Families, midwives and social policy: In search of the secret agents

Anne Matthews,

Professor P Anne Scott

School of Nursing, DCU

Outline of presentationSetting the scene(s)

Locating childbirth and midwifery within social policy Models of childbirth

Rediscovering midwifery What is a midwife? Midwives as advocates? Midwives as partners?

Midwifery in Ireland Context of current situation for midwives Research findings (Scott et al 2003, DCU)

The proposal of a model of empowerment in midwifery

Discussion: Achieving empowerment in midwifery

Families (with/without children), midwives and social policy?

An unlikely juxtaposition? Not so unlikely if childbirth is seen as a family and a social

concern rather than an individual/private concern (or to a midwife whose academic study has been of social policy!)

Natural if childbirth and midwifery issues are situated within a social policy context

The context which will be outlined is unarticulated “maternity policy/ies” invisible within social

policy midwives invisible within maternity policy thus midwives are invisible (secret?!) and often unwitting

(unwilling?!) agents of social policy

Midwives as secret agents?

Social policies Families

Midwives

“Maternity policies”?

Health policies

Social welfare

Models of childbirth

Social model Sees birth as a natural, (rather than medical), holistic,

woman-centred event Sees birth as a social/public health/family issue Involves community-based and accessible maternity

servicesMedical model

Childbirth as a medical event, normal only in retrospect, risk-laden

hence active management is logical- to get it over with- Postemotional birth- the mcdonaldisation of maternity services (after Herdman 2004)

What is a midwife?

A midwife is someone who is “with woman”- with “women”, with “birthing women”- their babies, families

WHO (1997): midwives are the most appropriate and cost-effective caregivers in normal pregnancy and birth (skills and attitudes)- “guardians of normal birth”

Midwives as advocates? Widespread acceptance that midwives have an

advocacy role- individual and social level- but in practice?

Midwives as partners? literature challenges whether partnership is realised in

practice (e.g. Fleming 1998)

Midwifery in Ireland

Historically the profession has been invisible without a clear and distinct identity from nursing

(With nursing) controlled by medical doctors since regulation 1918No Midwives’ Board since 1950; 1950 Act: the “definition of a nurse

includes a midwife”1985 Nurses’ Act: dissolved the post-1950 Statutory Midwifery

CommitteeCommission on Nursing 1998: recommended statutory Committee,

new legislation

“The role of midwives caring for mothers and babies in Ireland” pamphlet developed by NMPDUs of Health Boards Appears to espouse the social model

The medical model of maternity services in Ireland

60,000 births p.a. (CSO 2003) Hospital-based consultant-led services- explicit policy Lack of choice and continuity Active management of childbirth (lack of control?)

High intervention rates (up to 90% epidural rate!) Recent pilot midwifery-led schemes…

->Midwives on the margins of maternity services Midwives have not challenged the system in the main-

seen as “accessories” to it, there for the medical side of things (Murphy-Lawless)

Exception is independent midwifery (not institutionally bound) and individual midwives

Research evidence on midwifery in Ireland

Begley’s (1998) longitudinal study of student midwives (n=125) during their 2 year training Industrial or economic model of maternity care in

Ireland- process-centred care strict hierarchy in maternity units/hospitals

hierarchy makes development of autonomy and professionalism impossible

act as obstetric nurses rather than midwives professional socialisation- behave in way they

criticise horizontal violence against juniors as cannot

express anger to oppressors “shocking” level of bullying

National survey on empowerment in nursing & midwifery

National two-phase study commissioned by DoHC/ Steering Group on Empowerment through HRB.

Carried out 2001/2 by a team in School of Nursing, DCU led by Professor PA Scott

Context of national and international calls for the empowerment of midwives and women (and nurses)

Literature suggests that empowered midwives will positively affect birthing women’s experiences (Too 1996, Edwards 2000/2001, Halldorsdottir & Karldottir 1996)

The survey examined…

Beliefs about the meaning of empowerment (Meaning of empowerment scale- Scott et al 2003)

Levels of structural empowerment (Laschinger 1996)

Levels of job satisfaction (Warr et al 1979) Level of affect commitment (Meyer & Allen 1984 Beliefs about locus of control (Levenson 1981) (demographic profile)

Sample and response rate

Live Register of An Bord Altranais used as sampling frame for phase 2- national survey Stratified sample by division of Live Register

4,050 questionnaires posted, follow-up mail1,781 replies

1,340 completed questionnaires 441 not in practice

95 midwives in current practice (though 562 have midwifery qualification) >half practised outside Ireland, across Ireland, > part-time.

DCU survey resultsMidwives reported:

Low levels of support, resources, information<10% have “ a lot” of feedback <3% have a lot resources (temporary help)14% had a lot of information about organisation

Low levels of informal and formal power17% have “a lot” of collaboration with doctors 9% have “a lot” of reward for innovation

33% felt that the workplace is an empowering environment

DCU survey results

63% satisfied (global item) Low satisfaction- organisation managed, chance of

promotion High satisfaction- fellow workers, variety in job 79% satisfied with amount challenge in their jobs

High level of affective commitmentHigher sense of internality than a sense that

powerful others or chance control their lives

Developing a model of empowerment in midwifery

Developed through factor analysis of responses of practising midwives to Meaning of Empowerment Scale (Scott et al 2003) Scale developed through focus groups, literature Pilot-tested and revised

Exploratory factor analysis Principal Components Analysis, Varimax rotation 4 factor solution, loadings >0.55, missing values replaced by means,

explains 54% of total variance 9factor 1 explains 30% variance) 23 (of possible 24) items included (excluded the one item not judged

to be involved in empowerment by respondents “performing tasks doctors no longer perform”)

