“I walk beside you
Wherever you are
Wherever it takes
No matter how far
Through all that may come
And all that may go
I walk beside you
I walk beside you” (Petrucci 2004)
This article has grown out of the findings of a research study which explored holistic midwives’ knowledge in relation to the construct of ‘post-term’ pregnancy. The methods used in this study have been described more fully elsewhere (Wickham 2009) but, in brief, I set out to explore this area with practising midwives who were had a holistic approach and who worked with women seeking natural, physiological birth. Most of these midwives were working independently or autonomously and outside of institutional protocols, and they were based in five different countries, including New Zealand, the UK and the USA. I undertook interviews with these midwives and used grounded theory to explore their views and knowledge about post-term pregnancy. These are midwives who truly focus on how they can be with women, and I am not going to introduce them further at the outset because their words very much speak for themselves.
Early on in this research, I noticed that the midwives frequently referred to the concept of ‘journeying’ and to the notion that they journey alongside women as the women travel on their own journeys of childbirth. This article shares the findings of my study in relation to this area, showing what these midwives see as the core ideological values of holistic midwifery and highlighting a number of issues which further our understanding of how these midwives view the woman-midwife relationship to be a unique and special one which may differ in important ways from the kind of relationship that other health care providers may have with their clients.
Journeying Midwives, Journeying Women
This article discusses only one small element of the findings from this study, yet if there were one concept that would serve to introduce these midwives and the entirety of the findings in a qualitative sense, it would be that of journeying. Most of the midwives in this study used the word journeying and spoke of related concepts such as travelling, maps and signposts often and explicitly, while the remainder refer to these concepts implicitly. One of the most fundamental aspects of their worldview is the way that they see themselves as accompanying or journeying alongside childbearing women, who the midwives view as being on their own journeys. The midwives view their primary role as being with women on the women’s journeys rather than attempting to direct the journey themselves.
Ultimately it’s not my journey, it’s the woman’s journey … I don’t mind where they wanna go, where their journey’s meant to take them, even if it’s like I don’t understand it; great, go there. You know, I feel really comfortable with that. (SilverBirch)
This stance contrasts strongly with what the midwives in this study see as the production-line based process management approach that derived from the mechanistic model and which characterises the technocratic paradigm. They see this paradigm as being prevalent in systems of maternity care that are set up to care for hundreds or thousands of women each year and which are thus necessarily bureaucratic in nature (e.g. Davis-Floyd 1993; Dykes 2005). As far as the issue of post-term pregnancy is concerned, the application of this process management approach within systems of maternity care ensures that most women’s journey of pregnancy does not last longer than 41 or, at most, 42 weeks. This is despite a lack of evidence that routine induction at a particular temporal point reduces maternal or neonatal mortality or morbidity (see Menticoglou and Hall 2002, Wickham 2006, 2009) and in the face of largely ignored evidence that normal pregnancy is longer than is accounted for in most dating systems (Mittendorf et al 1990).
Figure 1: Notions embedded in the obstetric construct of post-term pregnancy
(1) That there exists an optimum (in relation to the goal of reducing neonatal mortality and morbidity) time frame during which human pregnancy should end, which is expressed in the form of a range of dates during which the woman’s pregnancy is deemed to be ‘at term’;
(2) That a specific end point (the EDB) should be set at the outset of a woman’s pregnancy (albeit sometimes later modified in response to data gathered through the use of ultrasound technology);
(3) That the relationship between the current temporal point and the EDB should be a key focus of interactions between the woman and her attendant, and a marker for the timing of monitoring, interventions and screening tests throughout;
(4) That, if the EDB passes before the baby is born, a further end point ~ the ‘induction date’ ~ should be set to mark the date on which the woman’s pregnancy is deemed to have carried on so long that her baby is at risk if pregnancy is allowed to continue;
(5) That medically led action (generally in the form of pharmaceutical or surgical intervention designed to bring on labour and birth) should occur if the ‘induction date’ arrives before the baby does.
By contrast, every midwife in this study has attended at least one woman whose pregnancy lasted longer than 42 weeks and the vast majority of them (as will be further discussed in a future article) use more individualised, more flexible and arguably more evidence-based means of negotiating a due date with the women they attend. The key word in that last sentence, to return to the notion of journeying, is ‘negotiated’. As far as these midwives are concerned, the determination of the expected date of birth (EDB) is not solely their remit, responsibility and right, but something to be individually negotiated with rather than imposed upon each woman.
