AIMS' Chair Beverley Lawrence Beech argues that it is time midwives started speaking up for themselves, for their profession and for the women in their care.
These are difficult times for midwives. Difficult because the definition of what a midwife is and does, and where her skills and authority lie is being dramatically altered.
At the same time numbers are dwindling. There are 33,987 registered midwives in the UK, more worrying there are 58,286 who are not practising and there are now less than 40 independent midwives left in England and those who continue to work in hospitals appear to disagree widely about what their roles and responsibilities should be.
Some would argue that a midwife, is a midwife, is a midwife. But they are not. Midwives come into midwifery for a variety of reasons. We have midwives who joined midwifery because they wanted to help women give birth, they may have had wonderful birth experiences themselves, or they may have had a rotten time, recognised why, and wanted to do something to change the system.
In the UK we have midwives who are more than happy to work from nine to five, collect their pay and turn off their thought processes once they step outside the maternity unit.
Then are those who have the greatest potential to do harm to women - midwives who, just like the obstetrician see childbirth as an ideal opportunity to exercise power and control and are not going to give that up for anyone. Also in this group are some of the midwives who have embraced the principles of nursing and who see childbirth as a mechanical process. Midwives who, like the current President of the Royal College of Midwives, see childbirth complications as "challenging, exciting, fulfilling and demanding" and the time between calling a doctor and his/her arrival is described as "golden " (Muirhead, 1997).
Not every midwife will want to carry her own case load, work in the community or practice independently. Hospital care has a place, and those women and babies at high risk need to be there, they too need good midwifery care and this should not be perceived to be in opposition to the care offered to the majority of women and babies who have no problems.
But wherever a midwife practices she must take on board the idea that midwifery must strive to strengthen its partnership with women (Pearman S, 1998).
Some observers argue that the (unacceptable) status quo in maternity care is maintained by women's lack of information and education (Bunkle P, 1988). I would suggest it is also maintained by the failure of the midwifery profession to pull together. As time goes by, midwifery becomes more and more a profession divided, squabbling amongst itself with a largely silent membership. When there are difficulties, when individual midwives are targeted and bullied the majority tend to stay silent. Why?
Perhaps the answer lies in our genes? When Ina May Gaskin was in Europe researching the witches trials, she found that in some towns in Germany practically the whole female population had been burnt at the stake. The only ones to survive were the wee timorous beasties, who did not speak out and who did not question. Hundreds of thousands of European women died in that madness, and we are descended from the ones who escaped - the ones who kept their mouths shut and who did not question.
Whichever way a midwife practices, the vast majority do so in the belief that they are acting in the best interests of mother and baby, even if the results sometimes say differently. Nevertheless, if midwifery is to progress all midwives have to work together and every single midwife has to stand up and be counted. Petty jealousies and a perception that those "other" midwives who are working in the community, in case load practises, in independent practice are somehow aberrations, rather than leaders of the profession who should receive support and encouragement, will impede the development of real midwifery practice.
The midwife who seeks to reclaim her real role of being "with woman" instead of being "with policy", not only threatens the medical profession, she also threatens those midwives who are content to work within the present system. As such she is a target for bullying within her professional group. This has enormous implications for women since bullied midwives may, in turn, end up bullying those in their care.
Bullying in midwifery must be exposed and stopped if midwives are to move forward. A profession whose members cower from criticism, or are willing to let "someone else" speak out, stand up or challenge is a profession which will not achieve its objectives. Midwives frequently claim to be a woman's advocate but to do that successfully midwives have to be strong themselves. Weak women make weak advocates.
During a conference last year I was fascinated to hear a Metropolitan Police officer who specialises in countering bullying in the Metropolitan Police comment that in her view midwifery was more macho than the police force. Midwives will soldier on in circumstances where any other group would have collapsed long ago. Those midwives who complain, or whose practice deviates from the hospital "norms" are often isolated and bullied. Bullying is endemic in the midwifery profession and it is time it was dealt with effectively, because if midwives fail to deal with it they will not achieve a strong, independent, and caring profession.
It seems strange to have to offer advice on bullying to grown women. Yet many of us are ineffective at dealing with such problems. One of the major mistakes a bullied midwife makes is the belief that she can reason with the bullies and make them understand her position. You can only challenge a bully from a position of strength, being nice to a bully only confirms their belief in their own superiority and intensifies their behaviour.
Also, deal with the problem on your own and you will find yourself isolated and an easier target. Thus, if you find yourself being bullied by colleagues, gather support. There will be other midwives, and doctors, around who will support you - encourage them to make it clear that they do. Never go to a meeting alone, immediately write up your experiences of the meeting afterwards and keep a copy of what you perceive happened between you and the bully.
Bullied midwives need to keep a file about what is happening to them. This may prove invaluable if, months or years down the road they are asked to produce evidence of what was happening. Furthermore, a contemporaneous record of an incident carries greater weight in any future enquiry than a statement of what a midwife has remembered of an incident. If a midwife is told that she must not speak to anyone about what is happening, remember there are always consumer organisations or individuals who can speak out on her behalf.
In a recent case, the midwife was so naive and cowed by threats of confidentiality she did not even give her lawyer a copy of the Trust's allegations, and was then surprised when they ran rings around him and succeeded in persuading her to resign. Which is another point, never resign. By resigning they have won, they have got rid of a thorn in their sides and are then free to pick off the next one. In a bullying culture the bullies make sure they select a group of compliant colleagues and when they find a less compliant midwife in their midst they develop strategies to get rid of them.
The problems in midwifery are compounded by the fact that throughout the world large centralised maternity units suffer staff shortages. One reason for this is administrator's failure to recognise that good midwifery cannot be offered on a shoestring and the costs of poor care delivered by overworked and emotionally burnt out midwives are reflected in the law courts and the high levels of iatrogenia. The irony is that the money is there, the problem is its misuse. Hospitals are more than willing to spend millions of pounds on fancy new equipment, or even old equipment, much of which is overused and inappropriate. This policy must also be challenged.
AIMS has always maintained that the only way we are going to improve maternity care for the benefit of all mothers and babies is by ensuring that the majority of women are cared for by midwives who carry their own case loads and offer continuity of care. If midwifery is to be strengthened it has to have its own independent status, and a Midwives Act is essential.
To win these battles - against our own fears, against bullies, against staff shortages and the declining standard of education - every single midwife has to address that which she knows is wrong with the current provision of care. Midwives, wherever they work, be it in centralised maternity units, the community or in independent practice have to support each other, and the profession has to address and help those who are threatened by the changes. Midwives need to foster contact and support for those medical practitioners who do support midwifery, they are a rare breed and deserve support and encouragement, and most of all midwives have to continue to inform women so that they continue to give their support and speak out where necessary. By working together midwives and parents will be able to counter the medical professions determination to undermine midwifery's considerable achievements.
We know that good midwifery care achieves good outcomes, strong mothers and healthier babies and women worldwide deserve nothing less. Speak up and ensure that the Millennium is a celebration of a strong, independent, financially secure, midwifery profession.
Bunkle, P Second Opinion - The politics of women's health in New Zealand, Oxford University Press, 1988.
Gaskin, IM, Personal communication, 1992
Muirhead L Presidential Address, Harrogate International Centre 1997, Royal College of Midwives, London, May 13
Pearlman S. Developing and Crafting a Vision - A strategic plan for midwifery, NZ College of Midwives Journal, 18, 1998, pp5-9.
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