Midwives are expected to use evidence in their decision making and use knowledge to inform their midwifery practice. In recent years, the term ‘evidence-based practice’ has been used to define the expected level of practice (Spencer and Yuill, 2018). The modern-day concept of evidence-based practice originated in medicine and was heralded by Archie Cochrane in the 1970s (King, 2005). This led to the formation of the Cochrane Collaboration and the rise of midwifery practice that is informed by randomised controlled trials, which were defined as the ‘gold standard’ in evidence (King, 2005).
The original expectation of evidence-based practice was not purely the use of scientific research and although the terms ‘research-based’ and ‘evidence-based’ are not differentiated in the literature, they are different. Sackett et al (1996) define evidence-based practice as ‘the combination of integrating individual clinical experience with the best available external clinical evidence from systematic research’. They define individual clinical experience as ‘the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice’ (Sackett et al, 1996). Sackett et al (1996) also state that there ‘are many types of evidence that can be used as evidence to inform practice’. However, as evidence-based practice originated in medicine, the focus is primarily on using scientific research evidence to inform practice. The patriarchal medical model of maternity care states that obstetricians are the most effective and safest providers of care. In midwifery, accepted practice is based on evidence. However, is this the knowledge that midwives use to make decisions?
Intuition plays an important role in midwifery practice, but historically it has often been associated with mysticism and other negative connotations
Authoritative knowledge is defined by Jordan (1997) as ‘the knowledge which forms the basis on which decisions are made and actions are taken’. Different types of knowledge have greater value in different societies. When a certain knowledge system is dominant, other forms of knowledge are considered ‘alternative’. The dominant knowledge thus defines itself as the ‘authoritative’ knowledge. There are many different types of knowledge system, including scientific, religious, spiritual, cultural, indigenous, embodied and intuition-based systems. However, scientific knowledge is considered to be the highest level of knowledge, and it is thought to be rational, neutral and definitive. Other forms of knowledge have been dismissed as subjective and therefore, unscientific and irrational (Ehrenreich and English, 2010; Davis-Floyd, 2017; Davison, 2020). This stance is particularly relevant when considering other ‘ways of knowing’ that are so often ignored.
The Oxford Dictionary (2021) defines intuition as ‘the ability to understand something instinctively without the need for conscious reasoning’ and the Cambridge Dictionary (2021) states intuition is ‘an ability to understand or know something immediately based on your feelings rather than facts’. Intuition is often described in terms such as inner knowing, a sixth sense, insight, instinct, inner feelings, hunches, premonitions or foreboding (Davis-Floyd and Davis, 1996; Green, 2004; Davis-Floyd, 2017). Another term used to describe intuition is ‘embodied knowledge’, because it is experienced within the body, as a ‘gut feeling’ (Reed, 2021). Unfortunately, these abstract notions have in the past been associated with witchcraft, feminine knowledge and mysticism, which has allowed scientists to denigrate the legitimacy of the role of intuition in clinical judgement (Towell and Bramall, 1986; Ehrenreich and English, 2010).
A midwife's intuition is considered part of a midwife's practice, although it is not valued as highly as other forms of knowledge (Reid, 2014; Fry, 2016; Davis-Floyd and Davis, 1996; Davison, 2019). The midwifery profession does allude to the use of other forms of knowledge within midwifery practice as an accepted form of knowledge. For example, the Australian College of Midwives (2021) midwifery philosophy states a midwife's practice is ‘informed by scientific evidence, by collective and individual experience, and by intuition’ and the statement of values and ethics of the Midwives Alliance of North America (2012) also refers to intuition, stating ‘we value the wisdom of midwifery, an expertise that incorporates theoretical and embodied knowledge, clinical skills, deep listening, intuitive judgment, spiritual awareness and personal experience’.
There is a small but growing body of research in relation to intuition and other forms of knowledge in midwifery (Davis-Floyd and Davis, 1996; Hunter, 2008; Reid, 2014; Fry, 2016). Reid (2014) conducted in-depth interviews with 12 privately practising Australian midwives and found that every midwife used intuition in their practice. Two themes, ‘trust’ and ‘knowledge’ emerged from the data. Within the theme ‘trust’, the midwives talked about three aspects of trust that influenced their intuition:
- Trust residing in their relationship with the woman
- Trust in the woman to take responsibility and make informed choices
- Trust in their own midwifery knowledge and skills, including trusting intuition.
The second theme identified from the data was ‘knowledge’ and was described in four ways by the midwives. It was described as knowledge gained through formal midwifery education and training, social and cultural knowledge learnt or modelled from within the institution that created a negative bias towards normal labour and birth (these attitudes and biases had to be un-learnt when the midwives began working privately) and knowledge gained and developed through many years of practice and had elements of wisdom attached to it (Reid, 2014).
Similar findings were found by Fry (2016) in a study that explored seven UK-based independent midwives' experiences of using intuition. The essential component in the midwives' use of intuition was the relationship that formed between a woman and her midwife. Fry (2016) believes that the midwives' awareness and understanding of the woman was integral to the midwives' intuitive knowledge.
Historically, midwifery was considered ‘women's work’ and knowledge was something that was shared between a woman and midwife (Towell and Bramall, 1986; Ehrenreich and English, 2010). Before midwifery became regulated, the empirically-trained midwife gained experience from attending births and knowledge was passed on through generations of midwives. Storytelling was an important part of sharing knowledge, with both childbearing women and midwives sharing stories and women's ways of knowing (Davison, 2019; Reed, 2021). This knowledge was welcomed and accepted. Midwives trusted women and they trusted their gut instincts, embodied knowledge and other ways of knowing. Is it time to reclaim this knowledge?