrown overboard. I could take this analogy a long way, the ship is being piloted by the Department of Health, isolated birth centres are smaller boats being tossed around by the wash of the huge vessel alongside. Independent midwives and their clients are further out but sometimes have to get aboard the liner to use its facilities. The liner is being captained by risk managers and consultants who can see nothing but rocks ahead. Sometimes there is a consultant midwife who can see patches of clear water to steer towards. The financial men are down in the bowels of the ship well below the waterline, oblivious of the activity above them. The women are the passengers on an overcrowded ship – the lucky few get one-to-one care from a crew member they know, while the majority are herded around, slotted in wherever there is space, attended by overworked crew anxious to get their passengers safely to their destination while looking forward to reaching the end of their term of duty.
Nobody wants to rock the boat. People don’t like those who rock the boat. Women are particularly good at controlling each other by their words and their looks; it is one of our least attractive traits. A raised eyebrow, eyes aimed at the sky looking slightly away from the person concerned, a snide comment here and there, damning with faint praise; we have all the tricks and, when constrained by a group culture, it takes almost super human powers to resist their effects, even if we don’t actually join in the torment. Groups then will tend to close ranks against anyone who threatens to disturb the equilibrium of the workplace, making it very difficult for any one individual to change anything. The social pressures to act with the rest of the group are immense, no-one likes to be ostracised or scapegoated, no-one likes to be left out in the cold.
The temptation for midwives to stick together in a group and toe the party line is even more intense than in other work places because the consequences of a mistake can be devastating; life threatening for the baby and sometimes the mother as well. Sometimes babies die and sooner or later this may happen to you. If it does happen to you, you may think you are less likely to be reported to the NMC if you have always abided by the rules of the group and have never stuck your neck out, but don’t take it for granted. You may think the group will stick up for you. This may be a false assumption because the group may close ranks against you for fear of contamination, you are no longer one of the crowd but have been singled out by fate. On the ukmidwifery list the phrase, ‘I’m not prepared to risk my registration’ is heard more and more. And midwives are having less and less control over their own regulation and registration; under the draft Orders for the new slimline NMC (July 2008) there is only one guaranteed place for a midwife on the NMC.
Having midwives concentrated in one place puts more of them into a position where it is far easier to be a bystander than to make a stand for what you believe in. There is plenty of research showing the power of peer pressure, and it is the wish to feel safe inside a group that makes it so hard to stand out against the crowd.
If midwives can act like this between themselves, how much more vulnerable are the women and the students who are already outside the group. The student and the woman are vulnerable because they are both outsiders in the hospital system; they are in other people’s territory and they are powerless. Student and woman enter as supplicants, the student to receive experience – for example, the students needs to be given the opportunity to assist in the requisite 40 births before registration – and the woman needs the help of midwives to give birth.
Students often complain that what they see on the wards bears no relation to what they are taught in the classroom, research based practice is taught at the university but the prime task of hospital placement is to assimilate students into hospital culture. This is not an explicit aim of education, indeed few will even be aware of this cause of the theory/practice gap. I doubt whether it is even an implicit aim of management, but placing a single student in a group of well-assimilated midwives will have the effect of inculcating into them the cultural norms of the group. They learn quickly that life will become intolerable unless they learn to conform. This leads to cognitive dissonance – meaning that signals on how to behave (care for women) are so conflicting that people are pulled in two directions at once, causing psychological distress. So many women go into midwifery wanting to change the system but the pressure to conform is such that in order to survive, many have to change their mindset from woman-centred care to hospital-centred care.
Another aim, perhaps more explicit, is desensitisation. Students must learn professional detachment in order to carry out their tasks. Professional detachment explicitly forbids relationships between clients and staff. Professional detachment means learning how to be comfortable with wiring up a woman up to a CTG monitor for an admission trace because it is hospital policy, despite knowing the research which shows it to have no benefit in normal labour. Students are taught by hospitals that it is unprofessional to get involved with their clients – but this is the very opposite of what a midwife is – with woman.
I’m reluctant to mention another mechanism of initiating student midwives into hospital life but it would be remiss not to touch on methods used in other institutions. When military police are initiated into conducting ‘intensive interrogation’ of political prisoners or suspected terrorists they are required at first merely to bystand, to watch and become accustomed to the violent methods. If they do not intervene, the act of bystanding makes them complicit with the torture and they find it hard to refuse to follow orders and carry it out such ‘interrogation’ themselves.
