Evidence that place of birth influences midwifery practice is discussed by Suzanne Miller. In this post, originally published in Birthspirit Midwifery Journal 2009; 1: 7-11, Suzanne introduced her own Masters research which examined similarities and differences in practice of a single group of self-employed midwives in New Zealand.
The shaping of midwifery practice is influenced by a number of things, not least of which is the woman’s chosen place of birth. Isolating the effects of place of birth is achieved more easily in the Aotearoa/New Zealand context, because midwives here follow the woman to her chosen birth place and not vice versa. As background to a recent research project, I explored some studies which focused on how midwives say their practice is altered (or not) by the birth setting they find themselves in. Some midwives who have been asked to describe aspects of their practice in different settings have suggested that they feel more relaxed and are able to establish an “easier interaction” with women when providing intrapartum care at home van Der Hulst (1999). Others have said that they prefer providing care in a hospital setting because they feel safer, because they’re used to being there Davis (2006), suggesting that familiarity with the birth setting is as important for the midwife as it is for the woman.
It seems that most midwives are able to describe ways in which their practice differs according to the birth setting. In a Dutch study van Der Hulst (1999), which surveyed midwives about behaviours which shaped relational care in labour, each of the 99 midwives who participated felt that their care was influenced by the birth setting, though the extent to which this influence was present was different amongst midwives. Relational care (aspects of care which facilitate the natural birth process such as communication and other activities which establish a relationship of trust between the woman and her midwife) was focused on separately from obstetric-technical care (activities such as performing examinations and procedures). She found that there were no differences with respect to obstetric-technical care apart from that midwives adopted a stricter selection process for women planning to give birth at home.
In contrast to this, several differences were found with respect to how midwives provided relational care. When attending homebirths, midwives reported spending more time with women in labour, and visiting more often during the dilation phase. They felt more sense of commitment to the woman, and involved the woman and her partner more in tasks which needed to be done, which van Der Hulst (1999) believed reflects as much the fact that the woman is in her own territory, as the philosophy that the birth process is a normal human experience. She notes that both these things empower the woman’s sense of control in the birth experience.
When providing care in the hospital, the midwives were more likely to sleep(!), be less patient and carry out more of their own tasks. They felt their approach was more efficient, they spent less time with the labouring woman, and they adopted a more formal attitude toward their clients. van Der Hulst (1999) suggests that when practising in hospital, midwives are often confronted with organisational structures and rules which are absent at home and therefore may feel more like they are guests in the hospital, just like their clients.
Different ideas about how the birth setting influences the behaviour of midwives were uncovered by Hunter (2000) in her exploration of how New Zealand midwives perceived differences in their care provision between a small primary maternity unit and a large obstetric hospital. She found that midwives felt more autonomous practising within the small maternity unit, and that they believed they were freer to practice what they called “real midwifery” along with having a greater acceptance of “carrying the can” (p.121). This coupling of autonomy and accountability was seen as one of the key differences between providing intrapartum care between these two settings.
The midwives in her study unanimously preferred providing care in the small unit, despite having experienced emergency situations there. This arose out of their belief that in most cases the outcome would be good, and their belief in their ability to foresee problems and anticipate their effective management. Linked to the notion of foresight is that time in itself may play an important role in women’s intrapartum experiences. The need to transfer out of the small unit if problems arose meant that judgements needed to be made about when the appropriate time to do that was. Time seemed to have different meanings within different contexts, with midwives feeling constrained by the clock and by obstetric definitions of what constitutes acceptable progress at work within the larger hospital.
In a conference paper based on her PhD research examining the culture of midwifery practice in different birth environments, Griffith (1996) suggested that midwives experience a “degree of dissonance as they try to establish congruence between their espoused beliefs and the reality of practice imposed by their work environment” (p. 357). She described her findings not in relation to the birth setting per se (i.e. home or hospital) but around a spectrum based on the degree of medicalisation evident within different care contexts. As the degree of medicalisation decreased, so too did the pervasive nature of the medico-technical focus on care provision. Midwives were more and more able to negotiate defined parameters of safety, and departures from medical protocols were more likely to be tolerated in less-medicalised settings. At the midwifery model end of the spectrum, medical ideas provided a background reference only and there was a recognition that the “ideology of technology was occasionally appropriate and useful” (p. 361), rather than that it defined and determined how care was provided.
