I love research papers that tell me things I already know. I especially love those that tell me things I already know about everyday midwifery practice that I don’t think about on a daily basis but which, when I read about them, I realise are really, really important. I love such papers for lots of reasons but, now that I am thinking about it, two of those reasons stand out.
The first reason is because such research makes me think about what I do. Most of us inevitably end up wandering through our days doing things fairly automatically and without really thinking about them, so any kind of trigger to ponder our activities can bring vital insight, learning and a fresh perspective from which we can, if we choose, allow our practice to evolve.
Passing on the knowledge
The second reason I love papers that tell me things I think I already know is because other people are also going to be able to read that information. I’m not saying that because I necessarily want to change anybody else’s practice today. (I don’t think that’s possible even if I did; we can only change ourselves.) But I am very passionate about ensuring that, in an age where the technocratic approach to birth dominates and there is less emphasis than I think there should be on valuing a more holistic approach to caring for childbearing women, good midwifery knowledge is recorded for future generations of women and midwives. As a perpetual optimist, I like to think that there will come a time when our daughters and sons will stand up and shout out a resounding ‘no’ to the over-medicalisation of birth. When that time comes, they’re going to need sources of wisdom in order not to have to reinvent the proverbial wheel.
A thorny midwifery problem
With that as an introduction, I’m now a tiny bit wary that the authors of the latest paper that I read and loved for the reasons above are going to think I’m saying that their findings are old hat, which is very much not the case. Reed et al (2016) have focused light on an eternally thorny problem, which I am confident that many TPM readers will be able to relate to, but their approach is insightful and new.
The problem is this: there are things that we, as midwives working in a modern world, are compelled to do to women in labour, such as listening to the baby’s heartbeat and assessing the woman’s progress. But, even if we are really focused on ensuring normality rather than looking for pathology, and even if we are really unobtrusive, careful, gentle and quiet, we know that these things can cause anxiety and distress to women.
‘Anderson found that assessments intended by midwives to confirm normality sometimes conveyed the message that there may be problems. For example, auscultating the foetal heart generated concern for some women about their baby’s wellbeing. This concern interfered with women’s ability to ‘let go’ during birth. The midwives in Blix’s study reported that their clinical assessments could disturb the labouring woman and interfere with the birth process. Leap suggests that midwives are trained to ‘do things’ to women during labour, including clinical assessments, soothing touch, and building rapport by talking. However, Leap argues that this well intentioned approach can interfere with the physiology of labour by disrupting the woman’s instinctive behaviours’ (Reed et al 2016: 2).
Reflecting on rituals
In this research, lead author and midwife Rachel Reed interviewed 10 midwives and 10 women (who had all experienced physiological, uncomplicated birth in a range of settings) about their experiences. All lived in South East Queensland, Australia, at the time of the study. The findings highlighted complex interactions between mothers and midwives, and the notion of rituals, which some readers may be familiar with from the work of Robbie Davis-Floyd (2003), is used to describe the words and actions that midwives enact when looking after women in labour.
One of the findings in this study that stood out for me was the identification of two different types of ritual:
‘Rites of passage were synergistic with women’s needs during birth and involved managing distractions and reflecting internal wisdom. Rites of protection involved performing clinical assessments to determine wellbeing and labour progress. These practices could contradict the rites of passage by disrupting aloneness and reinforcing external wisdom’ (Reed et al 2016: 1).
When you read such passages, as a midwife, the statements might seem really obvious. Yet such mysteries of midwifery are really not obvious to the outsider until researchers unpack what is going on. Even our textbooks rarely contain the kind of data that research studies like this one offer; hence the value of doing that unpacking and then writing it down.
The midwives whose voices can be heard in Reed et al’s (2016) paper describe rituals that will also seem everyday to many readers. They talk about how they create a dark, undisturbed environment for women, and how they ensure that women stay hydrated without disturbing their labour, by asking if they would like a drink every five minutes. The answer to the latter question, in case you are at the beginning of your midwifery career and haven’t learned it yet, is to simply offer the woman a drink, ideally with a straw in it so that she doesn’t have to hold the cup herself. If she drinks, then she wanted a drink. If she doesn’t drink, then she doesn’t want a drink. Don’t wait for a, ‘no thank you’. No language – and more importantly, no thinking – required. Simple? Yes. Clearly written down in places that student midwives can easily access? Not so much.
Both the midwives and mothers who were interviewed for this study saw certain examinations as defensive, invasive and having the potential to disturb labour. These included listening to the fetal heart and abdominal and vaginal examination. There is, the authors identified, a tension between the two different rites of passage that were described, and another valuable element of research papers like this one is that they give us language and tools with which to talk about and frame such tensions. The authors of this paper aren’t saying that they have the answers. But the fact that they have identified the questions and added to the perspectives from which we can discuss the issues is immensely helpful to those of us who want to reflect on our own practice and record the essentials of holistic midwifery for future generations.
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Davis-Floyd RE (2003). Birth as an American rite of passage, 2nd edition. Berkley: University of California Press.
Reed R, Rowe J and Barnes M (2016). ‘Midwifery practice during birth: ritual companionship’. Women and Birth, In press: doi:10.1016/j.wombi. 2015.12.003
This article was originally published as Wickham S (2016). The importance of everyday birth wisdom TPM 19(4):37/38.