May I respectfully suggest that something similar might happen to student midwives. I believe that student midwives are taught inhumanity to woman as part of the hospital induction process. It is part of professional desensitisation. I am not suggesting for one minute that anyone knows that this goes on, let alone encourages it, but there has to be a mechanism that turns women who enter a caring profession into people who find it acceptable to, for example, perform vaginal examinations and strap women to monitors against their will with no consent.
This may seem an outrageous thing to write. I too am outraged – on the part of mothers, but also on behalf of midwives because it dehumanises them too and must inevitably turn a vocation into a mere job. Read the article by Josie Ford on page 18 of this issue and then tell me it is comprised of rare isolated incidents. No wonder students decide midwifery is not for them, no wonder midwives leave. Society is likewise dehumanised. If inhumanity is taught at birth what hope is there for mankind? In Clarkson’s words – What a profound loss.
Petrushka Clarkson defines bystanding behaviour as essentially the denial of relationship and writes that the retrieval of relationship has become perhaps the most important moral issue of our time. It is certainly what ARM is working for in midwifery. The bystander is able to stand aloof because he does not acknowledge a human relationship between himself and the person in need of help. In this magazine Meg Taylor has written that, whenever attempts at creating relationships between mothers and midwives are made, management does all it can to disrupt them. There are cases of midwives being forbidden to care for family members – the relationship is likely to ‘cloud their professional judgment’.
What is the One Mother One Midwife Campaign but a campaign for the retrieval of relationship between mothers and midwives? Why has it failed so far? It is not difficult to design systems where mothers can have a relationship with their midwife but there is extreme management resistance to them. What is so hard to organise? A mother will need a midwife in labour anyway so why not give her the same one throughout pregnancy? Changing Childbirth acknowledged the need for relationship but failed at implementation stage because of a lack of will on the part of management.
Mavis Kirkham’s book, The Midwife-Mother Relationship, gives countless examples of how difficult it is to establish relationships with women unless there is continuity of carer throughout the antenatal period – and many of those examples come from home births and birth centres where there is a better chance of establishing relationships. In hospital, even relationships between midwives are disrupted.
Management does not want to lose the ‘benefit’ of the self-policing of midwives that occurs in large obstetric units. I suspect that this is one of the most powerful disincentives management has to set up isolated midwifery units and to sanction home birth. Management wants midwives under its beady eye. Isolating midwives in stand-alone units is dangerous; allowing them to form relationships with each other is dangerous for the hospital, however safe it may be for the mother and baby. Birth centres are closed following one stillbirth, consultant units remain open after four maternal deaths. Independent midwives are hauled up before the NMC after one stillbirth; there would not be a consultant left in post if the same thing happened to them.
Perhaps management is frightened of midwives’ power to facilitate normal birth? Allowing them to go alone or in pairs to a home birth or setting a few free to staff a small isolated midwifery unit is risky because the midwives demonstrate their safe practice – and they become uncontrollable.
The larger the unit, the more difficult it is to maintain relationships with each other, let alone with the women. Group culture prevails. The larger the unit, the less able the midwife will be to take a solitary stand against the prevailing culture in the unit. Why is there such a rush to amalgamate hospitals and combine units? It is the only way to keep women in their place. Look what happens when midwives work in a small isolated unit, for example Montrose, in NE Scotland – and I have the luxury of quoting from this very issue:
"All the midwives there are committed to midwife led care. There is a low turnover of staff. It is a flexible work environment, they are all good friends and support each other. There is no hierarchy." (National Meeting Report, 25)
Is there anything we can do with this present system of ours in the here and now? Most midwives work in large hospitals where there is a high turnover of staff, a rigid work environment, and whose colleagues do not dare to support anyone who strays too far from the obstetric line. I believe that the maternity system simply cannot change as long as services are concentrated in large impersonal hospitals. Students receive most of their clinical experience in these places; experience in birth centres is usually an optional extra, chosen as an elective placement. It is all but impossible to change the system as it is at present; the process is self-perpetuating.
How many Trusts allow newly qualified midwives to start their careers in the community? What about the practice of rotating community midwives back into the hospital to ‘update their skills’? That process is nothing about updating skills but all about putting community midwives back amongst well assimilated hospital midwives who know their place. The process of fitting midwives into the present system means that those who find themselves unable to cope with the initiation process leave midwifery, either before they even qualify or after they have become worn out by their attempts to buck the system.
