Among other things, the word ‘supervise’ can mean to oversee, to manage, to control, to run, to direct, to watch, or to observe. The midwifery literature has included ongoing discussion about whether midwives need to be supervised, given that a number of other professional groups do not have this additional kind of overseeing of their practice, and debates considering whether Supervision is a positive or negative adjunct to our UK model of midwifery practice (e.g. Flint 2002, O’Connor 2002, Fraser 2002).
Just as there are parallels between midwifing women and midwifing midwifery students, there are also interesting similarities between the experience of being supervised as a midwife and the experience of being attended in labour as a birthing woman. In both cases, the relationship can range from being controlling and directive to being supportive, encouraging and compassionate towards the needs of the person being supervised or attended. Can we learn anything about midwifery supervision as well as midwifery practice by exploring the question of how much control women currently have about the support and supervision of her birth and, in particular, the nature and number of her birth attendants?
How Many Midwives does it take to Attend a Mother?
A recent conference session caused me to stop and think about the question I’ve posed above. The topic under discussion was ‘protecting the perineum’ and one American homebirth midwife talked about how the midwives in their practice used the “four-handed catch”, where one midwife uses her hands to catch the baby, while another uses hers to protect the perineum. Of course, whatever you think about the idea of the “four-handed catch” and the concept of protecting the perineum in general, in order to even consider using it you need to have at least two midwives present at the birth. I began thinking about how, in different times and cultures, the number of midwives (and other people) attending a single woman during labour and birth has varied so much.
In my experience, the number of midwives who attend a birth in the UK tends to be governed by staffing levels, convention and the commonsense idea that the optimal number ~ generally considered to be one for labour and two for the birth itself ~ means that there is one midwife to catch the baby and attend the woman in the immediate postnatal period, and another to attend the newly born baby. Increasingly, women giving birth in hospital may only get about a third of a midwife in labour on average, as the poor soul is having to dash between several rooms to look after a number of women simultaneously.
Much has been said and written about the value of undisturbed labour and birth over the past few decades, which might lead to the idea that it would be better to reduce the number of birth attendants and to focus on increasing continuity. However, it would not be true to say that this is (or has been) the norm within all cultures. If you look at old paintings of births, watch the early videos made by The Farm midwives, or read anthropological studies of traditional midwives, you will find that it is not uncommon to have several midwives even at the kind of births where the most diligent of record-keepers would he hard pushed to fill an entire page with notes. But the issues are by no means clear: some of the people who take a pelvis-centred perspective argue that human women began to need midwives for physiological and safety reasons as we adopted an upright posture, while others argue that the ‘need’ for a midwife has no basis other than having become the cultural norm.
As with many issues, it may be that there is no ‘right’ answer to this, and that the important thing is finding out what each woman wants. I must admit that, when watching some of the American videos of party-like births attended by several midwives, I have a sense that this would not be my choice. Yet I have talked with some of the women at the centre of those births, and they loved it. Along the same lines, might some midwives prefer to have more than one supervisor, just as some postgraduate students prefer a single Supervisor, while others enjoy having a supervision team?
But, while those questions are interesting ones which we might ponder in the longer term, what about the issue of continuity for women in the here and now? No matter what any midwife writes or thinks about the optimal midwife/woman ratio, women themselves are beginning to speak out again on this subject of their own accord. They are making it clear what it is they want, and their voices are beginning to gather momentum. The group of mothers, fathers, midwives and others who are behind the “One Mother, One Midwife” campaign are asking, as you might imagine from the name, for every woman in the UK to have the opportunity to choose one midwife and to be provided with a maternity service which is built on partnership as well as information and choice. As with the oft-cited Changing Childbirth Report (DoH 1993), most women do not want control taken away from them. They want to be able to make decisions about their own experiences, and they want a midwife for their birth who is not only known to them, but who will be facilitative, supportive and compassionate. When you think about it, this is probably also what most midwives want from their Supervisor who, ideally, is someone of their own choosing.
Students, Visitors and the Medical Masses
Most midwives working in busy labour wards would probably agree with the statement that, when student midwives are present, the ratio of midwives to women increases, and a number of women get to experience the continued support of the same person over an entire shift. With the combination of the enthusiasm of many student midwives, their supernumary status (at least in theory) and their need to ‘get their numbers’, lucky women may find that a midwifery student stays with them until after their birth, regardless of any change of qualified staff. It is a curious sign of our times that women seem happier to welcome student midwives than ever, because, in some hospitals, it is the only guarantee that they will be able to have the continual, compassionate and facilitative midwifery support that they desire.
However, midwives and midwifery students are not the only people to attend births; there are also those companions invited by the mother, and those professionals supplied by the Trust. In both cases, the woman herself has little control over the number of people supporting and supervising her through labour, just as midwives may have little control over the options they have for Supervision, and the extent to which this sometimes become confused with management.
The number of birth companions invited by the woman is often strictly limited by local rules about how many people are ‘allowed’ to enter the birthing room, with little regard to women’s own cultural norms, and it is not uncommon to see families playing labour ward tag; taking turns to be the one who gets to be in the birth room rather than the waiting room. By contrast, the number of professional attendants can vary widely, and tends to increase with the perceived ‘riskiness’ of the birth and other issues such as whether the unit supports medical students who need to witness or participate in births.
As we know, women who are experiencing ‘normal’ birth may have only one or two birth companions and one midwife, while those women who have need of obstetric intervention may find that nine or ten people end up in their birthing room. However, although most women know they can decline having students, there seems to be less choice around having other attendants who are potentially surplus to requirements ~ have you ever heard a woman say, “Actually, I’d prefer not to have the new SHO shadow the Registrar at my birth”, or, “It is very kind of the paediatrician to invite the neonatal nurse to my labour room because SCBU is really quiet and she needs more experience at advanced resuscitation, but I know the midwife already and I’d rather she be the one to work with the paediatrician”?
The other issue to which we need to pay attention concerns the small but nonetheless important increase in the number of women who are choosing to experience their pregnancy and birth outwith the maternity services. I am not referring to those women who choose independent midwives, but to those women who make a conscious choice to give birth unattended. They are making the difficult, brave and controversial decision to have zero midwives. The reasons for their decision are complex and often linked with issues of trust, power and control. However, the parallel with Supervision ends here; where women have the right to do this, in that it is any non-midwife attendant who falls foul of the law rather than the woman herself, midwives do not have the right to decline Supervision. If Supervision fails midwives, their choices are far more limited, and may include leaving midwifery.
The drawing of parallels is by no means an exact science; there are as many differences between the experiences of being midwifed and supervised as there are correspondences, yet I believe that, by comparing the two, we might be able to learn more about both. In the interests of improving the experiences of women and their midwives, we could perhaps do worse than return to those 1990’s buzzwords of choice, continuity and control, and see if we can’t work towards models involving less overseeing and managing, and more compassionate facilitation.
Department of Health 1993. Changing Childbirth. Report of the Expert Maternity group HMSO, London.
Flint C Supervision of midwives: are we celebrating our shackles? – Practising Midwife , vol 5, no 2, February 2002, pp 12-13
Fraser J Time to celebrate supervision – Practising Midwife , vol 5, no 2, February 2002, pp 13-14
O’Connor M ‘Good girls’ or autonomous professionals? Part III: Beyond statutory supervision: quality assurance and the equality agenda – MIDIRS Midwifery Digest , vol 12, no 2, June 2002, pp 159-164
Wickham S (2005) Supervision and attendance: control or compassion? TPM 8(8):26-7.