How do midwives support women in bureaucratic health care systems?

How do midwives support women in bureaucratic health care systems? The past few years have seen some less than accurate depictions of midwives and midwifery practice so I was heartened to see the publication of a study that I chose to highlight in my Birth Information Update.

The title offers a great summary of the study’s aim: “Understanding how midwives employed by the National Health Service facilitate women’s alternative birthing choices: Findings from a feminist pragmatist study.” In this study, Feeley et al (2020) “explored how NHS midwives facilitated women’s alternative physiological birthing choices–defined in this study as ‘birth choices that go outside of local/national maternity guidelines or when women decline recommended treatment or carein the pursuit of a physiological birth’.

Supporting women’s decisions

Contrary to what one might read on some social media sites, many NHS midwives are not in agreement with over-medicalised care and are keen to support women who wish to make choices that are outwith local or national guidelines.

“These choices included healthy women declining routine maternity care practices such as labour induction after 41 weeks’ gestation, or vaginal examinations to assess the progress of labour or fetal monitoring during labour. Other situations include women with medical/obstetric risk-factors who sought midwifery-led care (e.g. declining continuous electronic monitoring or induction of labour) and/or non-obstetric settings (home or birth centres).” Feeley et al (2020).


How do midwives help?

The researchers who undertook this study talked to some of those midwives to find out how they facilitate women’s choices, especially in a bureaucratic system which isn’t set up to focus on the needs of the individual woman and family. As the authors note:

“A primary component of relationship-building was communication, specifically to understand the woman’s ‘viewpointher history and her ethos around birth’ [Jenny]. This was referred to as ‘listening to their story and seeing how they have got to the point they are at’ [Rachel, Claire]-also illustrated by Becky:

‘…I think is important is being able to get alongside the woman essentially and to be able to start to understand where she is coming fromAnd I think there are so many cases where women want to make choices it is really important to understand why they want to make those choicesand why it is they feel that is the best choice for them…’ (I)

Some of the midwives used phrases such as ‘really listening to her’ [Rachel], depicting the importance of active and authentic listening so women felt heard, a subtle nuance articulated by Edna:

‘…it really boils down to women feeling listened toI really believe that (.) you knowlisten to themlisten but don’t just listenhear what they’re saying you know? (I)” Feeley et al (2020)


Support, negotiation and tensions

The paper goes on to describe how midwives convey their support to women and families, how negotiation can occur, and the importance of care planning in documenting conversations and plans. The research also demonstrates the lengths that midwives go to in order to communicate with the wider team and to balancing the tensions that inevitably arise.

Is the care going to be as personalised and holistic as that which a woman and family could get from an independent midwife or outside of a health care system? Probably not; this is a system after all, and there is only so much that individuals can do, especially where they are only one part of a wider team. Especially when the framework, the language, the concepts that underpin care are technocratic and patriarchal. But the reality is that the vast majority of women still give birth within systems of maternity care. And this paper shows how midwives are trying to individualise the care given to the needs, hopes and desires of each woman and family.

Pondering generalisations…

This paper made me reflect about the polarisation that is increasingly a feature of our world, and a factor in many different conversations. It also made me ponder how often I hear generalisations being made about groups, such as midwives. Again, Feeley et al (2020) confirm that, “not all maternity professionals are offering full information based upon women’s wants/needs.” But their paper describes the “‘willingness’ [of the participating midwives” to engage with women making these choices.” 

I often find myself talking about this issue in our online courses, noting that this is a complex and nuanced situation, and suggesting that generalisations about particular professional or occupational groups are really unhelpful. That’s because there can be such a range of viewpoints and approaches among any group of people who have just one thing in common, such as their job or qualification. It is also the case that, as with many situations that we face today, the patriarchal economic and political structures that underpin our culture and influence professional practice and institutions like the maternity services are more frequently the problem than are individual practitioners. So I welcome this paper, which is freely available and I recommend it (and, actually, many of the papers it references) for anyone wanting to engage more deeply with such issues.


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Feeley C, Thomson G, Downe S (2020). Understanding how midwives employed by the National Health Service facilitate women’s alternative birthing choices: Findings from a feminist pragmatist study. Plos One.