Humanising Birth: A guide for practice E-book by Creativeworld

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E. Newnham, L. McKellar, J. Pincombe

Towards the Humanisation of Birth A study of epidural analgesia and hospital birth culture • Uses epidural analgesia as the lens for analysis of the current ontological and epistemological debates in maternity care 2018. XI X, 266 p. 3 illus. eBook € 39,99 | £ 29,99 | $ 44.99 Softcover € 49,99 | £ 39,00 | $ 89.99 Hardcover € 89,99 | £ 79,00 | $ 99.99

• Examines key sociological and philosophical debates in current maternity care practice and provision • Tracks historical developments in the field as the background to the wider debates to be addressed in the text This book examines the future of bir thing practices, par ticul arly by focusing on epidural analgesia in childbir th. I t describes historical and cultural trajectories that have shaped the way in which bir th is understood in Western, developed nations. I n set ting out the nature of epidural histor y, knowledge and practice, the book delves into rel ated bir th practices within

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the hospit al set ting. By critically examining these pra ctice s , which a re em b e dde d in a s cien tific dis cours e th a t ra tion a lis e s a n d relie s upon technology use, the authors argue that epidural analgesia has been positioned as a safe technology in contemporar y maternit y culture, despite it carr ying par ticul ar risks. I n examining alternative research the book proposes that increasing epidural ra te s a re not only due to gre a ter p a in relie f re quirem en t s or a cce s s bu t a re in fluence d by technocratic values and a fragmented maternit y system. The authors outline the wa y in which this epidural dis cours e in fluen ce s how inform a tion is pre s en te d to wom en a n d h ow this a ffe ct s th eir ch oice s a roun d the us e of p a in relie f in la b our.

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CONTENTS

E-BOOK SERIES

HUMANISING BIRTH: A PRACTICAL GUIDE FOREWORD Claire Feeley

CHAPTER 1 THE HUMANISATION OF CHILDBIRTH

Dr Elizabeth Newnham and Prof Lesley Page

CHAPTER 2 THE CIRCLE OF TRUST Dr Elizabeth Newnham

CHAPTER 3 RE-ENVISAGING LABOUR PAIN- A HUMANISTIC APPROACH

Dr Elizabeth Newnham, Assoc Prof Sigfríður Inga Karlsdóttir and Ruth Sanders

CHAPTER 4 THE PARADOX OF THE INSTITUTION Dr Elizabeth Newnham

CHAPTER 5 HUMANISING POLICY – THE CURIOUS CASE OF EPIDURAL ANALGESIA AND WATER IMMERSION Dr Elizabeth Newnham

CHAPTER 6 MIDWIFERY TECHNOLOGY: MIDWIFERY PRACTICE FOR THE HUMANISATION OF BIRTH Dr Elizabeth Newnham

CHAPTER 7 HUMANISING BIRTH – THE ROLE OF CRITICAL PEDAGOGY IN MIDWIFERY EDUCATION Janice Bass, Dr Lois McKellar and Dr Elizabeth Newnham

CHAPTER 8 HUMANISING BIRTH: WHERE DO WE GO FROM HERE? Prof Lesley Page and Dr Elizabeth Newnham

COPYRIGHT ©All4Holdings Ltd, 2020 www.All4Maternity.com All rights reserved. No part of this All4Maternity eBook may be reproduced in any material form (including photocopying or storing in any medium by electronic means and whether or not transiently or incidentally to some other use of this publication) without the written permission of the copyright holder, except in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of a license issued by the Copyright Licensing Agency Ltd, 90 Tottenham Court Road, London, England W1P 0LP. Applications for the copyright holder’s written permission to reproduce any part of this publication should be addressed to the publisher contact info@all4maternity.com Publisher: All4Holdings Ltd Designed and produced by Creativeworld Front cover and illustrations by Lauren Rebbeck

