Dear esteemed obstetric colleagues,
Before you write in and complain, please let me tell you that not only has this post been approved by some of my favourite obstetricians, it was actually commissioned and titled by one of them. It is dedicated with love to all obstetricians, but particularly those who seek to take a woman-centred approach and have removed the words ‘allow’, ‘patient’ and ‘trial of labour’ from their vocabulary, except perhaps for when they attend conferences and find themselves otherwise unable to communicate with their peers 😉
It is a truth universally acknowledged, that an obstetrician in possession of a scalpel must be in want of a holistic midwife to teach them woman-centred ways.
However little known the feelings or views of such an obstetrician may be on his or her first entering practice, this truth is so well fixed in the minds of the surrounding midwives, that s/he is considered as the rightful recipient of some – if not many – of their woman-centred values, primum non nocere viewpoint and ways of seeing birth as a normal, everyday event.
The power of the paradigm
Unless this is your first visit to this website – in which case, welcome – you’re probably aware that I often talk and write about the existence of two different paradigms (or sets of ideas) that exist in relation to maternity care. They’re often called ‘the obstetric approach’ and ‘the midwifery model’. Although I try never to mention them by these names without immediately adding the caveat that the names of these approaches relate to belief systems, not to people or professional groups. Because there are plenty of obstetricians who take a midwifery model approach, just as there are a good many midwives who are more closely aligned to the obstetric viewpoint. If you’re not already familiar with the differences between these models, this brief article explains them a bit further.
Many women value and want the ‘midwifery model approach’. It’s more inclusive of their knowledge and experience and sees pregnancy as a personal and usually healthy journey. The midwifery model approach is also supported by tons of evidence that it brings many benefits for women and babies. It places the woman firmly at the centre of her care and acknowledges her as the key decision-maker. The approach doesn’t reject technology and intervention where this is appropriate and the woman is happy to have it, but it is often respectful of non-Western approaches, ideas and therapies as well.
There are variations between different countries and areas, of course. And many midwives, doctors and others are already respectful and supportive of an evidence-based, woman-centred approach. They see enormous value in a model where midwives are the primary caregivers for women, with obstetricians being invited (if a woman wants this) to consult in situations which are not quite so normal or straightforward. There exists mutual respect between the two groups. Obstetricians are respectful of midwives’ knowledge, of their ability to determine when things are fine and normal and when a bit of help (of whatever kind) might be needed. Midwives in such settings are equally respectful of the obstetrician’s experience in dealing with less straightforward situations and of their surgical and medical skills which are sometimes the best pathway to a good outcome.
Yet in other areas women and midwives struggle to get their obstetric and other medical colleagues to see the value in this kind of approach. So this article offers a few suggestions from my own experience of how we – as midwives, birth workers, women and families who are trying to facilitate a greater uptake of this evidence-based, woman-centred model – can help facilitate the journey of those who have come from an obstetric paradigm background and who want to be more woman-centred (even though they may not know it yet 😉 )
Because I have quite a lot to say on this topic, I’m dividing this piece into two parts. In this first part, I am going to suggest that the first step is about understanding why people think, believe and do what they do, and then in the second part of this article I will look at how and why people come to reconsider and change their approach, and what we can do if we want to help facilitate reflection and change.
Understanding where medical-model focused people are coming from … and how they got there.
I don’t mean to suggest that everyone has been on the same journey. Far from it. So this needs to be individualised, but there are some key elements of our culture in general and of medical (and sometimes midwifery) education in particular which predispose people to taking a medicalised, technocratic approach to birth.
If you’re reading this as someone who has been part of ‘the birth world’ for quite some time, it is easy to lose track of how birth is viewed and portrayed outside of such networks. Turn on daytime TV for even just a few minutes (but only if you think you can handle it – I did just that the other day when I was unwell – big mistake!) and you’ll encounter all sorts of fear-based views about birth. These views are often in complete opposition to what we know from the evidence. So many people are affected by the mainstream Western cultural viewpoint – and the idea that birth is risky – before they even go into medical or midwifery education. It is, then, unsurprising that this notion carries on as a core element of many people’s belief systems.
