From MIDWIFERY MATTERS, Issue No.102, Autumn 2004
Anna Fielder, Mavis Kirkham, Kirsten Baker and Angela Sherridan
WE WANT TO DRAW ATTENTION to one of the ways in which midwives have learned to think, learned, that is, from society, medicine and indeed the culture of midwifery itself. Focusing upon thought doesn´t sound as radical, perhaps, as attempting to change the way midwives do things. Doing and thinking are often viewed as opposites of one another: as mutually exclusive. Yet maybe that is part of the problem. We often fall into the trap of looking at things in a dualistic fashion: to do – to think, radical – conservative etc. In other words, there is a tendency for us to try to make sense of the world within which we practise midwifery, and of the complex things that are happening to midwifery and maternity care, by grouping them into categories that we consider to be independent of and opposed to one another. In this article we want to explore this way of thinking. Could it be that in justifying our knowledge we have adopted habits of thinking which do not fit with the fundamentals of good midwifery? Have we unknowingly taken up the mental tools of that medicalised approach which makes the continuation of midwifery so necessary?
Midwifery thinking and writing is full of opposites: normality-abnormality, safe-unsafe, health-illness, life-death, safety-danger (or in more contemporary jargon, risk), pathology-salutology, professional-lay, autonomy-dependency. There are also other dichotomous, although less literally opposite pairs of concepts, such as breast-bottle, home-hospital, physiology-pharmacology, midwifery model – medical model and midwife-obstetric nurse.
Home – Hospital
Take the example of home-hospital. These places are different, and are often spoken about as if they were opposites. And yet such an assumption is inaccurate. Homes range from the primitive and unsanitary (now rare) to those lacking nothing the best hospitals contain (even rarer), as when the queen gave birth to her children in Buckingham Palace. Hospitals range from understaffed crises waiting to happen to the deeply supportive and caring; often the range of their technical facilities is in the opposite direction. The degree of technology, degree of care, degree of staffing are only three of many ways in which hospitals vary.
Yet it is not merely that we speak of home-hospital as opposites when they are not. This pair – this dualism – is weighted. For example, women denied home births for reasons of staffing or complications are transferred to hospital, sometimes in advanced labour. And yet, have you heard of many cases of women in labour being transferred home from hospital because all was well and their comfort and the chances of a good outcome would be greater at home? Yet this would be good management in many cases. Hospital is therefore the default position which is authoritatively endorsed.
As in most of these pairs of apparent opposites, there is a hierarchy: one side of the equation is seen as more important than the other and has more status. Which aspect of the dichotomy is most valued may vary for different people, although the dominant perspective within contemporary maternity care prioritises hospital birth over home birth. Often another dichotomy ‘safe-unsafe´ is drawn upon to reinforce the dominant view about where women should give birth, with hospital being labelled the safe place and home unsafe.
Safe-unsafe
The ‘opposites´ we work with tend to be constructed as good-bad, or positive-negative. They imply a value judgment, separating off what is unacceptable. The unacceptable or ‘other´ is something that is outside social norms for a particular group. The group can therefore deny responsibility, or it may be possible to subject the ‘other´ to ‘therapy´ in order to bring it back once again into the fold. At the extreme, midwives deemed to be unsafe to practise are singled out from the rest of the profession, held up as examples of ‘what not to be´ and, if some form of ‘therapy´ (such as supervised practice) is not deemed suitable to render them safe practitioners, they are ultimately struck off of the register. Unsafe practice is therefore externalised: seen to be something other then ourselves.
Yet definitions of safety are notoriously varied and subjective. Professionals tend to see safety within their own professional parameters: obstetricians as delivering a live child from a live mother, paediatricians as protecting a baby from infection. Parents also seek the safety of their children and for them this is within the wider contexts of families and lifetimes. The most liberating words in Changing Childbirth are seldom quoted:
Safety is not an absolute concept. It is part of a greater picture encompassing all aspects of health and wellbeing. Each women should be approached as an individual, and given clear and unbiased information on the options that are available to her, and in this way helped to balance the risks and benefits for herself and her baby. (Department of Health 1993 :10)
Despite Department of Health endorsement, this is incredibly difficult to achieve within institutions with deeply entrenched beliefs and practices regarding what is safe or unsafe for women in particular circumstances. It is difficult to achieve in institutions built upon polarised thinking.