CITATION INFORMATION To cite these chapters, please use their original citations from The Practising Midwife: Chapter 1 Newnham, E & Page, P. (2019) The humanisation of childbirth. The Practising Midwife; 22(8): 14-17. Chapter 2 Newnham, E. (2019) The circle of trust. The Practising Midwife; 22(9): 15-19. Chapter 3 Newnham, E; Karlsdóttir, S; Sanders, R. (2019) Re-envisaging labour pain- A humanistic approach. The Practising Midwife; 22(10): 14-17. Chapter 4 Newnham, E. (2019) The paradox of the institution. The Practising Midwife; 22(11); 16-19. Chapter 5 Newnham, E. (2020) Humanising policy – the curious case of epidural analgesia and water immersion. The Practising Midwife; 23(1): 14-17. Chapter 6 Newnham, E. (2020) Midwifery technology: midwifery practice for the humanisation of birth. The Practising Midwife; 23(2): 14-17. Chapter 7 Bass, J; McKellar, L; Newnham, E. (2020) Humanising birth – the role of critical pedagogy in midwifery education. The Practising Midwife; 23(3): 13-16. Chapter 8 Page, L & Newnham, E. (2020) Humanising birth: Where do we go from here? The Practising Midwife; 23(4): 15-17.

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FOREWORD As I embarked on my midwifery journey, I came into university education with a strong sense of what I thought it should be. Like many others, I found parts of the clinical practice experience to be jarring, confusing and often demoralising. ‘Woman-centred’ care was the buzz word at the time, a word to indicate that our work as maternity professionals, was to tailor our care around what women wanted and needed. Conceptualised as a ‘value’, it was to guide all levels of service provision; through the immediate midwife-mother relationships, information provision, services and all clinical care. As a value, it has been adopted throughout numerous guidelines, position statements, governmental policies as well as research. With all the best of intentions, and no doubt most professionals ascribe to ‘woman-centred’ care values, my experience as a student and thereafter found this concept was often tokenistic or perhaps even, just lip service. At the heart of the issue, ‘woman-centredness’ was applied to systems and structures that were created within patriarchal, over-medicalised and institutionalised cultural frameworks. Broadly, this means that ‘woman-centredness’ is butting heads with a structure not designed to support it. That does not negate the amazing work carried out each day by maternity professionals trying to meet the needs of individual women in their care, it does, however, require a broader look, critique and challenge. Here lies the power of this book. Humanising childbirth is more than a concept, it is a paradigm shift in our thinking, working, education, structures, services and collaborations. The list goes on. Succinctly expressed by Newnham and Page1 as ‘humanisation is about whole-system and whole-world transformation in attitudes and care around birth p.16.’ Firmly situated within political aims and goals, the humanisation of childbirth marks a radical shift in our thinking in maternity care. This collection authored by Dr Elizabeth Newnham and colleagues was first published in The Practising Midwife as a series during 2019-2020, now collated together in this new resource as a practical guide of how humanising childbirth can be implemented. Drawing upon the authors extensive clinical and scholarly experience, they first take you through the history of the concept, its position within current maternity service models and why it is a necessary paradigm shift. Importantly, the authors assert the need to move beyond the everyday polarised maternity debates that keep us going around the same circles. Rather, the authors collectively advocate for a top-down, bottom-up, inside-out cultural shift. Throughout the subsequent chapters, the humanising birth lens is applied to various aspects of midwifery and maternity care. Starting with the intimate relationship of mother-midwife, Dr Elizabeth Newnham walks us through its essence- a circle of trust. Thereafter, the chapter’s span across a range of areas; reimagining labour pain, the paradoxical institution, dominant discourses, midwifery as a technology and midwifery education. The final chapter, Professor Lesley Page compares the dehumanisation of women during childbirth to the wider climate change crisis, which I see as the microcosm reflecting the macrocosm; with a direct call to action.

Dr Claire Feeley 26th June 2020 REFERENCES 1. Newnham, E & Page, P. The humanisation of childbirth. The Practising Midwife. 2019; 22(8): 14-17.