Griffith (1996) described how in highly medicalised environments, medical texts and written protocols were considered the ultimate authority, and departures from the protocols were seen as a serious breach of the rules. In the least medicalised environments however, midwives believed that “much of the knowledge that is required for a ‘successful’ birth experience is located in the woman at both conscious and unconscious levels” (p. 364). Thus if women are supported in their choices, these midwives felt that women were more likely to achieve a successful outcome (on the woman’s own terms) and were less likely to experience medical intervention as a result.
The birth environment was also an important determinant of the visibility of midwifery practice in Griffith’s study. She noted that in a very medicalised environment, what was visible, valued and admired in relation to midwifery practice was the ability to use and interpret obstetric technology, inform the doctor and assist competently with the ensuing obstetric tasks. Midwives’ experiential knowledge was invisible in this context and midwives felt deskilled. As medicalisation decreased, midwives’ experiential knowledge became more visible and valued and midwives focused more and more on the centrality of the woman, and less and less on their own active birth skills and knowledge, seeing them as tools only, occasionally useful as an adjunct to their “way of being” as a midwife (p. 365), which was mostly framed around presence and holistic support of the woman.
One of the ways that midwives find themselves seeking to decrease the influence of medicine when caring for women in labour is to be creative with the level of disclosure of what is occurring for the women. Griffith calls this “cheating” (p. 365), and others have applied different terms to it, “obstructing the obstetric gaze” Davis (2006) and ‘misrepresentation’ are but a couple. What these words and phrases are describing are ways in which midwives seek to protect women in labour from medical interventions by obscuring the reality of what is happening. They may do this by action or omission. For example, they may understate the findings of a vaginal examination in order that medically-defined time constraints on labour progress can be achieved. They may decide not to document a particular finding such as full dilatation. An interesting finding in Griffith’s (1996) study was that midwives practising in home settings were much less likely to engage in these tactics, even in transfer situations where they might be assumed to want to protect themselves from judgement or censure for departing from medical definitions of normalcy. This provides a good fit with Hunter’s (2000) discovery of practising ‘real midwifery’ entailing a greater sense of ‘carrying the can’, but also describes the evolution of midwifery practice away from notions of ‘being seen to be good’, and towards honouring midwifery knowledge and ‘telling it like it is’. We cannot hope to demonstrate that a ‘long’ birthing phase once a woman is fully dilated is safe unless we are honest about when we believe it began. We can be clear also about whether a ‘diagnosis’ of ‘second stage’ has been made by observation of a woman’s sounds, movement and behaviour or a vaginal examination.
The provision of a humanistic approach to care was described by Freeman et al (2006), whereby technology was used alongside relationship-centred care. Their study of 104 New Zealand midwives found that the labour care setting did influence practice, identifying that practice was dominated by the medical model of care in an obstetric hospital. Despite this, they concluded that the midwives’ decisions were influenced by the needs of the women rather than the obstetric protocols.
Hunter’s (2000) assertion that midwives’ use of the self is a powerful tool in keeping birth normal by letting labour ‘be’, is echoed in Harris’ (2000) exploration of why midwives practising in homebirth settings pursue their practice even in the face of political and sometimes social opposition. She also discusses how midwives feel that assisting women at home is an easier way to practice their role satisfactorily, because of the belief in continuity of care and enjoyment of the partnership achieved with women. She suggests that it is easier for midwives to incorporate alternative therapies into practice at home, and that this may be a positive contributory factor in the achievement of normal birth.
Midwives’ use of birthing spaces is another area where differences in practice can be identified. As Davis (2006) describes, at home the birthing space is often already prepared by the time the midwife arrives, although she may add some furniture in the bringing of a birthing stool, or pool. The woman is free to roam at will, utilising a number of spaces within her home to be with others, or alone as her need dictates. The midwife will set up her equipment as unobtrusively as possible, to have at hand as necessary, but not to convey a message about risk or safety. In a hospital birthing space it is much more usual to find the bed as the focal point in the room. Because the woman has only one room, she is constantly scrutinised by those who are with her, which she may or may not want, but over which she has little control. Davis sees the obstetric hospital as a:
“…technology of biomedicine, as the design, furniture, equipment and culture presumes … a passive maternal body that is inscribed as a site of risk. Midwives and women are disciplined in this place, as the technologies of biomedicine attempt to bring their behaviour, choices and midwifery practices in line with obstetric norms” (p. 10).
