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Contemporary midwifery practice: Art, science or both?

02 September 2015
Volume 23 · Issue 9


Current midwifery practice is regulated by the Nursing and Midwifery Council (NMC), whose primary role is to safeguard the public through setting standards for education and practice and regulating fitness to practise, conduct and performance through rules and codes (NMC, 2012; 2015a). Practice is informed by evidence-based guidelines developed and implemented by the National Institute for Health and Care Excellence based on hierarchies of evidence, with meta-analyses and systematic reviews being identified as the ‘gold standard’. This positivist epistemological approach as developed by Auguste Comte (1798–1857), with scientific evidence at the top of a knowledge hierarchy, fails to acknowledge the ‘art of midwifery’, where a constructivist paradigm of experiential, intuitive and tacit knowledge is used by reflective practitioners to provide high-quality care. As midwifery pre-registration education is now degree-level, is the essence of midwifery practice being ‘with woman’ providing holistic care under threat, as the drive for a systematic and analytical approach to decision-making gathers momentum?

This article will consider the debate as to whether contemporary midwifery care should be based on policies and guidelines underpinned by systematic review (positivism), or based on evidence derived from experiential knowledge and intuition (constructivism). A critical review of current literature in relation to epistemology (the theory of knowledge) in a health-care setting has discovered a dearth of midwifery-specific papers; rather the focus has been on the acquisition of knowledge in a nursing environment. Comparisons can be made between the role of the midwife and advanced nurse practitioner in terms of autonomous practice, advanced critical reasoning and expert decision-making in time-critical situations; as a consequence, this article will use nursing literature in addition to midwifery-specific literature to underpin the discussion where appropriate.

Carper's (1978) taxonomy of knowledge offers four fundamental patterns of knowing in nursing:

Siddiqui (2005) applies this paradigm to midwifery knowledge using the terms theory, practice, research and the midwife's personal belief system, all of which come into play in clinical practice: underpinning theory and research via taught sessions within the university setting during training, complemented by practice both as a student and then as a registered midwife by building a library of knowledge through experiences in practice. This follows Bloom's (1956) taxonomy of a hierarchy of levels of thinking from being provided with information to comprehension, application, analysis, and synthesis, culminating with evaluation of knowledge in order to apply it appropriately in decision-making.

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