From Issue No.96, Spring 2003
John Mason
The paradox that wrecks so many promising theories of education is that the training which produces skill is so very apt to stifle imaginative zest. (Whitehead, 1978).
The verb "to educate" means indeed, to lead elsewhere, out of doors, outside of this world: in fact to cast off (Serres,1998).
Staff at NHS Direct, the government-backed telephone service where nurses offer 24-hour health advice, were forced to mimic answering machines when the automated call service broke down... They were given an official message to recite to callers while pretending to be a machine in order to get people to clear the lines... If callers became suspicious, staff were told to simply repeat the message like automatons. (Blackstock, 2000).
The impressive amount of evidence given to the Winterton enquiry in the early 1990s by many interest groups and individuals indicated the need for real change regarding midwives as 'lead professionals' in maternity services. This has not happened.
Overall, current midwifery education reflects the lack of influential midwifery power. With more than 95% of British births occurring under varying degrees of medical supervision and under the tight controls which are exerted over practice and education in accordance with the performance criteria of business management theories, the possibility of moving midwifery education in a liberal direction is minimal.
For these and other reasons, midwifery recruitment is tending to attract those with minimum educational attainment. Whatever might be achieved in basic or post-qualifying education, is initially handicapped by this fact.
The current knowledge base of midwifery education is scientific only in the sense that it relies on second-hand medical science based purely on the rational accumulation of data. An alternative approach could refer primarily to humanist and biological principles and their supportive theories such as those to be found on the website www.hippias-education.com.
The development of liberal education requires time and space for exploration, research, reflection and preparation. During the past 15 years the performance/efficiency/cost effective behaviours required by Trust managers of all NHS workers, have reduced employment to functional conformity and narrow interpretations of occupational skills. Many midwives are no longer even semi-professionals, but merely service workers driven by prevailing whims of government schemes which privilege both medical control and business management objectives over the development of independent midwifery practices. There are a few localised exceptions in the UK such as the Edgware Birth Centre, the Albany community practice, the Dover Birth Centre and so on, where a small minority of midwives are allowed the possibility of 'autonomous' practice with 'low risk' women.
Although some midwives are becoming increasingly aware of therapeutic skills such as aromatherapy, massage, reflexology and other ways of assisting reproductive processes, and a number have become qualified practitioners in these arts, there is no collective body of knowledge to supersede the current science-research base of midwifery education which is derived from the narrowly focused rationality of medical science.
State midwives appear to give little thought to the complex interactions of biological, nutritional, environmental, social, economic and political forces that converge at the moment of birth. This seeming indifference to an intimate knowledge of life-forces and an apparent deficit of political, philosophical and aesthetic awareness reflects and even defines the scientific and social status of midwives in Britain.
The situation continues because of active resistance to structural change within the cultural hierarchy of state midwifery. The 'gatekeepers' of this culture are the executive managers, established academics and professional bodies which represent the accepted values of universal [state] Midwifery. These values emphasise ultimate deference to medical authority and hierarchical managerialism. In addition, a restricted preference for individual intimacy, according to 'New' Midwifery's so-called one-to-one relationship between midwife and client takes precedence over an understanding of the interactional nature of social, biological and cultural dynamics.
State midwifery could become pro-independent, but this would require basic structural change to reflect the actual existing realities of maternity services and the inclination of client preference (Mason, 2000/1).
Without fundamental structural change in the definition and organisation of state midwifery practice and education, there is little possibility of acquiring effective knowledge in the public sector. The State appears to have an intransigent hold over midwifery education but there are possibilities for real change; however, such change involves unconventional commitments that most appear unwilling or unable to make.
Possible initiatives require risk taking, personal expense and research work in areas that lie outside the established parameters of state midwifery education and obstetric-led care. If substantial changes can occur from 'bottom-up' initiatives rather than 'top-down' planning, then midwives could set their own conditions for things to happen at a local level.
The widespread availability of various forms of information technology would enable local projects to link up with relative ease. A closer relationship between bio-social 'communities of practice' and local cultures would produce new learning and research opportunities relevant to the long-term health needs of local populations. Rural areas in particular are beginning to link up on every matter of interest via the internet, for example: www.digitaldales.co.uk/sitemap.asp.
Within this possibility, midwives' understanding of the complexity of factors that constitute human ecology generally and the health status of specific populations in particular would be enhanced by increased knowledge of the dynamic connections between intrinsic biological events and external environments (McNabb, 2002). Environmental and social effects on reproductive health would constitute legitimate sites of empirical research complementary to the primary referent of reproductive biology.
Specialised knowledge of interactions between molecular, social and environmental processes would enable these midwives to interpret local effects as matters of long-term health and human ecology. Instead of referring exclusively to a set body of knowledge, developmental biology would become the primary scientific touch-stone for midwifery research-practice. As holders of specialised knowledge, bio-socially minded midwives would base their assessments on how their client's reproductive potential is created and dynamically maintained by social and physical forces.
State midwives are too narrowly focused on the event of birth as it is interpreted for them by medical and managerial forces. To step outside this straitjacket requires insight and courage.
REFERENCES
Blackstock C (2000). 'Dial a mimic at NHS Direct', The Guardian, 10 February.
McNabb M T (2002). 'The fetus at birth: maternal and fetal preparations for postnatal development', in Nutrition in Early Life, J B Morgan and J W T Dickerson (Eds), Wiley, Chichester.
Mason J (2000). 'Defining midwifery practice', AIMS Journal, Winter, 12, 4 (http://www.aims.org.uk/ ).
Serres M (1998). The Natural Contract, (p114) The University of Michigan Press.
Whitehead AN (1978). Process and Reality, (p 338) Free Press, New York.
LW updated February 4, 2005