Do Women Want Midwives or Obstetric Nurses?

AIMS Journal, 2005, Vol 17 No 3

AIMS Vice Chair Nadine Edwards offers extracts based on her talk which embraced the whole theme of the joint conference between AIMS and the Association of Radical Midwives that took place on 1 October, 2005 in Birmingham

What kind of attendants do women need?

Whatever kind of birth women plan, they want attendants who are skilled, competent, confident and kind: usually, someone who expects birth to go well, but is watchful; ideally someone who is able to give advice on and respond to complications during pregnancy and birth from a broad knowledge base: always someone who engages with them, respects them, is on their side, trustworthy and sees birth in the social context of their lives, hopes and aspirations. The quotations that follow are a few of the observations that women in my study on home birth made about the qualities they needed, or appreciated in their midwives (Edwards 2001,2005):

"someone I felt had a lot of experience and a lot of knowledge but not the sort of person that loads it on you or says we've got to do it this way. Someone I really felt that I could trust, and would tell me the truth and someone that knew when to go away and when to come back. And someone who respected and who remembered what I wanted to do - a really good knowledge of me".

"She seemed down to earth and willing to listen. She said, we're going to do everything we can to keep you here and I'm sure you'll be fine. She was the first one that I've picked up a sense of a home birth is a really good thing to do rather than a home birth is something you need to make up your mind about and we're absolutely neutral - you know, a less medicalised view".

During their transitions to motherhood, women needed someone who could journey with them through the intensity, power and vulnerability of labour:

"you know she (midwife) stayed as cool as a cucumber, which if she hadn't - if she'd at any point suggested that I wasn't going to make it then that would have had a huge influence on me, cos I would have said, okay, I can't do it".

They needed someone who could share knowledge and build on women's own knowledge rather than assume the position of knowledge broker:

"I think women have a tremendous knowledge. I think we need unbiased information, not about how to do it, but about the possibilities - what movements make some labours easier, what things women find make labour progress better, what to do when your baby's in a breech position, what to do when different things occur during a normal pregnancy and birth. Knowledge is what we need".

Trust was seen as crucial by the women:

"I think trust is very important. The midwife that was there most of the time - I really trusted her and she did make me feel like she was there in the moment and this was a special thing for her too. And I really trusted what she was telling me because she'd listened to what I wanted. So I suppose the trust comes from feeling that you are an important part in the equation".

Yet when care is fragmented and midwives have too little time trust becomes problematic:

"it doesn't seem like a partnership and yet when you're giving birth, I think it must have to be".

"it's really hard to say (about trust) because I just don't know them well enough and some of them I've only met once for just a few minutes".

What do women and midwives need?

From the research done with midwives, it is clear that the current fragmented, industrialised system is not working for them any more than it is for women (Deery 2005, Ball, Curtis and Kirkham 2004, Hunter 2002). When we look at the research with women and with midwives there is a lot of common ground between women's and midwives' needs (Edwards 2005, McCourt 2005). The consensus seems to be that both want:

• A less medical and more social approach to birth
• More knowledge and autonomy - individually and collectively
• Time and skills to form trusting, mutually beneficial relationships

This being the case, let's not keep going back to the drawing board on these issues. Let's invest energy in developing sustainable ways of working that enable those things that women and midwives say are important to them to flourish. Christine McCourt (2005) explained so well at a conference on emotional work (see conference report by Lee Seekings Norman on page 16) in Huddersfield in September: let's not get bogged down and hemmed in by inflexible models of care, let's think creatively about how women and midwives can be together in ways that enhance their common needs.

How do we get there?

If we put together the picture we have, we have lots of clues about the kind of practitioners and approaches to birth that would benefit women. For example, I see women in my antenatal groups at the Birth Resource Centre in Edinburgh gradually changing their views about birth as they experience their pregnancies. But within a fragmented maternity service which leaves practitioners little time but to focus on physical checks, it is difficult for them to engage with that change, or to nurture it, or promote it. I believe that if maternity services were different, many of these women would make different decisions about place of birth, and pain relief during labour as their pregnancies unfold. But without engaged midwifery support, their confidence often cannot develop far enough to act upon their changing understandings of birth and their bodies.

New Zealand provides us with a good example of how a different way of providing maternity services can benefit women (Pairman 2000, Gilliland and Pairman 1995). Here, relationships between women and midwives are the basis of maternity services. Since this has been the case, women have been more satisfied with their experiences, but most women still give birth in hospital and intervention rates have not changed a great deal (though there has been a small but significant rise in home births). Some women and midwives in New Zealand are now attempting to address what they see as an over medicalised birth culture, as well as maintaining relationships at the heart of maternity care. They believe that this will begin to reduce intervention rates during birth. There is good reason to believe that this will indeed bring about change.

In the Albany Practice in South London, midwives provide maternity care for women living with poverty and other challenges. Relationships and a positive birth culture that enables many more women to have normal births, are intertwined in the service the midwives provide. Women booking with them make very different decisions about place of birth, pain relief and breastfeeding than might be expected. Many, for example, decide to birth at home, many use birth pools and most breastfeed their babies. Relatively few women use pharmaceutical and pharmacological pain relief and few women need interventions during labour, (Sandall, Davis and Warwick 2001) these examples suggest that we need to address the ways in which individual women and midwives engage with each other and how they collectively engage with the birth culture and how midwives engage with women's social networks. This is part of what the Community Midwifery approach and the One Mother One Midwife Campaign seek to address (information about these campaigns are on page 10).

To come back to the original question, in a sense obstetric nurse and midwife are just words. In another sense they are deeply political and implicated with women's place in the global community. If we want the kind of practitioners that many women need, we also need to think about putting our weight and voices behind changes within our culture that would genuinely value women, caring professions and the quality of life: The kind of changes in which women and midwives could come together and build on their commonalities and resolve their differences, and in which midwives could develop and redevelop birth skills and wisdom. So, answering the question, do women want midwives or obstetric nurses, is more complex than might first appear. The divisive thinking itself perhaps obscures what women tell us and what the results of a growing body of research show us (for a thought provoking discussion about this kind of thinking see Fieder etal 2004). Women certainly need and want skilled, competent practitioners. But they want these skilled practitioners to be rooted in a social approach to birth - able to work with them to help them give birth as straight forwardly as possible, but with the ability to draw on the skills of obstetricians and technology appropriately. Whether they have straightforward births at home, in Birth Centres or in hospitals, or complicated births that need all the medical skills and technological interventions we have, they need to be respected, nurtured and listened to. Wherever their birth journeys take them they need midwives in the true sense of its meaning - 'with woman'.

References

Ball, Linds, Curtis, Penny, Kirkham, Mavis (2002). Why do Midwives leave. Women's Informed Childbearing & Health Reasearch group (WICH), University of Sheffield in assocation with RCM