From Issue No.96, Spring 2003
Mavis Kirkham
THERE ARE clearly major problems with midwifery in the NHS. These problems are demonstrated in the current shortage of midwives. Many of those we look to as carrying midwifery forward into the future are leaving because they are unhappy with the midwifery they now have to practise within the NHS. This situation is not unique to midwifery but it needs addressing at a strategic level.
There are some good things happening in midwifery and in other health services. There are many short-term projects but they are limited in time and in geographic coverage and are required to be 'absorbed within mainstream services' in a few years time. Yet where are mainstream services going?
There are excellent documents and policies but these stay at the level of rhetoric. Maternity services are required to be 'woman centred' with 'empowered' women exercising 'informed choice'. If we repeat such words often enough we can come to believe they describe the service on offer. Yet, the reality experienced by most women is one of compliance with 'choices' which are defined by the service. Women are defeated in their attempts to choose options which do not fit with the services offered. Home births, care from a known and trusted carer, a vaginal breech birth, a physiological third stage of labour or an extended postnatal hospital stay are all unthinkable choices in many places. Midwives exercise great and self-destructive skill in ensuring that women exercise informed compliance and do not rock the boat. Women 'don't like to ask' because the midwives are so harassed and accept that when we say we will come back to observe their breast feeding when we have answered a buzzer, we are highly unlikely to return. Midwives end their shifts exhausted, anxious and feeling that they haven't really cared for anyone. What is to be done?
As an individual, I don't have the answers. As a researcher, my job is to map the current situation, to point out problems and contradictions and to highlight things that work.
As ARM, we can discuss and devise strategies. All the major improvements and ideals of UK midwifery over the last 25 years were first envisaged within ARM, then taken up by other organisations. We need to do this again, or we could lose midwifery.
Using Midwifery Matters
The editing of Midwifery Matters has been changed so that the work and the thinking are shared more. This should enable us to bring our ideas together more effectively. Margaret Jowitt has done a wonderful job in recent years and she will now work with the new editorial group from the next issue. I have pulled this issue together with a lot of help and Margaret's support. This gives me the opportunity to launch Midwifery Matter's debate on what can be done about the state of midwifery by saying a bit about how I see things. Then you can say lots of better things in the next issue.
This issue includes stories by three midwives of why they left mainstream NHS midwifery and the Why Do Midwives Leave research findings. Together these pieces say much about what is wrong. We work in increasingly large and centralised, hierarchical organisations. The size and structure of these organisations ensures that the needs and maintenance of the system is far more important than any client or midwife within them. We work increasingly hard just to keep that system going without supporting women or colleagues as people. In our everyday work, and with the best of motives, we collude with and maintain a maternity service, which devalues women as mothers and as midwives. As midwives, and women, we wish to provide care and often ignore our own needs. We are also swift to blame ourselves when things go wrong, a dangerous internalisation of a system which is itself quick to point the finger of blame. Marianne Tellier shows this tragically in her story.
Perpetuating an alien system
We, as midwives, are running this under-resourced and damaging system, the values of which do not fit with midwifery values. When individuals find this intolerable they tend to be blamed as unable to cope; we "pull each other down," as Sara Wickham reports. Midwives are being pulled apart by the many claims upon them - but these are the claims of the service not the clients. The system is such that the claims of clients only present as the last straw. We are the shock absorbers of a medicalised, inadequate and inequitable service. Shock absorbers take the strain, wear out and are disposable. Is that what we want?
I am not saying that midwives do not care. We give care, mainly, despite the system not because of it. For every woman with whom we discuss options carefully and then act as advocate there are many others processed in silence. Thus, even our best efforts perpetuate inequity and midwives who truly act as advocates are very vulnerable. Yet, we know that good midwifery support is the greatest bastion against unnecessary medicalisation and the fear that is corroding everyone's approach to birth in our society.
I do not wish to criticise those who battle on within the NHS. These midwives are heroic and they deserve a better work setting. I want to move the battle into the political arena where it belongs and out of the personal and the practice worlds.
