Editorial: Salutogenesis - Putting the health back into healthcare

ISSN 2516-5852 (Online)

AIMS Journal, 2020, Vol 33, No 1

Alex Smith portrait

By Alex Smith

The theme for our March edition of the AIMS Journal is Salutogenesis. Salutogenesis is a term introduced by sociologist and academician Aaron Antonovsky in the second half of the 20th century. It comes from the Latin ‘salus’ meaning health and the Greek ‘genesis’ meaning origin or source. By defining health from a salutogenic perspective as ‘holistic well-being’, rather than from a pathogenic perspective as ‘the absence of disease’, the term offers us another way of thinking about how to make things better.

The salutogenic approach and the pathogenic approach are not mutually exclusive; access to good quality medical care, offered in a timely, tailored and respectful way, is very much part of a salutogenic philosophy. The two perspectives form part of a spectrum. However, we know that outcomes in all areas of health, including maternity, are improved when the conditions and factors known to build and maintain holistic well-being are placed first and foremost.

These days, we often use the terms health care and medical care interchangeably and we refer to people with medical qualifications as healthcare professionals. In this way, and quite unwittingly, we have bestowed the monopoly of authority for all matters concerning health to a body of people whose primary authority is embedded in their knowledge of illness and medicine. It is then only natural that when we ask these people to create a model of maternity care, it will be a medical model, and when we ask them to look for ways of improving birth outcomes, they will turn to medicine for inspiration and answers. This was highlighted in a 2014 study of 102 reviews that looked at labour and birth outcomes, where only 8% of 1648 individual outcomes were agreed as salutogenically focused1.

Such medicalisation of birth has considerably narrowed the scope we give ourselves for finding ways of improving birth experiences and outcomes. It is as if we have a full chest of drawers of possibility to explore, but mostly only ever look in one drawer. The appropriation and medicalisation of birth has been enabled by the consistent disparaging of anything in the ‘other drawers’. When we talk about ‘old wives tales’, we are disparaging women’s wisdom. When we only hold with ‘evidence-based’ practice (with the 92% bias towards pathogenic research), we are disparaging the insights and skills of those with non-medical knowledge and expertise, and dismissing the voices and experiences of those who actually bring babies forth from their own bodies. When we look at non-medical strategies such as relaxation and breathing2, making the birth environment more homely3, positive visualisation and affirmations4 and sweepingly dismiss them as ‘all that hippy stuff’, or more quietly dismiss them by allowing them to go ‘out of the window’ the moment we enter the medical arena, then we are disparaging the evidence that these things improve outcomes and well-being; betraying our own bias toward the pathogenic 92%.

So deeply ingrained is the pathogenic way of viewing health and maternity care that the vast majority of people feel it is responsible and educated to think this way; to only or mostly turn to that one drawer. The pathogenic way of thinking is reflected in the very language we use to talk about our bodies so that we all agree that the ‘proper’ words to use are the medical words and that practitioners who speak in medical parlance are ‘the experts’. Even more insidious is the use of words that infer ownership of a medical procedure to the person being offered it, so that ‘your sweep’ or ‘your scan’ seem as natural and unquestioned a part of pregnancy as ‘your bump’. And more insidious still is how this pathogenic perspective has become embedded in the body itself so that it feels almost instinctive for a healthy person to consult a doctor about normal pregnancy, and feels almost naughty to look in the other drawers for ideas for keeping well.