The educational journeys of midwives, doulas and childbirth educators often include significant opportunity to unpack one’s own pre-existing cultural biases. And to reflect on situations experienced in practice as well as consider a wide variety of ideas and approaches. However, with the caveat that some innovative and exceptional courses are beginning to be offered by some medical schools, this is not generally the case in medical education.
And let’s not forget that our culture promotes the notions of doing over being, action over reflection and pharmacological pain relief over psychophysiological care and support…
The process of medical education itself may also have a significant part to play in informing the belief systems and priorities of practitioners. I don’t really need to write much about this – although it is a huge issue – because Robbie Davis-Floyd wrote a really interesting paper called ‘Obstetric Training as a Rite of Passage‘. She analysed the words and experiences of obstetricians, showing how the very nature of medical education has an effect on the way in which they thought about and saw the world. If you’re interested in this question and not already familiar with this work, I thoroughly recommend you go off and read that paper in full. It can really help to illustrate why people who go through different kinds of educational processes end up with different kinds of belief systems.
‘In the first two years of medical school, pressures of threat and uncertainty mount. A competitive emphasis on grades and tests, the unpredictability of pop quizzes, the overwhelming bulk of the work at hand, and the increasing isolation of the initiates – all combine to narrow the initiates’ range of cognitive functioning. In this process medical students do not become less intelligent; rather, the span of their intellectual capacities and concerns becomes constrained. A kind of tunnel vision develops: the cognitive overload which first- and second-year medical students experience forces them to focus only on what is immediately in front of them. Progressively less capable of reflexivity (Babcock 1980) and the conceptual distance from the socialization process which would accompany it, students gradually lose sight of the idealistic goals they may have had on entering medical school. If the rite of passage is successful, the new goals medical students eventually develop will be structured in accordance with the technological and scientific values of the dominant medical system. The emotional impact of this cognitive retrogression is aptly summarized by a former resident:
Most of us went into medical school with pretty humanitarian ideals. I know I did. But the whole process of medical education makes you inhuman….I’ve seen people devastated when they didn’t know an answer…. The whole thing can get you pretty warped. I think that’s where the feelings begin that somebody owes you something, ’cause you really, you know, you’ve blocked out a good part of your life. People lost boyfriends and girlfriends, fiancees and marriages. There were a couple of attempted suicides….So you forget about the rest of life. And so by the time you get to residency, you end up not caring about anything beyond the latest techniques you can master and how sophisticated the tests are that you can perform.’
Then, we need to look at the expectations that people have of doctors (and other professionals) these days, which are often – perhaps partly because of the erroneous ideas perpetuated by modern culture and the mass media – unrealistic. There are no guarantees, and yet that is exactly what some people want and expect doctors to provide. People who specialise in the abnormal are only ever really going to see that, and so it becomes harder and harder to remember that normal really does exist. Which explains why some people have such a hard time trusting women’s bodies, taking a woman-centred approach or feeling able to wait. In addition, some people don’t want to make their own health-care decisions (although of course many do) and the weight of expectation (and let’s not forget litigation) that some professionals feel can create immense pressure to perform. Along with an almost unbearable sense of responsibility. Add in the pressure placed upon people by the systems of care, budgets and other frameworks within which many are working, and I think it becomes easier to understand why some people end up taking an approach that seemingly ignores the individual and prioritises routine intervention.
There is little doubt in my mind that the best way to address much of this is to do so at a systemic level. Just being nicer to each other is a lovely idea, but it isn’t going to address the political, economic and socio-cultural impact of decades of medical model dominance. But while we await (or perhaps plan?) a system-level revolution, there are a few things that we can do in our relationships with those colleagues whose clients wish they would be a bit more open to their needs and to the ability of their bodies to birth without needing to be strapped to a monitor and held to the clock.