Midwives will sometimes attempt to mitigate these effects by manipulating the physical environment on arrival at the hospital. The bed may be pushed aside to enable the woman to adopt alternative positions on a mattress on the floor. Lighting may be dimmed, and some equipment removed or hidden. But for the woman and her family there is still a clear message that technology is ready and waiting to be deployed. More recently a type of ‘hybrid’ birthing space has emerged in response to women’s requests for more ‘homely’ environments within institutions Hodnett et al (2006). While attention is paid to ambience in the form of soothing colours, mood lighting and soft furnishings, it is interesting to note as Davis (2006) does, that it is the bedroom which is deemed to be the appropriate room to replicate within the hospital, rather than the living room or bathroom which are the rooms where, at home, more babies are born. Indeed in my own practice I can recall only one instance in eighteen years of a baby actually being born on the bed when it was born at home.
Davis (2006) argues that the ‘obstetric gaze’ is all-pervasive and follows midwives wherever they are practising, expressed as midwives’ fear of litigation and their need to ‘be seen to be good’. This can give rise to other ways in which practice is modified according to the setting. It can be seen in the way midwives document a woman’s labour journey, the idea that if it isn’t written, it didn’t happen. So women’s birthing stories, as told in hospital, unfold in fifteen minute intervals, and despite that this may interfere with a midwife’s ability to ‘be with’ the woman, it is seen as an important protective activity.
So the ways in which midwives have identified differences in practice between birth settings tend to be related more to aspects to do with environment, than to do with assessment and monitoring of the labouring woman. Midwives do not appear to do more or less vaginal examinations, or listen more or less frequently to the baby’s heartbeat in labour van Der Hulst (1999). They say they are more able to allow time, and yet paradoxically are very mindful of time when foresight is required in out-of-hospital birth settings Hunter (2000). They say that hospital protocols are influential in determining their practice, yet are able to stand in their space as midwives and be accountable for stepping outside the protocols when they are satisfied that both the woman and baby are safe Freeman et al (2006).
My own research Miller (2008) (as yet unpublished) asked a small group of midwives who practice in both home and secondary/tertiary hospital settings to describe ways in which their practice was similar and different in each birth setting. Their ideas were very resonant with those already discussed, particularly in relation to their use of time and space. These midwives felt that when they were able to ‘allow’ more time for labour events to unfold, which they found easier to achieve in a home setting, much less intervention occurred in the women’s labours. In contrast they believed that intervention rates were higher when women gave birth in hospital, where time was ‘restricted’ by protocols or guidelines operating within the unit. They felt also that consultation with obstetric staff occurred more frequently when women gave birth in hospital, in association with the sense of ‘restriction’ of time.
With respect to other aspects of care, these midwives reported providing similar care in either setting. When assisting women to work with the powerful sensations of labour, they said they offered the same support in hospital as they did at home. This would most commonly begin with the use of water immersion, massage, homeopathy or acupuncture. They all agreed that they did not offer pharmacological pain management techniques but would comply with a clear request from the woman for them.
The midwives’ discussion was followed up with a national survey in which the labour experiences of over two hundred first-time mothers were compared according to whether they planned to give birth at home (109 women) or in hospital (116 women). All the mothers were cared for by the same midwives, so that differences in practitioner ‘style’ could be controlled for as far as possible. The survey data revealed that the differences in practice that the midwives had identified in each setting were reflected in statistically significant differences in the labour and birth outcomes of the two groups of women. For example, among women who experienced a pushing phase of labour over two hours, in the planned homebirth group 92% achieved a spontaneous birth, compared with only 59% of those in the planned hospital birth group. The other 41% in this group had either a forceps or ventouse birth. This illustrates how when midwives are not constrained by medical ideas about how much time to ‘allow’ for second stage, better outcomes can be achieved, with no compromise to women or their babies.
Differences in the use of space revealed that at home 5% of the babies were born on a bed, and in hospital the figure was 57%. At home only one in five babies were born in the bedroom, which calls into question the persistence of the bed being the focal piece of furniture in a birthspace. The most compelling difference in midwifery practice centres around the consultation practices of midwives. In the home group 16% of women had a consultation in labour with a medical colleague. This figure was 45% in the hospital group. Intrinsically connected to this, 95% of the women in the home group achieved a spontaneous birth, compared with 79% in the hospital group.
The results of this study (only a few examples of which are presented here) provide some evidence that the behaviour of midwives is shaped by the birth place choices of the women in their care, and sit alongside the findings of the previously mentioned studies in relation to this. When women and their families are making choices about where to give birth, we can encourage them to explore these ideas about how their choice can ultimately influence what happens for them in labour. It would seem that not only the behaviour of women is influenced by the birth setting, but that midwives are strongly influenced also by the birthing culture present in different birth spaces.