It’s always nice to hear about midwives supporting alternative birth choices. To be fair, I don’t think my choice to homebirth with a BMI of 44 should be regarded as ‘alternative’! But, since only 1.1% of women and birthing people with a BMI over 40 birthed in a freestanding midwifery unit or at home in 2015-2017, I have to accept it is. Most people (in their first pregnancy, at least) generally follow whatever is suggested. Anything other than following hospital policy is therefore by definition ‘alternative’!
But while I regularly focus on the experience of women and birthing people on this site, and our right to determine what happens to OUR bodies, I rarely consider the experience of midwives in this sometimes unsupportive system. Turns out, not many people do! But this recent research has, and it’s very interesting reading. If you’d like to read the whole thing, access is free for the next 49 days!
Claire Feeley, Soo Downe, Gill Thomson
What is the research?
It’s described as ‘A narrative inquiry of midwives’ experiences supporting alternative birth choices’.
The researchers interviewed 45 midwives who self-identified as facilitating alternative birth choices. The midwives came from around the UK, at varying levels of seniority, all within the NHS.
Unsurprisingly the issue of BMI came up. Even if it hadn’t, the results and their implications for midwifery are compelling…
What did they find?
Stories of distress
19 midwives provided multiple examples categorised as ‘stories of distress’. But this was not distress within the mother-midwife relationship. The distress and conflict arose from tensions experienced in the working environment, from their peers and their managers. Some even told stories of professional isolation and ‘scapegoating’, when supporting choices at a birth which ended in poorer outcomes.
‘Katie’ (codenames used throughout) describes trying to rebuild trust with a woman with a raised BMI who’d had previous poor midwifery experiences. Katie’s manager was unsupportive of the woman’s wishes for a home birth. She insisted a further midwife was needed to try to influence the woman.
‘…my manager insisted I took another member of the community team to one of our appointments, which I did, but that really was the nail in the coffin… after that she text me saying that she didn’t trust me, that she wanted to freebirth… it was really stressful because all I wanted to do is support her’Katie’s experience
Midwives reported feeling personally conflicted when they felt institutional guidelines were doing a disservice to women and pregnant people. They reported feeling that they had to battle the system in order to advocate for the women in their care. Some felt choice is not respected, and the perception that going ‘off-guideline’ is risky is not borne out in the data. ‘Jess’ sums it up perfectly here:
‘…. I feel frustrated that it feels like a constant daily battle to support women who choose to go ‘off guideline’. It is expected that women will do what they are told as the guidelines and health professionals know best… we forget that it’s that pregnant woman and her partner’s decision to make, not ours. Women don’t tend to choose to put themselves or their babies at risk. But risk is relative and individual.’Jess’ testimony
Other midwives alluded to a ‘blame culture’. This suggests a working environment which is unsupportive of patient choice and unsupportive of staff; with an expectation on midwives to dissuade mothers from their birth choices.
I hate that, you get that a lot, ‘why can’t you talk her out of it?’Edna’s experience
Some midwives described supportive like-minded teams, which was a protective experience providing mutual support. But even this raised the potential for conflict, if the team is under scrutiny by other professionals with different values.
Big Birtha’s perspective
It is really interesting, and probably not that surprising, that midwives also find this conflict stressful. We as patients definitely do! Our feelings of frustration at attempts to browbeat us into accepting what ‘the guidelines’ suggest is best for us, are clearly also keenly felt by those midwives who are unwilling participants in the browbeating.
‘…My colleagues and supervisor of midwives have advised me that I should be ‘more forceful’ or get another midwife into the room to ‘help convince the woman’. However, I strongly believe that consent is a choice and, if you have thoroughly explained what you want to do and the rationale behind why you want to do it, if the woman does not want you to do whatever it is, you do not do it otherwise it is not consent and could be classed as abuse.’Leanne’s experience
We can assume that midwives enter the profession wanting to help people. But when there is a disconnect between helping people in the manner in which they want to be helped, and in the manner in which your employer/manager/peers think they should be helped, it’s problematic. It can only be extremely draining and infantilising to face regular challenges to your professional autonomy. Assumptions that a colleague who has never met your client knows what is better for them than either you, or the client herself, can only promote feelings of frustration and contempt!
