Questioning is a vital art, especially for those involved in birth. Childbirth has become dominated by pharmaceutical advances, technological interventions and the technocratic, obstetric approach, which focuses on measuring, monitoring and intervention. All of these things carry risk and have side effects and sometimes unwanted consequences. It is thus more important than ever to question what it is that we do when attending birthing women, and how appropriate our actions are. Those of us who seek to assist childbirth need to be willing to open our minds to discussion of what is truly useful to women and what may be unhelpful, especially when used routinely.
Many women’s birth experienced have been shaped, at least in recent times, by patriarchal attitudes. But I and many others have employed the process of critical questioning (which some might call lateral thinking, analysis or reflection) to reconsider the foundations of the knowledge we possess about birth. This is just one step in the reclaiming and rebuilding of useful midwifery knowledge in response to what we have learned and in ways which are more in tune with the needs of women, babies and families.
How this work began
I first wrote a version of the article that you are now reading in 2002. I suggested that we didn’t have nearly enough “midwifery knowledge”, especially about the interventions and routines which are being imposed on women. We still don’t, although I want to acknowledge the growth of that knowledge – despite opposition from various groups – and the amazing research that has been done by many people since then.
One of my offerings to this conversation was to suggest that perhaps critical questioning could enable us to look openly at the different types of intervention that women were experiencing. I hoped that this would enable us to explore when and how technology may be appropriate. I hoped that it would also help create frameworks which could be used to help women and families make the decisions that were right for them. I’d like to think it played a part in that debate, and I will come back at the end of this blog post to what happened to this work in the years since I first wrote it.
What midwives do
Another midwife who was pivotal in questioning this area and who led a related conversation was my friend and colleague Tricia Anderson. Like me, she appealed to colleagues to think critically about the things that we were doing. It wasn’t appropriate to assume that low tech, home-based forms of pain relief or induction of labour were somehow different or better than medical, pharmacological or technological interventions. All were interventions, and it was important to clear away some of those assumptions and look instead at some of the bigger questions. Not least of which is: why are we offering intervention in this situation, no matter whether that’s a back massage or an epidudal; castor oil or oxytocin.
Tricia wrote about this in another article the same year (Anderson 2002). She pointed out that we also need to deconstruct the things that midwives do, and how these actions and words are also interventions have an impact on women. Although doulas weren’t very common at the time, she went on to later note that this also applies to doulas and other birth attendants. Questioning is vital, for everyone. Everything we do, she argued, should be considered an intervention. Asking a woman to change her position, ‘guarding’ or massaging the perineum, drying and warming a newborn baby. This is not to say that these things are necessarily inappropriate, but that we need to begin – and continue – a dialogue about “what midwives do”.
So 2002 saw my first attempt to categorise some of the kinds of interventions which women might be offered in childbirth (Wickham 2002). Below, I describe the four categories I initially came up with; screening tests, clinical interventions, prophylaxis and elective interventions, and I give a short description for each. (If you want more, they are explained in far more depth in What’s Right For Me?)
The most important thing this work highlighted for me was that it showed the need to understand why we are setting out to do something, and what questions we need to ask ourselves – and the woman – in order to determine whether what is being suggested is really beneficial. After carrying out this exercise, I realised just how many of the things we routinely do, especially during prenatal visits, are screening tests. This begged several more questions. For instance: given that the point of a screening test is to detect a deviation from the norm in order to be able to act on that information, how much can we really do to help women who are not ‘within normal limits’?
But it’s not about the intervention itself. Some interventions might fall into more than one category. For instance, perineal support at birth may be practiced as routine prophylaxis to prevent perineal tears when it is part of a prescribed bundle of perineal care. Or it may be used as an individual clinical intervention when requested or indicated by the experience of an individual woman and her midwife. This list is not inclusive of all possibilities, and it forms only one way of considering these issues. Indeed, Anderson’s (2002) work highlights a number of other categories of midwifery interventions, including:
- Reassurance (verbal, via touch)
- Manipulation of the external environment (ensuring privacy, keeping the room warm, protecting woman and baby from intrusions)
- Psychological (asking the woman to ‘let go’ of her placenta)
Here are a few notes on the four types of intervention that I discussed and analysed; screening tests, clinical interventions, prophylaxis and elective interventions.
May be offered to the woman or the baby (though bear in mind that screening in pregnancy is often focused on the woman’s body but actually screening the baby).
Used to detect potential deviations from the norm.
Examples: Ultrasound, checking temperature, pulse, respiration, bloodpressure, vaginal examination, blood and urine tests, Kleihauer testing, fetal monitoring, measuring fundal height, antenatal check, postnatal check, Guthrie test.
Questions to ask: How accurate is the test? Risks of false positive and false negative. Impact on the woman’s psyche. Who is defining ‘normal limits’? Will the result change ‘management’ or decisions?
Notes: The value of many screening tests has been challenged but most are still a feature of ‘normal practice’ in organised maternity care.
May be offered on a routine basis or in response to an individual need.
Used to bring pregnancy, labour or someone’s wellbeing/health back in line with ‘normal limits’, which may be measured in time, or against norms.
Examples: Induction, artificial rupture of membranes, drugs to augment labour, blood transfusion, antiD, cord care, perineal support at birth, counselling, forceps, vacuum extraction, ‘emergency cesarean section.