So, in the face of this heavy weighting toward a pathogenic view of pregnancy and birth, the March journal takes a brief salutogenic glimpse at other ways of making things better. We open with an article I have written, which in part explores the politics of health philosophy. Mary Nolan introduces and explains the concept of self-efficacy, which refers to a person’s belief in their capacity to act in a way that will produce a desired outcome, perhaps by making decisions and taking actions in pregnancy in order to achieve a satisfying birth. This takes the helplessness and passivity of wishful thinking and turns it into positive action, no matter what the circumstances and preferences of the individual, and in doing so greatly reduces the chance of the events being experienced as trauma. Sophie Martin shows us how we can build on or undermine this sense of being strong and capable by the stories we hear and the stories we tell ourselves, explaining how language can and does have a positive or negative effect on well-being and can shape our experience of pregnancy and birth. Cathy Welch writes about yoga for pregnancy and how not just the yoga itself but the sharing of stories within a supportive social space is considered one of the key contributory factors to improved mental health in pregnant women, leaving many feeling stronger, more confident and filled with self-belief. However, when the going has been challenging, three authors show how coming together as women and parents to share our experiences enables people to discover their innate strength and resilience without pathologising their natural feelings. Katharine Handel describes The Motherkind Café, an Oxfordshire post-natal peer support group where women who are worried about their mental health after having a baby can come and talk about it in a supportive and non-judgemental environment. This model of mothers helping other mothers by drawing on their own experiences is a great example of salutogenesis. As part of the AIMS ‘Introducing’ series, Samantha Gadsden describes her awareness-raising forum, ‘They said to me’, which has gathered thousands of followers who draw strength from each other in exercising their rights concerning pregnancy and birth. Nicola Enoch writes an incredibly moving and inspiring account of her experience as a mother of a son with Down syndrome and of the wonderful support groups she has set up for other parents. Neve Spicer has shared her very attractive infographic providing links to the evidence of 23 benefits for babies and their parents of ‘baby-wearing’ or carrying the baby close to your body in a sling, while Anne Glover talks about the value of continuity of carer, the parents’ social support network, and, when needed, the additional support of a postnatal doula, working together in complementary ways to support the new family. And midwife, Professor Soo Downe, is interviewed by Jo Dagustun, an interview that includes Soo’s account of how a salutogenic approach might lead to improvements in the maternity services.

Moving somewhat away from the salutogenic theme, Annie Francis reflects on the five years since the National Maternity Review, led by Baroness Julia Cumberlege, issued its report, Better Births, in February 2016. Anna Madeley and Jo Dagustun both look at the Ockenden Interim Report, published on 10 December 2020. Gemma McKenzie and Virginia Hatton review ‘Birthing Outside the System: The Canary in the Coal Mine’, which, according to Gemma is a “jaw-dropping, anger-inducing, galvanizing text that makes you want to get out of your armchair and join the battle to protect human rights in pregnancy and childbirth.” And last but not least, the AIMS Campaigns Steering Group give their quarterly account of what they have been up to.

Thank you as ever to all our contributors, to our peer reviewers Emma Ashworth, Verónica Blanco, Jo Dagustun, Virginia Hatton, Maddie McMahon and Caroline Mayers, to Bonita Khan, Alicia Mosley, Judith Payne, Josey Smith, Zoe Walsh who proofread this issue, to Danielle Gilmour who uploaded all of the material to the website, and to all our readers and supporters.

We hope you will enjoy reading this issue. For our June 2021 issue we will be exploring the experiences, traditions, languages and cultures of people when they bring different, foreign or marginalized worlds into the world of "giving birth in the UK".

1 Smith V, Daly D, Lundgren I, Eri T, Benstoem C, Devane D. Salutogenically focused outcomes in systematic reviews of intrapartum interventions: a systematic review of systematic reviews. Midwifery. 2014 Apr;30(4):e151-6. doi: 10.1016/j.midw.2013.11.002. Epub 2013 Nov 11. PMID: 24290422
2 Levett KM, Smith CA, Bensoussan A, et al Complementary therapies for labour and birth study: a randomised controlled trial of antenatal integrative medicine for pain management in labour. BMJ Open 2016;6:e010691. doi: 10.1136/bmjopen-2015-010691
3 Jenkinson, Bec & josey, natalie & Kruske, Sue. (2014). BirthSpace: An evidence-based guide to birth environment design.. 10.13140/RG.2.1.3962.8964
4 Cascio CN, O'Donnell MB, Tinney FJ, et al. Self-affirmation activates brain systems associated with self-related processing and reward and is reinforced by future orientation. Soc Cogn Affect Neurosci. 2016;11(4):621-629. doi:10.1093/scan/nsv136

AIMS supports all maternity service users to navigate the system as it exists, and campaigns for a system which truly meets the needs of all. AIMS does not give medical advice, but instead we focus on helping women to find the information that they need to make informed decisions about what is right for them, and support them to have their decisions respected by their health care providers. The AIMS Helpline volunteers will be happy to provide further information and support. Please email helpline@aims.org.uk or ring 0300 365 0663.

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