Model: Domains of empowerment in midwifery

Working for women

Skilled practitioners

Professional partners

Respected employees

Factor analysis results

Factors and loadings1 2 3 4

Empowering my patients/clients 0.8 Having access to resources for staff education and training 0.7 Being an advocate for my patients/clients 0.6 Having access to resources for patients 0.6 Having autonomy in my practice 0.6 Being able to say no when I judge it to be necessary 0.6

Having the skills to carry out my role 0.8 Knowing what my scope of practice is 0.6

Being recognised as a professional by the medical profession 0.8 Being recognised for my contribution to patient care by the medical profession 0.7 Being involved in nurse/midwife-led practice 0.6

Being valued by my manager 0.7Being recognised for my contribution to patient care by my manager 0.7Having the back-up of my manager 0.6Having a supportive manager 0.6

Domains of empowermentWorking for women

Advocacy, empowering women, accessing resources, autonomy, saying no when necessary

Skilled practitioners Having requisite skills, knowing scope of practice

Professional partners Midwife-led practice, recognition as a professional and for

contribution to care from medical profession Respected employees

Having support, back-up and recognition from manager; being valued by manager

Model reflects existing literature on empowerment (regarding support etc), but is specific to midwifery

Discussion

Within the current system, it is unlikely that midwives can undertake their role of “working for women”

To facilitate empowerment in midwifery, a supportive, respectful environment is required for the continuous development of skilled midwives

Need for national and local midwifery leaders and leadership- traditionally very hierarchical structures

Need for opportunities for involvement in decision-making within planning and delivery of maternity services for midwives- and that midwives take up those opportunities.

DiscussionNeed to facilitate the wider social role midwives could

play would enhance the experiences of the women for whom they work- key to family support. Needs continuity and community based midwifery services

Explore possibilities for consumer and midwifery alliances

Choice and integration within maternity services would better serve a diversity of women’s needs.

A social model of childbirth would facilitate midwives to be midwives!-

Conclusion

Since the literature suggests that having empowered midwives working

for them is beneficial to birthing women, then relocating and

empowering these secret agents of social policy is of importance for

families and society

References (1)

An Bord Altranais (2001) Guidelines for Midwives. 3rd ed. Dublin: An Bord Altranais. September. Begley, C (1998) Midwives in the making. A longitudinal study of the experiences of student midwives

during their two-year training in Ireland, PhD Thesis. Dublin University. CSO (2003) Vital Statistics www.cso.ie Edwards, N P (2000) Women Planning Homebirths: Their own views on their relationships with

midwives. In Kirkham, M (ed.) The Midwife-Mother Relationship. Houndsmills: Macmillan Press. Edwards, N P (2001) Women’s experiences of planning homebirths in Scotland. Birthing autonomy.

PhD Thesis University of Sheffield. Fleming, V. E. (1998) Women and midwives in partnership: a problematic relationship? Journal of

Advanced Nursing, 27(1): 8-14. Fleming, V (2000) The midwifery partnership in New Zealand: Past history or a new way forward? In

Kirkham, M (ed.) The Midwife-Mother Relationship. Houndsmills: Macmillan Press. Halldorsdottir, S & Karldottir, S (1996) Empowerment or discouragement: women’s experience of

caring and uncaring encounters during childbirth. Healthcare for Women International 17(4): 361-79 Herdman, E A (2004) Nursing in a postemotional society. Nursing Philosophy 5: 95-103 Hyde, A (1997) The medicalisation of childbearing norms: encounters between unmarried pregnant

women and medical personnel in an Irish context. In Cleary, A & Treacy, M P (eds.) The Sociology of Health and Illness in Ireland. Dublin: UCD Press

Hyde, A & Roche-Reid, B (2003) Midwifery practice and the crisis of modernity: implications for the role of the midwife. Social Science & Medicine (Article in Press)

References (2) International Confederation of Midwives (2003) Mission statement. www.internationalmidwives.org Kennedy, P (2002) Maternity in Ireland: a women-centred perspective. Dublin: The Liffey Press. Kitzinger, S (2003) The politics of birth. Letter from Europe. Birth 30(3) Laschinger, H. K. S. (1996) A theoretical approach to studying work empowerment: A review of studies testing

Kanter’s theory of structural power in organisations. Nursing Administration Quarterly, 20(2): 25-41. Levenson, H. (1981) Differentiating among internality, powerful others and chance. In Lefcourt, H. M. (Ed.)

Research with the locus of control construct. New York: Academic Press. Meyer, J. P. & Allen, N. J. (1984) Testing the test-bet theory of organisational commitment: some

methodological considerations. Journal of Applied Psychology, 69: 372-378. Murphy-Lawless, J. (1998) Reading birth and death. A history of obstetric thinking. Cork: Cork University Press. Scott, A., Matthews, A. & Corbally, M. (2003) Nurses’ and Midwives’ Understanding and experiences of

empowerment. Final Report. Dublin: Department of Health and Children. Too, S-K (1996a) Do birthplans empower women? A study of midwives’ views. Nursing Standard 10(31): 44-48. Too, S-K (1996a) Do birthplans empower women? A study of women’s views. Nursing Standard 10(32): 33-37. Walsh, D & Newburn, M (2002a) Towards a social model of childbirth: part one. British Journal of Midwifery

10(8): 476-481 Walsh, D & Newburn, M (2002b) Towards a social model of childbirth: part two. British Journal of Midwifery

10(9): 540-544 Warr, P., Cook, J. & Wall, T. (1979) Scales for the measurement of some work attitudes and aspects of

psychological well-being Journal of Occupational Psychology, 52: 129-148.