Questions to ask: Physical and other risks. Side effects. Cascade effect of intervention.
Notes: The routine use of many of these have been questioned. Intervention is more appropriate as a responses to individual need. ‘Normal’ still needs defining.
May be offered routinely or in response to an individual need.
Used to prevent potential problems from occurring. Does not itself give information on the likelihood of a problem.
Examples: Vitamin K, anti-D (rhogam), cord care*, perineal support at birth, withholding foods and fluids in labour.
Questions to ask: Efficacy (does it actually work?) Do the risks outweigh the benefits on a routine basis? What are the implications?
Notes: Many are offered routinely in order to prevent a rare but serious problem. Thus, individuals may or may not choose them when weighing up the pros and cons.
May be offered/performed in response to maternal request or because of a perceived clinical benefit.
May be unrelated to the general situation or impacting ‘progress’, but still used as an intervention in a proportion of women.
Examples: Pain relief (epidural, pethidine, entonox), water for labour/birth, elective cesarean section.
Questions: Do the downsides/risks outweigh the potential benefits to the individual woman?
Notes: This area raises lots of ethical questions regarding choice. At times, these examples may become clinical interventions – according to individual needs and situations. Depends on the ‘indication’. More on this in What’s Right For Me?
Thinking Interventions Through
So how can we take this kind of questioning into practice? How can we think through the interventions we use, and determine when and whether they are truly useful or warranted? Well on one level that’s totally not our decision: it’s up to the woman to make the decision that’s right for her. Our role is to offer information to help her to do so. But it’s also possible, of course, to look at this and gain a deeper theoretical understanding, which in turn can help us to determine what information women might want and need.
Using an example from the table above, we might ask ourselves if it is really useful to measure fundal height during pregnancy. The basic aim of measuring fundal height is to determine whether a baby is growing ‘within normal limits’. The notes above show that it classifies it as a ‘screening test’. The idea that measuring fundal height (or, indeed, performing any screening test) is a beneficial intervention to perform on a routine basis assumes that:
• It is possible to measure fundal height accurately. (Is this the case, or might there be differences between the people and / or instruments used?)
• There is agreement over what ‘normal limits’ are. (Are current guidelines and charts accurate? What are they based on? Do they take variation into account? Are there few or many cases where predictions turn out to be wrong?)
• It is possible to ‘act upon’ findings which suggest that the baby is not growing within ‘normal limits’. (Is this really the case? Is there a clinical intervention which can enable the baby to grow faster – or slower – and actually affect the outcome in this situation?)
Other questions that might be asked in relation to this screening test include:
• What is the rate of false positive and false negative results? (i.e. how many babies deemed ‘small for gestational age’ turn out to be bouncing eight-pounders, and how often are ‘small for gestational age’ babies not picked up during prenatal checks?
• What is the potential impact on the woman’s emotional wellbeing of being told her baby is smaller or larger than average? (Especially where there is no effective ‘treatment’ for an adverse finding).
• What is the evidence relating to ‘small for gestational age’ babies generally?
• Might nutritional advice impact on the situation? Does inequality matter? Could a woman’s diet, social situation, psychological wellbeing or any of a hundred other factors affect the rate of baby’s growth? How does this relate to the idea of using fundal height as a routine screening test? What about the idea of offering better support, nutritional advice or a minimum living wage to all women as a preventative measure?
When we are considering the relative accuracy of using our hands and experience or using a tape measure, we might also consider the other qualitative factors which impact the situation. For instance, the height and weight of the woman, the position of the baby, any previous experience of the woman. Does she carry her babies in a particular way? Does she never look very pregnant but give birth to nine pound babies? Some midwives and doctors argue that a tape measure is no substitute for being able to take these factors into account.
Given these questions, and in a context of individualised care, we may feel it isn’t appropriate to use the measurement of fundal height as a routine screening test. It might be useful to gain individual information about the pregnancy and as a tool for reassurance rather than worry. Would it be better to reflect on the appropriateness of this for individual women? How can we make it so that pregnancy screening tests are performed only when someone has made an informed decision? Rather than it continuing to be an assumption, an expectation, that women will lay down and offer their bodies for measurement without knowing enough about what we are doing, and why, and what the bigger picture around that might be?
These are huge conversations and the questioning needs to continue. I realise that I have only raised the questions here, and not provided all of the answers. That’s partly because we all have to make decisions about our own practice, in the context we work in. The decision should always be the woman’s, but setting and context do make a difference. And this is just one corner of a much bigger set of questions and considerations. my work on this area is just one example of the type of question which can help challenge the routine and consider the ‘bigger picture’ which may affect a woman’s situation.
I first wrote a version of this article in 2002, and concluded that we needed more critical thinking in this area. Later that year, I turned the article into a chapter in the very first edition of ‘What’s Right For Me.’ I’m delighted to say that this book has now been extensively expanded, developed and updated and contains a much more in-depth discussion of this area, along with many others. I have continued this conversation and analysis in several other books as well.
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Anderson, T (2002) Peeling back the layers: a new look at midwifery interventions. MIDIRS Midwifery Digest 12(2): 207-210.
Wickham S (2018). What’s Right For Me? Avebury: Birthmoon Creations.
A version of this article was originally published as Wickham S (2002). The Art of Questioning. Midwifery Today 63: 42-43.