Keeping the conveyor belt running smoothly can make us feel skilled and even secure but the cost is powerlessness. Midwives report their powerlessness to give and to facilitate support for women, colleagues and themselves. Managers too feel powerless. On a professional level, powerlessness is linked with oppression. On a personal level, powerlessness is linked, tragically often, with depression. Oppression and depression both erode our ability and will to work for change.
Research studies repeatedly report midwives' need for support but we are too stretched to give support to each other and it is not part of the NHS culture. Indeed, we see our own needs as shameful and 'selfish', a complete devaluing of our very selves.
If we can't support each other, how can we support women? If we are too tired and oppressed to articulate our own needs, how can we help women to express their needs? If we devalue ourselves, we devalue those around us. Yet, we have a responsibility to foster confidence in women and in ourselves. Where midwives practise with confidence, that confidence is spread to women and to colleagues. Women's confidence is the bastion against fear of birth and there is too little confidence and too much fear about.
Technical/medical tasks are so much easier to define and to measure. We take on more and more such tasks, this ensures that we process people rather than listen to them. This facilitates an increasingly medicalised service and allows fear to spread.
Deconstructing the conveyor belt
I want to make three suggestions: these concern scale, parallels and diversity.
In my view, the current centralisation of maternity services is a big mistake. It does not even make economic sense and it makes good midwifery practice very nearly impossible. Belinda Wells describes her reasonable decision to leave the conveyor belt. I think we must deconstruct the conveyor belt, before too many others leave.
Midwives work best and women feel safest where the scale of the service is small enough for relationships with women to be of primary importance, where individuals are heard and attended, not processed. To achieve this we must make changing the scale of the service the priority. This means supporting local services, birth centres, case-holding, midwifery beds in the cottage hospitals which are returning for other medical services, continuity of specialised midwifery and medical care for high-risk women and many other changes. We should do this with the deliberate aim of breaking up the big bureaucratic services. I know there are tremendous vested interests within them, but they don't work for women and they don't work for midwives. There are lots of local campaigns which could be unified with appropriate strategy and leadership.
Breaking down maternity care into a human scale would mean that we could not hide within the system. Passing the buck and covering our backs are major concerns in large units. Where services operate on a small, human scale we have to take professional responsibility. Appropriate support is vital and we can learn how to build such support from those who already practise in this way. If we exercise our power as midwives, responsibility and trust become major issues. Midwives have to be trusted and they have to trust themselves, only then can they trust women to birth their babies.
Since we offer a service primarily to the well woman, there are many parallels between the needs of mothers and midwives. We need to study these and build upon them. We have to do this actively. We need support but cannot expect it to be provided for us, that expectation just perpetuates our powerlessness. Studying our own needs, designing our own support and learning to trust appropriately will enable us to achieve the support that suits us as individuals. It should also equip us to help women to tailor our support to fit their needs, and prevent us from experiencing this as rejection. Such parallels focus on relationships and are a long way from the current demeaning processing of women. Such awareness and resulting actions take us and our clients off of the conveyor belt.
There are many different ways of dismantling the centralised bureaucracy. There is value in diversity. "Different people need different kinds of midwives," states Jan Tritten in an eloquent discussion of diversity in the current issue of Midwifery Today. Different midwives work differently and many working arrangements are needed to reflect our diversity. Yet, Jan goes on to stress the unity contained in, "our simple knowledge that women can give birth". With confidence, comes the ability to gain support from others, rather than seeing them as a threat. As well as diverse midwifery services, there is a place for antenatal educators, doulas and many others who share our values and aims. We must not let our professional identity isolate us from potential allies.
What I am proposing is highly political. I am very aware that in many respects the values of our society and of the present government do not fit with midwifery aims in empowering women to realise and use their strength around birth. Yet, the health outcomes favour diverse provision on a smaller scale which values the relationship between midwife and mother. I believe in midwifery and in women and I think they are worth working for. We have many potential allies in lay groups and service users. Many workers and users in other areas of health care would respond to our lead in working to redefine the service. The alternative is a fearful service designed to fit the values of the insurance companies, not those of women (see Jane Evans' article). This is rapidly becoming the reality. We much act politically to change this situation. I look forward to the debate on how best to achieve this.
LW updated February 4, 2005