I am going to draw upon some of these ideas and share a few suggestions from my own and others’ experience of working with medical, midwifery or other colleagues who were actually Midwives in Disguise but just didn’t know it when they met us
1. Understand where colleagues are coming from.
The first part of this blog post is very generalised and everybody’s experience will be different. If you want to help facilitate someone’s journey to being a more woman-centred practitioner, get to know them and make it your mission to understand why they might not be taking that approach now. Not because that’s the best way to work out how to sell your idea (though I do believe from watching The Apprentice that it might be). But because it is genuinely interesting and hugely valuable to understand people and their journeys. And because, if we are truly espousing a people-centred approach, then we need to listen just as hard to proponents of the medical model and hear their voices too.
If we don’t ask about and genuinely listen to colleagues’ stories, how can we expect them to ask about and genuinely listen to women?
The richness of the experiences that I have had talking to women and holistically-focused colleagues about their birth journeys is matched only by the richness of the experiences that I have had talking to more medically-focused colleagues about theirs. One example that I have permission to share is that of a medical colleague who grew up in Africa and decided to train after watching his grandmother serve as the local midwife. It turned out that he was very keen to see the intervention rate lower in the hospital that we both worked at. But he felt forever thwarted because the midwives kept asking him to get involved. He taught me something very early on in my career that has remained with me ever since.
2. When you discuss a woman’s care with a colleague, be clear about what you are saying.
My (at the time) obstetric registrar friend pointed out that midwives would sometimes call him in because they felt they had to. For instance because a woman’s labour had exceeded the so-called normal time limits. Often, in situations where they really didn’t feel that intervention was warranted.
They would tell him how things were going and, as he saw it, they often sounded a bit unsure about what they wanted. They would make the conversation open-ended, leaving the decision to him.
“Why ask me and then be upset because I intervene or impose a plan they don’t want?!”, he would say, in his booming voice. “It’s my job to interfere! If you bring me what looks like a problem and make it my responsibility, then I have to step in and do what I know to solve that problem. If all is well and you are telling me out of courtesy, then tell me that and be confident, and keep responsibility! Then I will be confident too. And I can drink coke in the staff room while you rub her back, because you don’t need me to do that. But if you ask me to take responsibility, then I have to do that, and you might not like my decision.”
That obstetrician remains one of my favourite colleagues ever. And, over the years I have passed his words of wisdom on to many, many midwives. He taught me the importance of being very clear about roles and responsibilities and in what I was thinking and saying in my conversations with colleagues.
He also helped me understand how, if you take ‘what looks like a problem’ to somebody ‘and ask them to take responsibility’, then they may well interpret that as you saying that you think intervention is required. Even if that is not at all what you are saying.
I have since talked to many people who have appeared to be very medical-model focused but who, when we sat down and really talked, weren’t at all. In some cases they didn’t feel they had the support of their colleagues, or they felt that people were concerned about a situation and trying to pass responsibility on to them and so they (actually quite understandably) chose to act rather than trust.
3. Ponder and invite reflection upon critical events.
Over the years, I have known many people in many fields whose practice has been strongly influenced – for better or worse, though who are we to judge what is good or bad – by just one or two significant experiences. Often, those experiences were particularly emotionally traumatic.
Like the midwife who was very pro home birth, but only as long as women had a scan. She had once seen a woman have an APH at home because of placenta praevia.
This is arguably even more likely with obstetricians, who are pretty much always going to be present when a woman’s experience is particularly dramatic, traumatic or eventful.
“One emotionally experienced “disaster” can influence the beliefs and behavior of an obstetrician far more profoundly and powerfully than hundreds of normal deliveries. This single phenomenon goes a long way toward explaining why obstetricians cling so tenaciously to the birth rituals that have been consistently presented to them as the only means of preventing those disasters.” Robbie Davis-Floyd.
Again, midwives and birth workers are far more likely to get the opportunity to reflect on this kind of scenario than our obstetric colleagues, and they are also (in my humble experience) more likely to be offered emotional support, which is why we also need to follow my next step.
