From MIDWIFERY MATTERS, Issue No.98, Autumn 2003
Sophie Hinsliff
MANY OF US will have read with interest the recent research on why midwives leave the profession (Ball et al, 2002). The findings resonated powerfully with my own experience. However, I'd like to turn the question around and look at my experience of staying in the midwifery profession, albeit in different roles. Personally I have found it really hard to be a midwife, to be in the middle of emotional and physical experiences that have led me to question my values, what I wanted for myself and the women in my care, and what I could or should provide. Many of my anxieties centred on knowledge and expertise: what I did know, what I should know, what I wasn't supposed to know. When writing this article, I wondered if it was appropriate to describe a struggle that was specifically about me. Would it be relevant to anyone else? The doubts and uncertainties described here are a product of my personal experience and attributes, but midwifery is personal, undeniably so. Working as a midwife means crossing women's emotional and physical boundaries on a daily basis, something that I don't think happens in quite the same way in any other job. To do this I think we have to take account of our own experience, our presence in that situation. Sharing it may help us do this. The intimate emotional and physical relationships that we as midwives set up with women touch on issues of power (ours and theirs) and privilege. These are political issues, and we gain a lot of understanding by evaluating our actions and our professional role in these terms. In a very real sense in midwifery, 'the personal is political'.
I first came across the slogan, 'the personal is political,' during a course on feminist studies which I took at university before I was a midwife. My degree was in English and Cultural Studies, and I was able to focus on women's writing about their physical and emotional experience, particularly health-related issues such as childbirth and menstruation. I became interested in feminist theories of how these were written and spoken about: what could be said, what shouldn't be mentioned. Thinking about women's experience led me to want more active, hands-on expertise in the field. 'Practical' was the word that sprang to mind, a word I've thought about long and hard since. I applied for midwifery. Here's where the story diverges. For a long time, I framed it only one way, until a friend pointed out that my version of events was just that, a version. The first story goes like this:
Midwifery wasn't what I expected it to be. I moved from a highly political social and academic circle to the maternity services, where I was taken aback to find that not all midwives were feminists. I struggled with practical tasks like taking blood and doing episiotomies, I decided in fact that I wasn't very practical. Maybe I was too academically orientated to be a good midwife? The phrase, "clever but got no common sense" often sprang to mind. I hit a particularly bad point mid-course and nearly left. I lurched on through two years of clinical practice, berating myself for mistakes, worrying about decisions I'd made, wondering whether midwifery was right for me, whether I was right for midwifery. Eventually I escaped to an academic research post.
Here's another story. I was brought up in a family culture which encouraged and rewarded good progress at school. I went to a grammar school, where elitist values about education were reinforced, and from there I went on to university. When I trained as a midwife, I left my home and the academic world for which I'd been groomed to go to a strange place and to do a very different job. During my midwifery course, I struggled hard to reconcile my (perhaps rather na‹ve) preconceptions with the reality of NHS work. I qualified despite this. I moved to a different hospital where I made new friends. I started to develop midwifery skills and am still in touch with a number of the women I cared for. I now had the resources to combine my two interests: theory and practice in women's health. I'm now working as a researcher but I am thinking of doing some more clinical work.
Which version do you believe? Would you be surprised if I said that, until very recently, I would have told you the first one? What do midwives believe? During my English degree, I was taught to take stories apart and examine their meaning, to look underneath the surface at what could have been said, what remains unsaid, how the speaker delivers the words and how the audience receives them. I came to love this deconstruction because I felt that it taught me a lot about who we are and how we relate to each other. In this article, I'd like to deconstruct my experience as a research and clinical midwife.
First, I'd like to look at the concept of midwifery as 'practical' rather than academic. What does 'practical' mean? What does a practical person do? Thinks ahead, plans, anticipates problems, works out the best way to solve them, doesn't mind getting their hands dirty, is physically dextrous. These sound like some of the qualities a good midwife might have. Many of them are skills I've needed as a researcher. But I think to some extent these qualities have been hijacked in midwifery by the concept of efficiency: a good midwife gets the job done with a minimum of fuss and a maximum of speed. Those who take too long over a task, need to get it checked too many times, spend too much time on invisible work (like communicating with women) might not seem that fast or efficient. I worried about being too slow, not learning new skills like suturing quickly enough, looking as if I panicked in an emergency. I decided that this meant I wasn't practical enough, that I didn't have that extra something it took to be a midwife. Maybe I wasn't impractical, maybe I was inefficient, in the sense I've just described. I've held on to the term 'practical' though because it stuck in my head for so long, and I think words often do that for a reason. If I felt, over and over again during training and working as a midwife, that I lacked some indescribable hands-on, efficient capability, doesn't that have something to say about practice? About what we think practice is?