‘Trish’ felt it is important to centre on the personal relationships with women, through which she was able to resist her colleagues’ assertions that such birth choices are ‘crazy’ or ‘reckless’:
‘…what you will get is somebody saying ‘oh my god’ and they haven’t actually met the woman so it all gets blown out of proportion…’Trish’s experience
Positive stories from the research
Fortunately, not all stories are negative, or have some positive elements, at least! Some reported being in amazingly supportive teams. Kerry described her colleagues as being like sisters:
‘I get emotional just thinking about it, they’re just really really supportive and caring and I was able to ask questions, I wasn’t afraid to ask questions…’Kerry’s response
20 midwives spoke of a personal sense of fulfilment. For some (seemingly lucky, after reading previous testimonies!) this was completely ‘ordinary’ for them, with midwifery practice marked by supportive environments with a lack of conflict, animosity, or distress. This was often a factor of midwives’ personal motivations, along with effective managerial and institutional leadership and support.
Five senior midwives supporting alternative birth choices discussed how they were personally attempting to affect change in their institutions, since promotion. One spoke of the speed of change that is possible, when creating a ‘safe’ non-punitive environment for the midwives, and when wider Trust systems and culture change at the same time to accommodate it.
‘James’ spoke of a realisation in previously unsupportive midwives that supporting women in their choices is a actually professionally a less stressful position:
‘it just causes them more stress than it does the women because the women are quite formidable when they want to be, they’ll just say ‘no I’m not doing it’ ‘James’ experience
Hands-on management supporting alternative birth choices received praise:
‘…our deputy head when we’ve had two homebirths going on at the same time, he, on multiple occasion gone out to a homebirth himself you know? You know homebirth is very protected, it’s very sacred…’Amy’s experience
Where do doctors come in?
Other midwives spoke of a less hierarchical relationship with doctors being beneficial in supporting women’s choices:
‘…the two consultants who come out to our area to cover it have been there for quite a while and they kind of know that we will support the women regardless so they may as well go along with us…’Claire’s perspective
‘Claire’ also reported a procedural change with obstetricians that had benefits in their Trust; women thought to be at moderate risk of adverse outcomes stayed within midwifery care. This had two benefits. First, midwives were enabled to support the women to meet their needs; second, the doctors valued their time being freed up to focus on ‘women that really needed their input’.
How does this relate to the current crisis in midwifery?
Up and down the country there are reports of a shortage of midwives, experienced staff leaving the profession in droves, overstretched services and all this further pressuring those midwives who remain.
Midwives in this study reported feeling sad, and angry. ‘Beatrice’ described herself as ‘burning with rage’:
I became a midwife because I wanted to protect and enhance women’s health and their rights. It feels more and more that I am ensnared in a mad conspiracy which licenses obstetric butchery.Beatrice’s experience
At least one midwife reported being so disillusioned that she was planning to leave the profession. She felt a strong sense of loss, that midwifery had not turned out to be what she’d been taught:
‘…as a student going into midwifery, you expect it to be… advocating for women and fighting their corner. But actually when it comes to the grindstone, when it comes to the crunch, it is not about advocating for women, it is about protecting your back…’Leanne’s interview
But there are also clear stories of midwives enjoying their work. Positive experiences reflected an alignment between the midwives’ philosophy and that of their colleagues and/or organisational cultures and supportive, trusting working environments.
A key finding of this study indicated that where organisational cultures did not value or support women’s or midwives’ autonomy, this constrained midwives who wished to deliver woman-centred care. Where midwives worked in unsupportive environments, their accounts revealed high levels of emotional labour and/or mental load; some experiencing high levels of stress and distress.
Surely the path forward is clear?
The researchers put it simply:
“In this study, negative organisational cultures appeared to be distinguished by a patriarchal culture that permeated all levels of the organization characterised by; poor leadership, unsupportive middle management, unsupportive obstetric staff, lack of peer support, and where guidelines superseded women’s and midwives’ autonomy. Moreover, the study findings specifically highlight issues of the organisational culture as problematic, rather than those of the organisational environment, such as staffing, resources, workload or busyness, that has been highlighted in other studies.”
“Woman-centred organisational values and culture created the optimal environment for midwives to deliver woman-centred care where women’s (alternative) choices were made acceptable and part of ‘what is done around here’ – therefore, deemed normalised practice. Midwives reported ongoing and accessible support across the maternity continuum; antenatal care planning, intrapartum care and/or postnatal. Another important strategy was colleague debriefing; where midwives had access to supportive, non-judgemental peers or senior staff they reported greater confidence in delivering woman-centred care.”
So, if banging on about OUR satisfaction with maternity services isn’t enough to effect supportive change, could the fact that it ALSO creates a culture where midwives get more satisfaction from their jobs and maybe stop leaving the profession be persuasive?
All I do know is that something has got to give – and it’s not going to be us birthing in the way we want to.