I would almost go so far as to say that hospital placements are designed to weed out the mavericks, the radical midwives, to show students that there is no place for them in the profession. Those who do manage to remain find coping strategies to enable them to maintain their sense of integrity, strategies well known to radical midwives such as doing good by stealth, dropping the episiotomy scissors, delaying diagnosis of the onset of second stage and so on.
Some students decide to go straight away into independent midwifery where sooner or later the NMC will try to get them to learn the error of their ways. Clarkson writes that change is possible only when people in organisations stop gossiping (does she mean moaning in the coffee room?) and start taking responsibility for systemic failings. Early in the book she quotes Roberts (1984) saying:
"There are no innocent bystanders because to choose not to be part of the solution is, in fact, to choose to be part of the problem."
And later on:
"Many people in organisations cling to the myth that they are disempowered, and seek to experience empowerment as being given to them from the powers-that-be, as opposed to reaching for the strengths and freedoms which are within their own power."
The hospitals are never going to give midwives power, it is too disruptive and it seems that midwives are unable to seize power – collective action is out of the question, midwives will not go on strike, even over their pay and conditions and any working-to-rule adversely affects the women. Any change that has happened has been slow and incremental and I think swiftly counteracted by new technologies – the routine shave and enema eventually became outdated only to be replaced by the CTG and managed third stage. Choice and control have been embraced only on paper, in reality women are as controlled as ever they were. Midwives plead for mothers to refuse interventions but the mothers are too vulnerable to go against medical advice.
What can we do in the here and now? Returning to Clarkson the first thing is to stop bystanding and to start standing alongside people who are being victimised, whether they are midwives, student midwives or the women themselves. There is no middle way; to choose not to be part of the solution is to choose to be part of the problem.
For the moment we must live with the immediate problem, what to do when some are hurting and others who have power don’t care? Standing alongside is possible in small ways without necessarily putting oneself totally in the firing line. Sometimes it is enough merely to stare knowingly at the person doing the bullying, as if to say, "Your action is not going unnoticed". This may not be enough to save the victim but will make them feel less alone and may encourage other bystanders to take a similar line.
In the long term political action is necessary. Signs are good. The AMA's call for legislation against out-of-hospital birth shows that Ricky Lake's campaign is unnerving the medics in the USA; they have opened a political debate. As for the UK, I believe that hospital midwifery can only ever be damage limitation and that the only way to reclaim birth for women is to take birth out of hospitals and put it back into the community where there is the possibility of midwives having healthy relationships with each other and forming relationships with women without being berated by their peers. We have to go all out to reclaim birth for midwives and women. Whenever there is a witch hunt we have to shout from the rooftops and stand up for those being persecuted. We have to lobby for the NHS Community Midwifery Model. We have to become politically active and lobby NMC members whether they be midwives, nurses or lay people. We have to carry on doing what ARM has always done and respond to each and every threat to midwives and mothers with vigour and with passion.
I hope that this analysis of the problem of hospital birth may open a few eyes and provide the momentum for real change. Of course the byproduct of taking most birth out of large hospitals will be to reduce the number of midwives working in hospitals and thus rehumanise hospital birth for those that need the extra help that hospital, doctors and technology can provide. The NHS Community Midwifery Model does provide a mechanism for gradual change – if women bring their community midwives into hospital with them the pool of hospital midwives will become smaller and better able to trust each other. This alone should have a rehumanising effect. Midwives must play their part by making positive efforts to trust, respect and support each other wherever they are based.
In the meantime, ARM members should wear their ARM badge with pride and stand up and be counted, secure in the knowledge that they will be supported by fellow members.
Clarkson P (1996). The Bystander (An end to innocence in human relationships?) Whurr Publishers Ltd, London.
Donnison J (1988). Midwives and Medical Men, Historical Publications Ltd, London.
Kirkham M (ed) (2000). The midwife-mother relationship, Macmillan Press Ltd, London.
MANA (2008) Response to Resolution 205. .
IMA NHS Community Model, to be found at www independentmidwives.org.uk
This article was originally published in Midwifery Matters ISSUE 118, Autumn 2008, p11
AH updated 18 April 2009