The idea that women journey through childbirth is not a new metaphor. A significant number of midwives have described women’s pregnancy, childbirth and breast-feeding experiences as journeys (e.g. Rountree 2003; Gaisie 2004; Dykes 2005; Locock 2005; Rolls and McGuinness 2007, Leap et al 2010) and the use of this term is not limited to those who view themselves as holistic. As this article will demonstrate, however, the use of the journeying metaphor is intended to convey a number of aspects of this concept that are specific to the way that the midwives in this study view themselves as being on their own journeys alongside journeying women.
Overall, these midwives place significant focus on the ‘ings’ of journeying and of being with woman. Although they and the women they attend are strongly focused on babies’ well being, they perceive a baby’s physical well being only in relation to the multi-dimensional well being of the woman and her personal and social context. Unlike the technocratic approach, within which some have argued that babies may be seen as the end product of a process whose success is measured in the limited terms of perinatal mortality and morbidity, the midwives are as focused on women’s experiences of the journey to birth as they are on the destination of motherhood. They see the emotional, spiritual and social aspects of the journey as important and they are engaged in being with women on a journey which may include experiences and learning in these realms. Both the journey and the destination are deemed worthy of constant attentiveness.
The midwives’ journeying entails an ongoing relationship and engagement with their own beliefs, ways of being and knowing practice as well as with women and their journeys. Several of the midwives in this study explicitly describe aspects of their own personal experience as journeys.
I’ve been independent for seven years now and I did feel it in the beginning, I felt nervous about being independent, just on that journey itself… (Kate)
As Kate implies, the journeys that some of these midwives have made into a different kind of midwifery practice from the norm have been fraught with obstacles, not least of which are the way that the technocratic model is seen as authoritative and the fact that they are deemed by some working within this model to be deviant in their behaviour and practice. This may serve partly to explain why it is that the midwives are passionate about issues such as developing and preserving midwifery knowledge, women’s rights and especially for each woman’s right to make personal choices about her childbirth experience. Some of this passion emerges as positive statements which highlight the strength of the midwives’ beliefs in their ideological standpoint and serve to explain why they see midwifery as a way of life rather than as a job.
...we [midwives] believe passionately in what we do (Sue)
Some of the midwives’ passion, however, also emerges in their expressions of anger about technocratic norms and practices. I hate calculating, I hate this whole dating culture…(Sally)
I feel so passionately because in my work I pick up a lot of the pieces of the broken women … you know the broken women who’ve been through this [experience of induction], and virtually it’s a story that we could all recite by heart… (Kate)
In most cases where this is expressed, if is followed by a statement that reveals the midwives’ strong desire to change what they see as the unjust or harmful effects of the obstetric process management approach.
I just see the morbidity that’s attached to that [induction for post-term pregnancy] and it breaks my heart. All those primips with their syntocinon drip in one arm and their sore fannies from all the prodding and they’re on the monitor ‘cause there’s that whole package that goes with it … it breaks my heart (Kate)
As Kate’s words show, these midwives understand only too well how the tendency for obstetric intervention to lead to a cascade of further intervention (Inch 1982; Davis-Floyd 1993) can negatively affect women’s experiences and self-concept (Edwards 2001, 2005). They are also clearly aware of the historical and social context of modern approaches to birth. There also exists a personal and emotional dimension, however, as can be seen where, in the above quotes, Kate repeatedly uses the word ‘heart’. Some of the participants in this study became midwives as a direct result of their own childbirth journeys; because they were not attended in the way that they wanted to be during these journeys, and they thus want to help other women to develop agency and have their emotional needs met.
I felt like a person who was decided when I learned from my first birth experience that it’s necessary for women to take responsibility for birth or if they don’t do that they might have a whole unexpected struggle. And some of the consequences of losing in some degrees some elements of that struggle can affect you the rest of your life. So having met a number of women and having us all compare decisions, compare experiences and finding there is a pattern here, we just decided to save our skins. I‘d never hired a doctor before [my first birth experience] for anything. It just didn’t occur to me that I could fire him and get another doctor. I should have but I might not be here today if I had so that’s how deep it went for me. (Amy)
Most of the midwives have a large degree of self-awareness about their feelings and knowledges, and often describe their own journeys in relation to this and to self-discovery.