‘Opposites´ and bullying
If one side of an opposite is seen as good, this can justify demonising the other which is therefore seen as bad. When we are socialised into the paired thinking of institutionalised medicine, polarisation becomes a habit. This may account for some of the horrible ways in which midwives treat ‘other´ midwives. Accounts of opposites underpinning such behaviour are reported in research. Examples are:
We tend to demonise the ‘other´ who is different from us. Once such issues are constructed as opposites, rather than differences or stages in the journey of a career, the door is open to the bullying which springs from equating the different with the inferior. There is a lot of that in midwifery.
The invisible between the extremes
In a world of polarised opposites everything between the opposing poles can be ignored. The crystalisation of opposites in our minds prevents us from acknowledging the actions of others which do not fit within the dualistic framework. For example, the literature on early infant feeding talks primarily of breast and bottle feeding, and little is said about mixed feeding. Midwives promote breast-feeding and when a woman decides to give her baby a bottle it is often assumed that she has given up breast-feeding in favour of bottle feeding. However, vast numbers of women mix breast and formula feeding; others feed their baby from bottles filled exclusively with expressed breast milk; and some women mix breastfeeding and bottle feeding with expressed breast milk. These are rarely discussed in a narrative which sees breast and bottle as opposites.
Dichotomous thinking forces ideas, persons, roles and disciplines into rigid polarities. It reduces richness and complexity in the interests of logical neatness … (Sherwin 1989:32)
Thus in our own actions and those of our clients, thinking in opposites limits what we allow ourselves to see.
Why do we behave like this?
So, if it is not representative of reality, and constrains the way we see the world, why does dualistic thought continue to exist within midwifery? The immediate answer is probably because it is so prevalent in our society. Indeed, it could be said that society is based upon the assumption that people can be categorised into different polarised groups, and that one of the groups in any given schism assumes power over the other. The example of ‘black and white´ is perhaps one of the most notable, and has been embedded in social systems reaching at least as far back as slavery.
Categorising things as opposites, one of which is ‘good´, has a neatness about it which saves us thinking. This approach is easy to act upon, even when our actions may be damaging. The results of some demonising dualisms are now illegal, such as some manifestations of racism and sexism, but the habits of thinking which underpin them remain.
Dualisms in our society underpin and reinforce power differences.
Patriarchy and institutions
The male – female polarity sets up a pair of apparent opposites with an imbalance of power.
…the creation and use of dichotomies seem to be important elements in the very structure of patriarchy – the institution of patriarchy involves power relations that rest on the assumption of fundamental and unbridgeable differences between the sexes reflected in multiple forms of polarity. (Sherwin 1989:32 )
She is defined and differentiated with reference to Man, and not he with reference to her; she is the incidental, the inessential as opposed to the essential. He is the Subject, he is the Absolute – she is the Other. (de Beauvoir, 1953/1993, xliv-xlv).
Once industrial development made it possible for medical and maternity services to move outside the domestic world, we see a polarisation which equated women with the domestic and men with the public world. It is only relatively recently that the notion of a woman being her husband´s property has started to be legally challenged. Women have therefore been defined in terms of men, rather than in their own right. The feminist literature equates this polarisation with repression. We need also to be aware that discussion of emancipation from male oppression accepts the dualistic construct of one side as oppressive and one as oppressed.
Celia Davies describes masculinity and femininity as “expressed as differential developmental trajectories – the one towards separation and autonomy, the other towards connection and attachment.’ She highlights the “suggestion that the route to masculinity gains its coherence in important measure by denial or repression of the qualities expressed as femininity’ (Davies 1995 p36). It is the masculine vision which shapes our institutions and, while they are dependent upon the care given by women such as midwives, that care remains invisible and unvalued. Thus we are stymied as we operate within and are employed by a health service dominated by institutions whose values deny our basic function.
