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

1. Families, midwives and social policy: In search of the secret agents Anne Matthews, Professor P Anne Scott School of Nursing, DCU

2. Outline of presentation • Setting 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

3. 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

4. Midwives as secret agents? “Maternity policies”? Social welfare Midwives Social policies Families Health policies

5. 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 services • Medical 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)

6. 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)

7. 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 1918 • No Midwives’ Board since 1950; 1950 Act: the “definition of a nurse includes a midwife” • 1985 Nurses’ Act: dissolved the post-1950 Statutory Midwifery Committee • Commission 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

8. 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

9. 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

10. 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)

11. 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)

12. 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 mail • 1,781 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.

13. DCU survey results • Midwives 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 power • 17% have “a lot” of collaboration with doctors • 9% have “a lot” of reward for innovation • 33% felt that the workplace is an empowering environment

14. 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 commitment • Higher sense of internality than a sense that powerful others or chance control their lives

15. 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”)

16. Model: Domains of empowerment in midwifery Working for women Skilled practitioners Respected employees Professional partners

17. Factor analysis results

18. Domains of empowerment • Working 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

19. 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.

20. Discussion • Need 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!-

21. 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

22. 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)

23. 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.