The journey of personal discovery … I feel like it’s been an incredible personal development journey, you know, doing it as an independent midwife. (SilverBirch)
SilverBirch later describes herself as a justice warrior, and a number of the midwives either state or imply that they use their distress with the nature and consequences of the technocratic approach to fuel their work; work which involves investing a good deal of time and effort into being with each woman. Again, the midwives’ use of the journey metaphor to describe their personal development is not unique; a large number of midwives have written about their own journeys, often using the word journey in the title of their work as an explicit marker of their meaning (Leap 2004; Kirkham 2005). Additionally, others have written about literal or metaphorical journeys that are collectively shared by groups of midwives (Thompson 2003; Horobin 2004; Thomas 2004); an idea that also emerged from the data in this study, as the next section will show.
The concepts of relationship and connection are both integral to the overall category of journeying in that a number of the midwives were very keen to stress the shared nature of journeying near the beginning of their interviews. This manifested in two main ways. Firstly, the midwives emphasised the important part that women have played in their personal and epistemological journeys.
I think for me the place of real growth in my knowledge was what women want to do, you know, and it’d be really grossly unfair to not give that a huge proportion of space in this ‘cause it is about women asking you to do things that you haven’t done before that you kind of feel in your gut is okay, but you haven’t been there… (SilverBirch)
…they’re women who also wish to push boundaries, aren’t they? And that’s why I love working with those women so much. (Sally)
They also seemed to feel that the journey of being a holistic midwife was one that was shared between them.
I suppose maybe in midwifery we’re on that journey…(Kate)
We [holistic midwives] are all different but by and large the majority of us work very similarly and have hadsimilar journeys and have learned similar things along the way. (SilverBirch)
The point that SilverBirch makes about holistic midwives’ journeys being similar resonated with my analysis of the data gathered in this study as a whole. While each of the midwives in this study who journeys with women might do so in a slightly different way, three aspects of the concept of journeying appeared consistently and frequently throughout the data. Two of these aspects related to the ways of knowing and seeing that were used by the midwives and will be discussed elsewhere, while the remainder of this article focuses on the first aspect of this the way in which the midwives journey in relationship with women.
Journeying in Relationship
The quality of the midwife-woman relationship has been argued to be unique amongst relationships (Kirkham 2000) and has a direct impact upon the outcomes of a woman’s birthing experience (e.g. Halldorsdottir and Karlsdottir 1996; Homer et al. 2002; Hallgren et al. 2005, Leap et al 2010). All of the midwives in this study saw the nature and quality of their relationships with women as key to their ability to attend women in a holistic way.
SilverBirch: It’s really, really strongly connected to the fact that you’re in relationship. We get to know women really well, and even if you don’t feel like you know the woman particularly well, because you know some people are easier to get to know deeply than others, you still have got a sense of her, you know, because the fact that you’re not getting to know each other well is significant in itself … So for me I suppose it’s about that relationship… it feels like there’s a sort of spiritual umbilical cord…
Sara: Between you and the woman?
SilverBirch: Yeah, yeah, yeah. I suppose the easiest way for me to understand it is you know there’s that spiritual umbilical cord. It’s almost like, because you’ve agreed to do it together, when it’s happening to her it’s almost as though her thoughts or her Spirit gives out the vibe and it comes to the people who wanna be involved in it. It’s about the quality of a relationship for me… I think it is about the quality of attention that you pay … it’s about what you’re attending to, and, really, for me, it’s about really wanting to hear who that woman is and who that couple are which means that you have to be really clear about who you are and where they’re not you and all of that. Yeah, and I think, it sounds, you know when you say it, and I hear myself say it, it sounds like so obvious and so simple but I think it’s really, really the sort of sacred space of really wanting to connect with something other than you, be that a person or whatever.
As SilverBirch’s words show, the relationships between these midwives and the women they attend are complex and involve a number of aspects. The midwives view these relationships as sacred, and the sense of connection that they seek and offer contrasts strongly with the technocratic paradigm’s adoption of the concepts of reductionism and separation. Maggie Banks has described a similar sense of connection:
“I found my relationship with the women I served became a ‘walk in oneness’ a journey of mutual goals and strategies of support” (Banks 2007: 9)
The midwives also talk of the fundamental importance of relationship as a means through which they gain personal knowledge about what makes each woman unique, which contrasts strongly with the technocratic tendency to gather knowledge of populations, measure women through technological means and apply the principles of process management en masse. I mentioned above that these midwives seek to help women develop agency, and they view relationship as the vehicle through which they can find out what a woman wants.
…it all does vary a bit, you sort of play it by ear with each woman [depending upon] how they want it to unfold. (Sally)
This can perhaps be seen more clearly with a specific example. One of the key aspects of the technocratic approach to the calculation of an EDB is the importance of the clock as a “crucial organising principle” (Helman 1992: 42). A series of notions are embedded in the obstetric construct of post-term pregnancy, and these are shown in figure 1. These technocratic notions describe the specific ways in which the setting of temporal boundaries is used in order to attempt to control risk on a population basis, despite the fact that, as above, the evidence does not support such an approach. The midwives in this study are concerned with many aspects of this, one of which is how the woman herself views the issue of temporality around the question of the due date.