The quest for certainty and professional power
Opposites arise in clinical practice partly because people are looking for certainty. A labouring woman´s questions of “how long?’ can be answered by supporting her in the state of uncertainty which is labour, or with the heroic declaration of active management that labour will take a maximum of 12 hours. Society endorses the quest for certainty and, while this gives professions great power, it increases the risk of litigation when they do not live up to expectations.
The medical and the professional authority rest upon the expert having the specialist knowledge and being ‘right´. Indeed, professional maternity care, in this country, is underpinned by the law; calling for the attendance of a non-professional in labour is illegal. Legal-illegal constitutes a very powerful pair of opposites.
Midwifery has grown up within this context. Indeed, since professionalisation it has been viewed as the ‘other´ in contrast with obstetrics: the much needed but seldom recognised, hand-maiden. As such, midwifery has inherited and adopted (some midwives more eagerly than others) many of the opposites that define obstetrics.
Radical dualisms?
One of the difficulties is that even in its most radical of guises, midwifery does not seem to have been able to step outside, or to overthrow, the dualistic ways of thinking that it has inherited. Radical midwives have been at the forefront of inverting the dualisms. For example, asserting the autonomy of midwives (against a view that they should be the hand-maidens of doctors); promoting normality in a climate where so many babies are born instrumentally or by caesarean section; recognising the power (rather than powerlessness) of women; promoting the benefits of a midwifery rather than a medical model. But the dualisms themselves are seldom challenged.
For example, from a radical midwifery perspective, the home-hospital dichotomy can be, and often is, turned upside-down. Homebirth is celebrated. And yet sometimes there is a danger that the flipside of this is that hospital birth is viewed as something to be avoided and maybe even (implicitly if not explicitly) something of which to be ashamed. Do we as midwives feel a pressure to express our radicalism by referring to homebirths that we have attended (for example, no VEs, in the pool, aromatherapy etc.)? Maybe we are less keen to talk about the births that differ from that; the times when we are with a woman who plans a homebirth and transfers into hospital in labour; the times when a woman opts antenatally for a hospitalised birth; or when a woman we are working with has a complicated instrumental delivery or caesarean section. Do we (as women and as midwives) somehow feel that these reflect badly upon ourselves? We would hazard a guess that over the years there have been many more birth stories in Midwifery Matters of homebirths, than of instrumental or caesarean births. Homebirth stories are inspirational and enjoyable to read. But what, if anything, does the relative lack of stories about hospital or assisted births say about our values as an organisation? Have we invented our own hierarchy of births, in which home birth has more kudos than hospital birth? If so, what are the implications of this? And how does this affect the women we work with; particularly those who for whatever reason give birth in hospital?
Midwifing a woman who chooses to give birth in hospital or who plans a homebirth and transfers into hospital, can be more challenging for the midwife than a physiological homebirth might be. Such births can be a humbling experience for midwives who challenge the status quo: a reminder that we ourselves are not omnipotent, and that there are times when, for whatever reason, hospital is a good place for a woman to be. There is much to be learned from such experiences. We need to share rather than hide them.
Normality or complexity?
A dichotomous interpretation of birth also suggests that birth is either normal or abnormal, when in reality a vast array of births and clinical situations would probably fit better in neither category. What about the woman who has a spontaneous purely physiological vaginal homebirth, but is traumatised by the experience? Does her experience constitute a normal birth?
There is a wide range of clinical situations in which the crucial question must be: is this normal? And the answer is often unclear. Indeed, much of the art of midwifery lies in being able to live with uncertainty, of being able to tolerate the inability of classifying a woman´s condition as ‘definitely normal´ or ‘definitely abnormal´. This is one reason why the selection criteria set for birth centres or homebirths are problematic: the implication being that women who fall outside the inevitably somewhat arbitrary criteria are in some way abnormal. Yet many of these women will go on to have normal births, especially where their ‘normality´ is supported.
What can midwives do?