4. Hug obstetricians.
Many midwives work in environments where they get to hug each other – and sometimes women and babies – pretty much whenever they need to. Obstetricians don’t always get hugs. And – perhaps even more importantly – doctors don’t always get as much emotional support when things go wrong. In some cultures, medical staff are expected to ‘man up’, get out the stiff upper lip and not display any emotion. Male or female. But it doesn’t hurt any less to have a bad day or a bad outcome just because you have a different kind of degree. We need to create spaces where all staff can safely ask and receive emotional support, hugs and TLC as and when they need it.
5. Invite obstetricians to see normal.
As I said in the first part of this post, if you only get involved when things go wrong, you can get used to the idea that birth is abnormal and risky. It is then very hard to remember that, in most cases, it all goes really well as long as we don’t interfere. Which means we need to find ways of enabling prospective proponents of the midwifery model to experience what we experience. When I said on social media that I would consider letting a handful of my obstetrician friends come and sit on the sofa and knit (in order to keep their hands busy) during my home birth, I was only half joking.
It is, in my humble opinion, unreasonable and unrealistic to expect professionals to support something that they don’t have experience of themselves.
If we want certain colleagues to be more accepting of holistic midwifery care, then we may need (with women’s permission, of course) to help them see what that looks like. And we all know that updating is important too, so they may need a refresher every now and again!
I totally understand why some midwives want to bar the door, and we absolutely need to make sure that we only think about this with women who are OK with it (and with colleagues who will be respectful of the environment) but I think this is an important one to think about. If nothing else, we should be offering loans of videos and sharing useful pictures, memes and infographs (with credit to the originator, of course).
And it’s not just about birth. Invite medically-focused colleagues to childbirth education groups. To coffee mornings, to breastfeeding sit-ins, to anywhere else where there are healthy, pregnant women who can help put the amount of abnormality they see in their work into perspective and serve as a reminder that birth works really, really well and is better left alone in the majority of cases. And, frankly, where they can also hear women tell stories of the way they feel about the care and treatment they are receiving.
6. Invite obstetricians on dates.
OK, maybe not in a romantic way (unless that’s your thing). The kind of dates I mean are those that might also help more medically-minded colleagues to experience midwifery model thinking and being. Yes, you may have to judge this carefully, but you might invite them to come and see the latest birth-related film with you and your colleagues. Or, when you meet people who are a bit further along on their journey, to a workshop or midwifery conference.
Pick the sessions / workshops carefully. Your colleague may be more receptive if you can find them someone who is very evidence-based, or who shares some of their views. Or whose approach / humour / dress sense you think they will appreciate.
Encourage them to join you for dinner before or afterwards. Or, if it’s an overnight event, to hang out at the bar. Consider including them in the pyjama parties and the storytelling circles.
I am stressing this for two reasons. I personally know several obstetricians for whom this has really helped them better understand the midwifery model, and I also have obstetrician friends who are on a journey and who struggle because they no longer fit in to their medical world, yet they don’t always feel they belong in the midwifery world either. If we want more people to join (and stay in) our world, we need to make space for them in it.
7. Understand the power of personal experience.
Finally, and even though I talked a bit about this above, I want to share one more thing from Robbie Davis-Floyd‘s work in this area.
Robbie also co-authored a book called ‘From Doctor to Healer: The Transformative Journey‘, in which she analysed the experiences of doctors who had come to reject the medical model approach and embrace a more holistic, people-centred way of being. The single biggest message which I took from that book is that, in most cases, what changed these practitioners’ perspective wasn’t a rational analysis of the research, or even a long-term relationship with a low-tech midwifery unit with the chance to attend normal births, but a one-off emotionally-based experience which got their attention and caused them to re-think their worldview. Maybe it was the experience of being at one birth, or hearing one sentence spoken at a conference. Alison Barrett writes about this, and please read her article #notallobstetricians, because she also writes about several other really important elements of this discussion that I’ve not had the time to go into here.
We can’t know what the trigger will be for a particular person, and it may be that these one-off experiences only make such a difference because they are part of a bigger journey, but what I take from this is that all of the things I have suggested above – which all expose our colleagues to fundamental elements of the midwifery model itself – will make it more likely that others will be able to see what it is that we see in this approach and why it is so valued by and important for women.