…there have been a few cases recently where [I’ve talked to other midwives about setting a due date] and that’s exactly what they’ve said, the baby’s due sometime between sort of mid October and mid November, and that’s because the women, that’s how they want to operate, they don’t want a fixed date… if that’s what the woman wants then that’s cool. (Bonnie)
This is a very clear example of negotiation in action. However, another really key and important element of their approach is that, while they all support and promote home birth (and sometimes other out-of-hospital locations) and a more non-interventive approach, they do not seek to impose either this or any element of their practice upon all of the women in their care. The midwives acknowledge that some women have not challenged the notions inherent within the technocratic paradigm and, because they view relationship and women’s agency as paramount, they (arguably unlike the technocratic paradigm, as Oakley 1980, 1984 and Murphy-Lawless 1998 have showed) prioritise the woman’s ideology and concerns rather than imposing their own.
Oh, sure, I’m really, really OK with women who have less of a sense of what they want. I just mean that it’s important [for me] to know who they are, what they want, and whether those wants are really strong important wants, or just preferences. (Cerridwyn)
It is also clear that the midwives seek to journey in relationship with women in a holistic way rather than focusing, for example, on aspects of their physiology or on the relationship between these physiological aspects and population norms. For these midwives, taking a wide and connected view is of fundamental importance, both ontologically (in relation to being) and epistemologically (in relation to knowing).
It’s very difficult in other words to separate who the woman is from what she’s going through with the pregnancy because she is the pregnant woman. It’s not her body, it’s her whole self… (Anna Andhra)
This focus on connectedness (as well as other aspects of the midwives’ ways of being and knowing), shows that the midwives are similar to the women that, in their work on women’s ways of knowing, Belenky et al (1997) described as ‘constructed knowers’. Like Belenky et al’s (1997) participants, these midwives seek connection between different aspects of women’s being, with different kinds of knowledge, between different ways of knowing, and on wider levels. They, like the British independent midwives who participated in Claire Winter’s study (Winter 2002, Winter and Duff 2009), understand that complexity is key, and seek to work in ways that embrace and expand their understanding of this notion.
The notion of connected (as opposed to separate) knowing also implies a conception of the self in relationship to others rather than as an autonomous, or separate, being (Gilligan 1993; Belenky et al. 1997). In some ways, the juxtaposition of the midwives’ view on connectedness and their seeking to help women develop agency may be viewed as paradoxical.
For example: I am a midwife who would rather take each individual woman as independent and just really, just look atwhat’s going on with this woman and this baby... (Anna Andhra)
Many of the midwives express views like this; views that resonate with MANA’s (1992) notion of valuing “the oneness of the pregnant mother and her unborn child” (11). Anna Andhra describes how there is often no epistemological separation for the midwife between finding out about the woman and finding out about the woman-and-her-baby, an idea that has also been captured in the development of the term motherbaby by some midwives (e.g. Edmunds 2001; Tritten 2005, Davis-Floyd et al 2010). The paradox, however, only arises when the term individual is taken to mean separate, and the midwives rarely use the term in this way. Rather, they use it to differentiate the way that they see each woman as special in her own right from what they see as the approach taken within the more technocratic process management approach, which tends to apply monitoring and manipulation on a population level without always taking into account the individually special aspects of each woman.
Many good research studies have explored the nature of the woman-midwife relationship over the past decade or so. Although this was never the primary intention of this particular study, which was designed to explore midwives’ knowledge in a particular area of practice, it is interesting (if not entirely surprising, given the importance that these midwives place on relationship) that so much data relating to this area emerged from our conversations. One of the key features of this research is that it looked at midwives who – like many LMC midwives in New Zealand work autonomously and without the constraints of institutional protocols. The findings in this area suggest that, where midwives are able to work in this way, there may be something unique about the quality of their relationships with women that makes them different from relationships within the wider area of health care practice. They are self-aware, passionate and engaged. Their engagement with midwifery and with women has led them to challenge the problems they see deriving from the application of the technocratic management approach, and they are taking active steps towards embracing and reclaiming ways of being, knowing and doing which address these issues and align with the principles of holistic midwifery.
