Feature

Midwives and medicine: what will the future deliver?

A new, research-based and woman-centred midwifery is emerging from the shadow of medical dominance. But what vision do midwives themselves hold of the future? Jane Muzira reports

Midwifery is in a state of change. Midwives’ training, hospital practice, and midwifery in the community are all being affected by new structures in the NHS, the demands of women and midwives themselves, and new research findings. In addition, the current government enquiry into maternity services is expected to have a profound impact on the future of midwifery practice. I talked to midwife tutors and students to find out what they thought of the changes, and what the future holds for midwives.

Research is a hot topic in the current debate on the midwife’s role. Research is essential if midwifery is to develop and change because midwives need evidence to back up claims that current practices are dangerous, or fall short of what they are meant to achieve. But there are criticisms of research practices in midwifery, in particular that sound research findings are not being implemented, and that research is being repeated at many different institutions even when conclusive evidence has been found.

One midwife tutor felt strongly that ‘repetition of research is unethical’, giving the example of maternal directive pushing, when a midwife urges a woman in labour to push the baby out, regardless of whether the women herself has the urge to push. The reasoning behind this has always been that delay at this stage of labour can adversely affect the fetus. Evidence now shows that maternal directive pushing is associated with fetal distress, yet the practice and research on it continue.

It was felt that conservatism lay at the heart of this problem - people’s difficulty in changing old ways. It raises the issue of what midwives think they are doing with women: whether they are acting for, to, at, with, or on behalf of women. ‘It means midwives have to see themselves and the profession as an intervention that is up for change.’

Another example of the difficulty midwives and obstetricians have in changing old ways is the practice of continuous electronic fetal heart monitoring in labour. ‘Various reasons re put forward as to why we can’t not use it now we’ve got it; one is that midwives have lost the skills to monitor without electronic equipment. Some midwives unquestioningly accept that the more information it gives, the better the technology is. But the argument is that we don’t know how to use the information, therefore it is not of benefit.’

’Midwifery as an intellectual activity has only recently developed, but must continue to develop. There is a tendency for midwives to research things that other people think are important, instead of areas that are important in our practice.’ This midwife also questioned why ‘the experimental model of research is considered the best way to evaluate care when it may not be appropriate’.

All the midwives I spoke to agreed that feminism has had an impact on midwifery ‘through its influence at all levels of society’. A student midwife said: ‘Feminism has given women confidence and power and, because most midwives are women, feminism as an ideology has filtered into midwifery practice. The results show in the practice of mainly younger midwives who take responsibility for their own actions.’

It was felt by one tutor that there were occasions when ‘professionalism can impede a midwife’s innate ability to identify with women. And when midwives do identify with women, they experience the feeling of powerlessness’. On the other hand, ‘midwives have to recognise that they can be just as oppressive as doctors by virtue of professionalism. We should be careful about how we develop so that we don’t represent different but equally controlling choices for women’.

Independent midwives have been responsible for extending the definition of what is normal in pregnancy. A tutor who had practised as an independent midwife said: ‘Independent midwives set high standards of care. Some have

crashed through sound barriers in terms of the definition of the role of the midwife.’ They aim to ensure that women have a choice in childbirth. But this midwife went further in her vision of alternative midwifery: ‘It could be said that even alternative forms of care taken on aspects of the dominant discourse in terms of control of women, for example, psychoprophylaxis, water birth, managing the third stage physiologically... The alternative is rejecting all forms of discourse so that, to quote Smellie “woman can consult her own ease”. Some independent midwives are creating the environment where women can discover for themselves what is right.’

Her view of the role midwives should aim for centres on the World Health Organisation definition, midwives being the gate of entry for maternity care. ‘ There should be units where doctors are not involved unless requested by a midwife. Any model of care that improves continuity would be good for women and midwives.’ There was a consensus of opinion that to change the midwives’ role radically, so that they care for all women with a normal pregnancy, would mean a radical change in society, but it should be possible within a national health service.

One change in midwifery education is the amalgamation of schools of nursing and midwifery, giving midwives less control over their own education. Other changes include more emphasis on continuous assessment, less on exams. This has the potential for giving students a wider experience, ‘an understanding of the transitoriness of knowledge, a more research-based approach so that they can feel part of the knowledge-creating process, and the ability to reflect on the outcome of various practises’.

’It gives scope for schools to develop progressive educational practices, but these might not be used in every institution.’ There is also the possibility that progressive teaching methods will not be matched by progressive practices. ‘Midwives still leave the profession because they are unable to practise the way they are led to believe they will in their training.’

The advantages of the ‘pre-registration’ course lie in a greater emphasis on pregnancy as a normal condition and not a disease. Midwives will take on less of the role of nurse and more one of women’s advocate and supporter. But it was felt that ‘the introduction of different routes into midwifery qualification, for example the diploma course and the degree course, has the potential for creating hierarchy and divisions in the future’.

A more recent development is the bill incorporating recommendations by Peat Marwick McLintock for amendments to the Nurses, Midwives and Health Visitors Act 1979 which will probably appear before the House of Commons in January 1992. The changes will seriously reduce midwives’ control over their own education, as there will be no elected midwives at National Board level, where responsibility for validating the midwifery courses will lie.

Further, more positive changes are expected to follow the government enquiry into maternity services. In 1991 the House of Commons health committee was set up to ‘enquire into maternity services to determine the extent to which resources and professional expertise are used to achieve the most appropriate cost-effective care of pregnant women and new-born babies’.¹

Among others, the Royal College of Midwives, and the Association of Radical Midwives have submitted evidence to the committee, as well as consumer groups representing women. The RCM emphasised the need for more midwives in the maternity services, providing safe and adequate care for pregnant women, and that increased technology does not in itself provide this care but depends on midwives to interpret results.

A recent RCM report agreed that senior midwives should take responsibility for all births except those with known medical complications, and that local midwifery clinics should be set up. In November 1991, during the government enquiry, the president of the Royal College of Obstetricians and Gynaecologists, Stanley Simmons, agreed that midwives could well be maternity team leaders, with appropriate training.

The midwives I spoke to expressed hope that, following the enquiry ‘more will move into the hands of the midwife. There was good evidence from people proposing that the midwife’s skills should be used more fully - for economic as well as ideological reasons. I think the government will start to bring about changes that we have wanted for a long time. It’s just a question of holding on to the changes as representing what we want’.