Letting mothers lead

What do mothers want from midwives? Over the years, I have been privileged to listen to many mothers. No matter what their age or experience most want the same thing the woman they have read about in books. The friend, the confidant, the woman who i

At the beginning of their pregnancies women are romanced by this idea of the midwife being the "with" woman. In The Experience of Childbirth, author Sheila Kitzinger writes that a mother and midwife ". . .form a team working harmoniously towards the same end. There is little need for talk, as each understands what the other is trying to do."

We believe this. We all want to believe this. The truth can, however, be less comforting. For instance: "I saw her as unhelpful, unkind and rather a bully" (AIMS Journal, Autumn 1993). "Through the test of my labour [the midwives] talked over me about how tired they were and how they wouldn't be able to take their clinics the next day." (AIMS Journal, Autumn 1994). "What she was doing to me, rupturing my membranes, the constant internals, felt like abuse. Like I imagine sexual abuse would feel. I hated her for it." (Private client, October 1993).

Midwives can be tyrannical. They can be abusive. They can do damage. These are harsh words, but perhaps the time has come for harsh words. In the struggle to maintain midwifery in Britain and to establish it in places like America many of us have looked the other way and made excuses for those who we know have acted in a way which is detrimental to the health and well being of the mothers in their care.

For years it's been the system's fault, the supervisor's fault, the consultant's fault, even the mother's fault when things go wrong. Criticism levelled at midwives is always made in a roundabout way if it's made at all. The pill is sugared in a way it would never be if we were criticizing the actions of any other professional.

Midwives can fail mothers in many different ways. The most common and well documented is by undermining breastfeeding (BMJ, August 1, 1992).

But there are other abuses such as imposing time limits on labour, forcing pain relief on a mother who does not want and may not need it, badly timed, painful internal examinations, rupturing membranes, episiotomies, speeding labour up with drugs, or invasive procedures such as cervical massage.

These procedures are often performed under a cloud of emotional blackmail, with the midwife insisting that a baby is in "danger" or "distressed" even when there is no real evidence of this. Mothers who opt for home births, hoping to avoid these abuses, are often astonished to find that the midwives simply bring the hospital with them into the house.

In each instance the mother gets pushed into following the midwife's programme instead of her own. The question is where the midwife's "programme" comes from.

Certainly the system can fail them. Those who choose to practice in hospitals find their hands tied by the fear of rocking the boat within the established hierarchy. Those who choose to practice independently can be crippled by the high cost of indemnity insurance.

Midwives are already professionals in their own right, able, in theory at least, to practice autonomously. They are the only practitioners, again in theory, who are experts in "normal" delivery. Yet many highly abnormal, managed labours take place at the hands of midwives. Midwives are, in fact, in danger of becoming the new technocrats of the delivery suite.

Midwives are even losing control over education. Many midwifery schools are being taken out of the hospitals and amalgamated into colleges of higher education in order to raise professional credibility.

To prevent this, we must help our midwives to gain greater personal awareness and a sense of the social context of their roles. Midwives who come from nursing backgrounds must be helped to make the necessary shift from viewing women as patients to viewing them as partners in an important, life changing process.

When midwifery schools screen candidates they look for educational and professional qualifications. but they do not ask vital, basic questions like: "Why do you want to become a midwife?" and "What personal/emotional baggage are you bringing with you to your job?"

During the course of several workshops which I held recently at King's College and Thames Valley University I encouraged midwifery students to look deeply at their own backgrounds and at the social roles of women and how they relate to the role of the midwife. We talked about the difficulty of disentangling one's own sexuality and sexual experience from the professional practice of birthing babies. We explored "compassion fatigue" and the many other personal, professional and social factors which cause midwives to "switch off" and stop listening to mothers.

The written feedback was universally positive, fuelling my belief that for the profession to become "powerful" educators must first address the sense of personal, social and professional disempowerment felt by many women who train as midwives. Once qualified, midwives must have somewhere to go, perhaps peer counselling groups, where they can put the day in, day out emotional strains of their very demanding jobs into perspective. Without this support there is a growing danger that over stressed midwives will simply act out their professional and personal problems on unsuspecting mothers.