In some ways, these midwives could be said to be living the ideas expressed in Campbell’s (1984) notion of skilled companionship, whereby the relationship between the midwife and woman is a commitment which is considered important in and of itself. For these midwives as well as Campbell, a “good companion” (1984: 49) is one who accompanies another on their journey without dictating the route that the journey should take. Loyalty is an important aspect of this, and these midwives are more easily able to be loyal to the woman than their counterparts who have to pay attention to the rules of a system. They make clear pacts with each woman to be with her on her journey, to respect that it is her journey rather than theirs and to be an encouraging, knowledgeable, skilled friend. They undertake to meet each woman’s needs whenever possible, to use knowledge and resources to suggest other avenues if the woman has a need that the midwife is unable to meet and to be physically and emotionally present for the woman when needed.
Yet it would be unfair and inaccurate to say that the midwives’ ways of approaching their relationships with women (and also those women’s families, although this article has focused on their primary relationships with the women in their care) could be fully described by any theoretical model. This is in part because of the multidimensional and nuanced nature of the midwives’ approach. It is also, perhaps more importantly, because the midwives have not settled on a static way of being, but are actively developing, reflecting on and (where appropriate) modifying their approach as they grow in knowledge and experience and in relationship with more and more women over time.
While I am reluctant to make stark generalisations about groups of practitioners who were not the subject of this research, I would tentatively suggest that there is a key difference between the way that these midwives relate to women and the way that health care practitioners are encouraged to relate to and communicate with their clients or patients. This difference lies is in the closeness of the relationship; the relationships that these midwives have with the women they attend seem to be closer and more personal perhaps in a way that suggests elements of friendship than is the case in health care practice more widely. There are probably many reasons for this, but one may relate to the difference between the journey of birth which is generally undertaken by well women and the journey of, say, being ill and seeking medical care. Furthermore, the birthing journey may be unique in that it holds the potential for growth and transformation on a number of levels. Midwives are privileged to share some of the most special moments and journeys of life with the families they attend, and, when these moments and journeys occur in ways and places that are truly woman-centred, it is perhaps unsurprising that the relationships that grow may be qualitatively different from those which exist in other areas of healthcare practice. Many of these midwives remain in close contact with the women that they attend, often because women seek to work with the same midwife for several birthing journeys, but also because the special nature of the birthing journey means that women and their families want to maintain contact with the midwife with whom they shared such a personal and special time.
In the conclusion to her edited volume about time and childbirth, McCourt suggested that:
A number of practices have been examined in depth, for which there is even in terms of what is considered to be authoritative scientific evidence in evidence-based medicine little evidence of measurable benefits and considerable evidence of iatrogenic risk, yet those practices continue because of their established nature, ideologies, relationships and structures of power. (2009: 249)
The words of the midwives who participated in this study show that, by contrast, it is possible to work with women in ways which do challenge practices such as the application of technocratic notions around post-term pregnancy. There can be little doubt that the nature and quality of the relationships that these midwives have with the women they attend are absolutely pivotal in this, as well as being important in myriad other ways. These midwives are not accepting of “established … ideologies, relationships and structures of power” (McCourt 2009: 249). They place a high value on women’s agency, on autonomy and on providing individualised care that sees the woman’s journey as primary. They take extreme care in developing good, healthy and appropriate relationships with women and their families. In most cases, however, they do not hide behind a mask of professionalism which implies not only a distance that may be inappropriate given the acutely personal nature of the birthing journey but also a degree of epistemological exclusivity, wherein professionals perceive that they are more knowledgeable about a situation than the women whose bodies (and minds and spirits) are undertaking this journey. Instead of thinking that they always ‘know best’, these midwives have a high degree of humility about their own knowledge and embrace and value women’s personal knowledge amidst many other forms of knowledge that they call upon in practice.
There is always a need to carry out more research and look further and more deeply at issues and questions which are raised by studies such as this one. I would suggest that these findings also highlight the need to protect the existence of the woman-midwife relationship as primary and acknowledge and honour the very special nature of the relationships that midwives can have with women. We absolutely need to continue to reflect upon the nature of these relationships and further explore the extent to which the nature of the birthing journey makes them different. In addition, if midwives are going to continue to challenge those structures, constructs and ideologies that do not serve women, babies and families, it may be that there is also need to stand up and own the fact that midwives’ ways of journeying with women who are on birthing journeys may not always sit easily with traditional understandings that prioritise separation and distance rather than connection and companionship.
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A version of this article was originally published as Wickham S (2010). Journeying With Women: holistic midwives and relationship. Birthspirit Midwifery Journal 6: 15-21.
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