I came to midwifery because I was interested in relating theories about women's experience to their actual experience. Experience has taught me that theory and practice don't always mesh (the much-talked about 'research-practice gap' reflects this). There are two different bodies of knowledge, and I'm trying to wriggle between them. This feels difficult, but isn't it often the case that we can learn from situations that are awkward or uncomfortable? Certainly my clinical experience taught me that you learn by your mistakes. We need to ask where we want to place theoretical, research-based ('academic') knowledge, and the people who hold it, within the midwifery profession. One issue is that there may be a power differential between people with practice-based expertise and those with theoretical skills. Academic knowledge has traditionally been vested in a powerful group: those who, like me, have been lucky enough to have educational opportunities. At the top of the tree, this tends to mean men, or at least middle class women. Knowledge held by a privileged group is powerful, and can be used to dominate other kinds of skill (Rolfe, 2002), such as the practice-based knowledge traditionally held by midwives. Is this one reason for the uneasy relationship between research and practice?
Having come from a clearly academic background, I certainly felt that I might be a threat. Hence at the hospital where I trained, I kept quiet about having a degree in a different discipline; as a new researcher giving seminars, I bent over backwards not to intimidate experienced clinical colleagues with my scary intellectual knowledge. When I fumbled to suture a woman's perineum, or anxiously questioned my clinical decisions, I imagined midwives thinking, 'huh, she might be well up on the research, but can she actually do it?' Now I wonder how much that's about me, rather than them. And yet, and yet: two versions of the same story. Did I really make up those feelings of anxiety, of awkwardness, the perception that my recent academic experience and theoretically derived interest in midwifery made me a bit of an anomaly?
Recent debates around the value of evidence-based practice (EBP) for nursing and midwifery show that knowledge tends to be compartmentalised (Sackett et al, 1997; Rolfe, 2002). Evidence-based medicine, the model for EBP in other professions, has been criticised because research, rather than clinical expertise, is its central feature. Clinical experience is reduced to an aspect which is taken into account during the logical, ordered process of accessing and applying research, as if it were just an optional extra. A contrasting view is that clinical expertise drives decision-making, and that research is just one of the factors that influence this (Rolfe, 2002). In both models, forms of knowledge are seen as packages that can be added or subtracted, and which come to dominate other types of knowledge. EBP is based on rigorous, 'scientific', linear (dare we say 'male'?) principles, all of which are valued by the quantitative tradition, which dominates medical research (Rolfe, 2002). Do we want midwives who are confident with this sort of knowledge ('academic' midwives) in our practical, hands-on profession? Do we feel threatened by them? How does their knowledge fit with the wisdom of midwives with many years' experience of being with women?
When I left clinical midwifery and began to work as a researcher, I came full circle to the 'academic' roots that first led me to midwifery. However, I'm not at the place I started from, because my clinical experience has given me another perspective on what might be important to women. I'm pleased to say that my experience of research has made a lot of sense of my experience of practice. I think I'm a much better researcher than I would have been if I'd gone straight down the traditional academic route. Being 'practical' has made me a better academic, then, and this has made me rethink my perception of the two as opposed. Maybe, just maybe, you can be skilled at both? And maybe my colleagues knew this all the time, and my discomfort with my academic knowledge was my problem?
And yet, I was practising and learning as part of a system. Consciously and unconsciously, the message I took on board about being a midwife was that speed, efficiency, manual dexterity, Getting the Job Done were important. Research, intuition, communication were sometimes (not always) less so. When I struggled to suture a woman's perineum or to make a clinical decision, I felt as if I was overbalanced: having 'too much' theoretical knowledge and not enough clinical experience. As I've discussed above, in the literature on EBP, knowledge is divided into different camps. In clinical practice, it's also important to have the right amount of knowledge. Students can be 'too cocky'. Newly qualified midwives worry that they will be found out for not knowing 'enough'. Midwives with many years of experience need to gain 'enough' paper certificates and qualifications to show that they deserve that next promotion. Women can 'know too much' about their choices. Interestingly, this excess of knowledge can be dangerous. Haven't you ever heard dire predictions to the effect that those women who deeply desire a normal birth, who have educated themselves about the available options and written a detailed birth plan, are the most likely candidates for an abnormal labour and delivery? This has always fascinated me because it reminds me of the eminent 19th century obstetricians who argued that women shouldn't be educated because the diversion of the body's resources to the brain would cause their wombs to atrophy (Ussher, 1989). Too much knowledge is a dangerous thing. Is this why you can be 'too clever by half'?
I've raised a lot of questions in this article, and I'm conscious that I haven't provided any answers. Even while writing this, I'm still thinking it through. One thing that seems clear is the way in which different types of knowledge are used to dominate or devalue others. It seems very difficult for women and midwives (who after all are mostly women) to have exactly the right sort of knowledge in the right proportions. Am I the only one who feels uncomfortable with expectations of what I should know and what I do know? Maybe the expectations (ours and other people's) are the problem? One way forward would be to accept that knowledge, like people, comes in all shapes and sizes, all of which are acceptable. This article is a way of thinking about how that might happen.
(IK 21 September 2003