Meg Taylor is a radical midwife (retired)…
In 1999 she wrote an article for the AIMS (Association for Improvements in the Maternity Services) journal: The Death of Midwifery? – It May Be Closer Than You Think and in 2000 she wrote Is Midwifery Dying? for ARM (Association of Radical Midwives). This post is a look at both of those articles since they are, as their titles suggest, very closely related.
Taylor refers in her writing to the medicalisation of childbirth, which had become so extremely doctor-centred that even the government agreed that something had to be done. In Is Midwifery Dying? she describes the situation in the 1970s:
The NHS reorganisation of 1974 brought domiciliary midwives under the authority of the NHS hierarchy rather than local authority bureaucracy and they thereby lost authority and autonomy: the Peel Report had advocated 100% hospitalisation of birth; technological advances in obstetrics, most notably the reliable administration of artificial oxytocin by intravenous infusion, meant that women’s bodies were being manipulated to suit the timetables of their care-givers.
Within hospitals through-shaves and enemas were unquestioned routines, episiotomy was recommended for all primigravidas and any woman who’d had a previous episiotomy, birth took place in the lithotomy position, babies were routinely kept in nurseries, breast feeding was scheduled four hourly for restricted lengths of time according to the age of the baby, and breastfed babies were bottle fed by staff without the mother’s knowledge or consent.
In 1993, the government produced an agenda for change, “Changing Childbirth”, which was to create a woman-centred approach with midwife-led care and continuity of care.
This agenda had some successes, because things did improve at least on the surface. However, according to Taylor, the underlying problem stayed the same (this is from The Death of Midwifery?):
There is a hierarchy of power, now as ever, in which the obstetricians come top and the women come bottom. Midwives exist painfully in between. Some are woman-centred. Some are obstetrician centred. Some are burnt out. It is difficult to state this, precisely because Changing Childbirth has happened. According to the authorities the structures for the implementation of woman-centred care should be in place, and if they are not it is because the idea must be unworkable. Changing Childbirth was set up to fail, and it did. It is my theory that the Tory government wanted midwives to undermine the medical profession, as part of their ideology of undermining all professions where the prime motive was care of people rather than the marketplace. It didn’t work like that.
Midwifery has been undermined and obstetricians have co-opted the language of choice. We have seen this in the caesarean-sections-on-demand movement. Obstetricians sometimes save lives, this is undoubted. But their scope of practice has become too wide, they have medicalised normal childbirth to the point that it scarcely exists, certainly in hospital. Locally, when discussions were occurring about the implementation of Changing Childbirth, it was decided that midwife led care was only appropriate for 15% of women. In other words the bodies of only 15% of women in our area are considered capable of giving birth without medical intervention.
I wonder whether the continuing medicalisation of the normal has a punitive element: if midwife-led, woman-centred care ceases to be an aberration provided by independent midwives for a mad, middle-class minority, but becomes incorporated in the structures of the NHS, it is dangerous because it implies a fundamental change in the power balance between professionals and all clients. But maybe also these midwives are just getting too uppity and need to learn their place. Maybe the continuation of over-medicalisation in contradiction of all evidence is a response to the threat Changing Childbirth, if implemented fully, posed realistically to doctors’ power in childbirth.
It is my perception that Changing Childbirth itself led to midwives’ demoralisation. There are midwives who, for their own defensive reasons, do not want to work in a woman-centred way. And there are midwives who are desperate to do so and who found themselves working in a piecemeal situation where projects started without any strategic plan and with very little resourcing, and none to support their continuation if they were found to be effective. Caring midwives were frustrated that they could not take advantage of this opportunity for the benefit of women.
And it is this frustration which is part of the death of midwifery. Caring midwives, midwives who want to adopt a woman-centred approach, are in despair. They are in despair because, now that “Changing Childbirth has happened” they are no longer allowed to complain, because they have already had their way. They are in despair because they are totally unable to provide the one-to-one continuity of care that true midwifery demands, due to staff shortages that are not even acknowledged. Meanwhile, interventions continue to be normal and Caesarian rates increase.
The chronic is less sexy than the acute…the midwife who sits for hours with a woman in labour seems to be dispensable. The doctor who, excitingly, intervenes surgically is not. Yet surgery might be prevented with good emotional care. And instead of providing more midwives and such care, which costs money obviously in the short term (although it probably saves money overall by cutting down morbidity) the nature of surgical intervention is redefined so that it becomes the norm.
Taylor paints a bleak picture, making more points than the few I have picked out to highlight in this post. She argues convincingly that the struggle to reclaim childbirth as the province of women is all but a lost cause. The power dynamics, the mindset, the economics all militate against reclaiming total, holistic care for labouring women; and promote instead the continuation of fragmented, emotionless and inadequate treatment.
As Taylor says in my favourite sentence of all: The institution is like an organic entity which compensates for change almost homeostatically in order to protect itself and its defensive structures. (Yes, I had to look up “homeostatically” as well. It refers to an organism that has self-stablising / self-defence mechanims to render it unchanging and unchangeable.)
My own experience of childbirth was, thankfully, better than this.
But still the care I received was fragmented, occasionally even brusque. Post-natal care was at a bare minimum. The emotional support I did receive was, as a result, less than empowering.
I never felt empowered in labour because, as often as the midwives and antenatal teachers told me I had choices, I never really felt it to be true. For example, although I remember clearly that my waters were broken by ARM (contrary to the preference expressed in my birth plan), I have no memory of choosing to have them broken. I don’t doubt that I gave consent – such as a woman in the transtitional stage of labour can give, anyway – but I’m very sure that it wasn’t a considered, informed consent. More of a “Shall I do your waters while I’m in there?” – “OK, yes, whatever” kind of thing. And that was in a midwife-led birth unit, where my experience generally was very positive – compared, at least, with the stories recounted by friends.
Meg Taylor has a great deal to say that is worth hearing. To get the full benefit, read her articles, not my edited highlights.