As with any problem, knowledge of its manifestations must be the starting point, for only when the problem is identified can we start to seek for solutions. ‘Solution´ itself is a polarised concept and we need other ways of thinking. “The master´s tools will never dismantle the master´s house’ as Audre Lorde (1984) so perceptively said. We need other mental tools and habits.
If we are to live with uncertainty and not discount all that could be defined as ‘other´, very different ways of thinking are called for. Seeing things as ‘black´ and ‘white´ (to use that value-laden dichotomy that has had barbaric political implications over the years) provides the illusion of safety, but the reality of midwifery is that most of the situations we encounter are better described as grey, and there are many, many shades of grey. Or perhaps it would be better still to compare these situations to the colours of the rainbow – colourful, varied and, it might be added, beautiful, if only there were space for midwives to enjoy the beauty of the uncertainty. Looking at the world in dualistic terms does not provide that space. Indeed, it renders it impossible.
Thinking of a continuum, rather than two poles, might help. A vast range of experience can be placed along a continuum, and positions upon it can change. This can help us to fill in the world between the opposites. Yet the poles have much in common (Smale 2004). For instance: the extremes of the home-hospital polarity both hold the context of birth to be highly important. People advocating home birth prioritise the context in which the woman feels at home; advocates of hospital birth prioritise the context where the professional is most efficient. So the polarising opposites become loops where differing values are demonstrated in areas of common concern.
Within the tradition of midwifery, connectedness is likely to prove more fruitful than polarisation. Carol Gilligan´s (1982/93) study of women experiencing relationships as a web, rather than a hierarchy, gives an image of complexity and support rather than simplified opposites.
Mindful of such traditions and possibilities we can talk, listen and develop ideas of how practice could be developed beyond the comfort zone of thinking in terms of ‘them and us´. This would be a massive challenge but offers much potential to be inclusive, rather than walling out all that is different. Would it be possible to develop midwifery education to include our awareness of how we see the world and of other possibilities?
Other disciplines have succeeded in deconstructing their own approaches to their subject. Midwifery is very new as an academic field and we have not embarked upon this project. Yet only if we can analyse the binary thinking which holds us will we be able to identify forms of resistance to the habits of thinking which now go unchallenged. This is not, however, just an academic project. It is just as much, if not more, relevant to clinical practice. If all of us (at the next antenatal visit, birth, management meeting, lecture or research seminar we attend) watch ourselves, and observe the times when we begin to think or talk in ‘opposites´, then we can start the process of challenging our own midwifery values. Only when we are aware of how we are seeing the world, can we start to ask ourselves what we are missing, what we are rendering invisible, and what we are implicitly devaluing by seeing the world in such a way. Then we can begin to move forward.
By questioning our own thought processes we can begin to look for alternatives; more positive and affirmative ways of thinking about and doing midwifery. Such work could make it possible for midwifery to develop very differently. However, without such work it is likely that the narrowness of thinking in opposites and the danger of being defined as ‘other´ will continue within midwifery; and will continue, as it currently is, to be destructive of both individuals and of relationships.
REFERENCES
De Beauvoir S (1953/1993). The Second Sex (translated and edited by H.M. Parshley, with introduction by Margaret Crosland) London, David Campbell Publishers Ltd. (Everyman´s Library)
Davies C (1995). Gender and the Professional Predicament in Nursing, Open University Press, Buckingham.
Department of Health (1993). Changing Childbirth, HMSO, London,
Gilligan C (1982, 1993 edition). In a Different Voice: psychological theory and women´s development, Harvard University Press, Cambridge Massachusetts.
Lorde A (1984). Sister Outside: essays and speeches. The Crossing Press, Feminist Series, New York.
Sherwin S (1989). ‘Philosophical methodology and feminist methodology: are they compatible?´ In: Garry A and Pearsall M eds. Women, Knowledge and Reality, Boston, Unwin and Hyman, quoted by Oakley A (1992) Social Support and Motherhood, Blackwell, Oxford. p xi.
Smale M (2004). personal communication.
IK updated 1 December 2004