It's time to stop the conveyor belt and rise above the bellies, bottoms and boobs

June 23, 2006

The medical establishment is slow to yield to changes wrought by midwives in academe, labouring to give women a better birth experience, says Sheila Kitzinger

A sea change is sweeping through midwifery education, attracting students who want to give one-to-one and evidence-based care and form a partnership with women. They are eager to offer care that is not just about "bellies, bottoms and boobs".

Students coming into midwifery are eager to understand how they can help create a positive birth experience for every woman. They give of themselves not only techniques and time. They are building on the best traditions of midwifery in cultures around the world. They are concerned for women who are disadvantaged and on the edges of society - including pregnant asylum seekers and new mothers, women in poverty, those giving birth in prison and women on drugs.

Maybe I encounter a special kind of student - one who wants to be able to offer water birth, home birth, massage, to know how to deliver a breech baby vaginally, to understand how posture and movement can affect the physiology of labour, to deal with shoulder dystocia and resort to Caesarean section in exceptional circumstances only.

But my impression is that students are challenging the medical establishment and often their midwife colleagues, mentors and midwifery managers, too. Their vision of midwifery is much broader than bureaucratic and authoritarian medical institutions can tolerate. They are set on a course that is bound to conflict with the present system.

I hear regularly from student midwives, those writing dissertations and post-registration midwives who find their work exciting and challenging but who are being worn down by a rigid, uncompromising National Health Service system of care that treats them as if they were factory operatives, with women giving birth as if they were on a conveyor belt in that factory, to be spat out at the end with a baby.

Women ring the Birth Crisis phone service to talk about a traumatic birth that has left them distressed weeks, months and sometimes years after the event. Increasingly, midwives ring Birth Crisis because they are trying to come to terms with a birth in which they have been traumatised and disempowered by the medical system.

Mary Renfrew, professor of mother and infant health at York University, says there is a gap between academic university-based midwifery education and clinical midwifery practice. As a result, midwifery lecturers may not be integrated into the university culture, and an NHS-based midwife who is working as a student's mentor may not have access to the learning resources the student needs, including the university library. This leaves the student moving between two cultures that are out of step with each other. It also highlights the gap between ideas and practice that runs through a midwife's work.

For example, midwives are often caught between responsibility to a client and a duty to their employer. A midwife who does not follow orders from above is at risk of being fired. This is what happened to Paul Beland in Ipswich, who attended a planned home birth (on his day off) when he had been told not to because his hospital was short staffed.

The Nursing and Midwifery Council updated its advice to midwives in March; a press release headed "The NMC supports women who wish to have home births" says that "should a conflict arise between service provision and a woman's choice for place of birth, a midwife has a duty of care to attend her". That statement is unequivocal.

Midwives who step out of line, however, are often bullied to conform. Those who persist in challenging authority are likely to be scapegoated and victimised. This is one reason they leave the profession. Research by Mavis Kirkham, professor of midwifery at Sheffield University, into why midwives leave found that about 30 per cent expressed dissatisfaction with midwifery "because they were not able to form, or develop, effective relationships with women and their families".

The model imposed on midwifery is becoming increasingly centralised, reducing room for new ideas. Midwifery-led care schemes are created, are highly successful, but are closed to save money (Kirkham's school of midwifery has been axed and Stroud Maternity Hospital is facing closure). Nearly a third of well-established midwife-run birth centres are under threat. The money saved is poured into recruiting more obstetric consultants.

This wider focus cannot be achieved by introducing courses in basic psychology. Midwifery training must be much broader. Twenty years ago, psychology was largely irrelevant to midwives' relationships with clients.

Now there is a developing sociological awareness. It is not enough for midwives to keep their clients contented. They have to understand how to relate to midwife colleagues, obstetricians, anaesthetists, managers and women and their families. They need to see birth in its social context and to be aware of how power and powerlessness are major themes in any large institution, and how this affects behaviour, thinking and interaction.

Training also needs to challenge NHS politics. Jane Sandall, professor of midwifery at King's College London, believes midwifery lacks "political critique".

"It feels like we are sending lambs to the slaughter," she says. She wants to see care moved out of the hospital, to devolve power. Her final-year student midwives carry a caseload in the community and get to know women and their families. When a woman needs to come into hospital, they come with her, instead of being part of an institution to which patients are admitted.

Another vital ingredient for midwifery courses is communications studies, and it is increasingly recognised that effective communication is at the core of midwifery. Research by Helen Baston, a midwifery lecturer at York, shows that how women experience an emergency Caesarean section is directly related to the quality of communication they have with their caregivers.

But communication can mean different things. Some caregivers think it is just a matter of explaining things clearly and being understood.

Communication studies can readily turn into acquiring the art of persuasion. Communication also involves listening and learning from the woman. The main problem is not failure in communication but the messages communicated. If all a midwife can say to her client is that she must have her labour induced or that she cannot have a home birth or a water birth, kindness is unlikely to help her feel she is free to choose between alternatives and that she has her midwife's support. Instead, she feels trapped. And so does the midwife.

Midwives are in the impossible position of being trained in the NHS in subservience while simultaneously learning at university how to serve as advocates for women.

Sheila Kitzinger is a social anthropologist of birth and an honorary professor at Thames Valley University who lectures worldwide. Her book Birth Crisis is published by Routledge. Helpline information at

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