The culture of midwifery and autonomy

02 September 2014
Volume 22 · Issue 9

In previous columns this year I explored the impact of recent NHS reforms and health policy on UK midwives and maternity services. I suggested that these reforms might be of interest and significance to our profession because such government driven policy creates a pervasive culture of healthcare provision that affects our professional practice. These analyses focus on the role of midwives and has lead me to wonder How do midwives see themselves these days?

Midwifery culture in the UK

Such a question addresses what constitutes current UK midwifery culture, requiring us to consider our: ideas, attitudes, values, behaviours and customs. This activity is essential in order to understand our cultural identity. Expressing and debating our cultural characteristics is a worthy contemplative exercise. This is because if we define ourselves only through what we do, there is a danger that we might lose sight of our aspirations and ideals and thereby diminish our ‘professional selfhood’.

Problems arise when trying to determine our cultural traits, in part because a midwife's role is very diverse, but categorically includes supporting women throughout pregnancy, the childbearing process and during their adjustment to parenting (Nursing and Midwifery Council, 2012). This is ideally undertaken through providing as much accurate information as is possible, to allow women to make their own informed choices about the options available to them for their maternity care. Pregnancy and birth are not simply clinical events, they are ‘social and psychological transitions of tremendous significance’ (Royal College of Midwives, 2008: 1).

Reviewing the research that addresses our contemporary midwifery culture reveals surprisingly little overarching literature on the subject. Mavis Kirkham's seminal, and somewhat disturbing, work on the culture of midwifery in the NHS is now over 15 years old (Kirkham, 1999). I personally struggle with the notion that there has been little change in the disempowered, bullying culture of midwifery portrayed so distressingly in her work. This is especially so when I view just how much positive change has taken place in our profession over that time. For example, there has been a veritable explosion in studies attributable to midwives who have designed, undertaken and/or collaborated in an incredibly diverse range of research related to midwifery. This activity has underpinned our flourishing evidence-based knowledge and has been especially exciting and affirming in relation to the Birthplace findings (deJonge et al, 2009) and birth centre research (Hodnett et al, 2012).

We are certainly more ‘professionalised’ than ever and an increasing voice alongside the medical profession, as demonstrated by the recent Lancet series on Midwifery. Compared to when I trained as a midwife in 1997, there is more evidential foundation to our role than ever before. Yet still as a profession we face certain perennial struggles with prejudicial attitudes towards homebirth and what represents the best model care for women, this is exemplified by the significant number of negative responses to the Birthplace study.

When I ask myself what motivates me as a midwife I am consumed by the thought that our culture fundamentally centres on the fact that we exist for women. The midwife's role is inimitable in mother's lives, providing care that is centred on their unique needs—ideally ensuring that it is holistic, empowering, proactive and sensitive to the social context and changes in healthcare provision. To be ‘with woman’ the midwife must be the woman's advocate, in true partnership with her care (Silverton, 1993; Guilliland and Pairman, 1995).

Autonomy and choice

With this in mind, I believe it is central to our culture of midwifery to support the notion of choice and promote decisional autonomy for women.

Autonomy confers a personal sense of control that has been identified by political scientists (Barry, 2006) and applied psychologists (Ryff, 1989; Deci and Ryan, 2000) as an important component of the emotional state of wellbeing.

The perception of choice is a feature of a sense of autonomy. Government policy first supported choice for women in maternity service provision in 1993. Changing Childbirth; The Report of the Expert Maternity Group (Department of Health (DH), 1993) was published by the DH having been commissioned in response to the preceding two decades of ‘medicalised’ childbirth (Silverton, 1993) that had culminated in widespread dissatisfaction with maternity services among women and midwives (Symonds and Hunt, 1996). Changing Childbirth was the first DH publication to state that the ‘medical model’ of care should no longer drive the service and that women should be given unbiased information and opportunity for choice, in the type of maternity care they receive. Accordingly, the new focus of maternity care was to be women-centred, conducted in partnership between professionals and women. Intrinsically, this approach requires that women receive unbiased information, thus enabling them to make ‘truly informed choices’ (Mander, 1993).

Choice is important to mothers and can only be exercised by policy that places women at the centre of their maternity care. The concepts of choice and control have been indicated to be intimately linked (Jomeen, 2010). Anderson and JackAnderson and Jack (1991) suggest that women need the opportunity of choice to feel that they have control over their bodies, thereby enhancing their experience of childbirth and pregnancy. The role of the midwife within this framework therefore, includes that of empowerment through provision of information and health education. This philosophy is endorsed by the findings of Green et al (1990) who consider that informed choice is important because it allows women to feel in control of their decisions about their maternity care, thus allowing a more fulfilling experience of pregnancy and birth. A similar sense of control is also desirable for the antenatal period (Levy, 1999).

It is significant that despite supporting evidence concerning the importance of choice for women being both central to the culture of midwifery, and endorsed by government policy, the reality of women's experiences in UK maternity services is that choice remains an elusive notion (Kirkham, 2004; Jomeen, 2006; Jomeen, 2010). This may be due to ‘professional nervousness in a litigious climate’, or the ‘dominance of evidence-based care models’ which impact on the information presented to women, thereby affecting their perceptions of choice (Jomeen, 2010). It may also be as a result of the language of choice being presented to women in terms of the ‘risks’ associated with their ‘choices’ for care (Symon, 2006).

In the light of the above, it is evident that while the role of the midwife also encompasses health education and promotion, this is not a straightforward issue. Mander (2001) suggested that the information upon which choices are based will crucially effect the type of choices made by women. This further highlights the importance of the role of the midwife as education provider. It illustrates that, in order to provide unbiased information, midwives need not only evidence-based knowledge but also awareness of their own prejudices. The information midwives provide in this context should then allow women to make truly informed choices (Egan, 1990; Steele, 1995).

However, as Edwards highlights (2004), choice in maternity care might be construed as a fundamental right, but in reality it may be a potentially coercive cultural construction, based on ‘subjectivities’. Furthermore, the execution of choice is related to the extent to which a woman's selfesteem ‘enables’ her to make a choice. In this regard, choice in maternity services seems an impossible ideal, despite the prevalence of policy supporting the ‘informed choice’ concept. Health promotion (and education) is an important and increasing aspect of the midwife's role (Public Health England, 2014). However, if the concepts underlying health promotion are interpreted by midwives in a dogmatic way, or they constitute a ‘cultural construction’ perpetuated by midwives, the role and the autonomy of the midwife will be compromised and this will inevitably have detrimental effects on a woman's autonomy.

Sue Battersby's article in last month's BJM (Battersby, 2014), highlighting dissonance and conflict in midwives negotiating the promotion of breastfeeding policy is a good example of the tension between our intrinsic cultural values and the expectation of our expanding role as health promoters. Increasing regulation, policy direction and role extension is a feature of current healthcare service provision that may create a conflict for midwives when they advocate for women. Yet if we are to retain our fundamental cultural value of being ‘with women’ we need to remain vigilant that our loyalty is first towards women. Respecting womens’ decisional autonomy must not be compromised by either our own prejudices or policy and healthcare system culture. It is a laudable goal to improve care for and of women and infants. Yet if in doing so we stop listening to what women want, because we become acculturated with current social or government policy ‘norms’, then quite simply I believe we fail those women as midwives.