CHAPTER 1: THE HUMANISATION OF CHILDBIRTH 05

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CHAPTER 1

THE HUMANISATION OF CHILDBIRTH Dr Elizabeth Newnham and Professor Lesley Page

INTRODUCTION This book, a collection of authors, curated by Dr Elizabeth Newnham, will be examining the concept of the ‘humanisation of childbirth’. They identify the need to prioritise humanisation, and explore some of the ideas around humanised birth and how this might effect practice change. Some of the papers draw on the findings of an ethnography of birth in a hospital setting, which was published last year as the book Towards the humanisation of birth: a study of epidural analgesia and hospital birth culture (Newnham et al 2018). In this first chapter of the series, Dr Elizabeth Newnham and Lesley Page consider the importance of humanisation of birth in all contexts, and set the scene for the following chapters, by outlining its history and defining features.

*A word on language from the authors: we acknowledge that there are people having babies who do not identify as female and support the idea that midwives use language and terminology that is decided by individuals as appropriate for them. However, we are also committed to recognising the historic and ongoing gender and power issues that accompany childbirth. We therefore consciously use the terms ‘woman’ and ‘mother’ (and ‘father’) in this series, while remaining respectful to all of the wonderfully different and various individual and family characteristics that exist.

CHAPTER 1: THE HUMANISATION OF CHILDBIRTH 07

HUMANISATION OF CHILDBIRTH DEFINED Humanisation of childbirth as a term was first coined in Brazil in the late 1990s. Beginning as a positive-language movement to address obstetric violence, humanisation of childbirth has now been enshrined into legislation in several South American countries. The humanisation of birth movement, situated within an agenda of human rights and ethics, is a resistance to dehumanising, disrespectful, medicalised and industrialised birth practices (International Confederation of Midwives [ICM] 2017; Newnham et al 2018). An ICM discussion paper defines humanised childbirth as: “care that recognizes the significance of birth for individuals, family and society, and that respects the human rights of the woman to access high quality, evidence based care. Humanized care puts the woman at the centre of care, recognizes that the mother and baby are inseparable. The woman her baby and family are treated with dignity and respect, and the woman has the right to make decisions about her care. This decision making process will be enhanced by a relationship of reciprocity with her midwife or midwives, and supported through the appropriate provision of high quality information“ (ICM 2017: 1-2).

Table 1 Characteristics of humanised childbirth (adapted from Page 2019) Medicalised/industrialised

Humanised

Depersonalised/fragmented

Respectful, relationship-based care

Mother and baby separate

Mother/baby dyad inseparable

Mistrust of normal physiology/focus on pathology and risk

Physiology of birth trusted and supported/focus on salutogenesis/promoting wellbeing

Cultural belief in ‘safety’ of technology/medical intervention/unnecessary intervention

Evidence-based, appropriate care/ intervention when indicated

Environment designed for clinicians, intervention and risk assessment

Environment (including choice of place of birth) seen as important influence on birth

Focus technology/institution

Woman at centre of care

Eradication/limitation or mistrust of midwifery

Scaling up midwifery

WHY WE NEED TO ‘HUMANISE’ BIRTH In the recent Lancet series on maternal health, Miller at al (2016) identified two co-existing problems in maternity care: care that is too little, too late (TLTL) (lack of resources and access to quality care) and care that is too much, too soon (TMTS) (medicalisation, over-intervention and iatrogenic harm). To avoid TLTL and TMTS, care needs to be tailored to each woman in order to achieve the optimal birth experience for her unique needs. It is common to believe dehumanised childbirth practices occur only in low-resource countries, but TLTL and TMTS are parallel problems seen around the world. TMTS can be particularly problematic in low-resource settings where funding is limited. This is why we need to get birth right in all settings and to mitigate against factors such as poverty, racism, war, fragile states and geographical disasters as well as geographical location and context. Scaling up midwifery is a vital part of the solution to this complex problem. Despite overwhelming evidence, progress to implement midwifery has been slow. Renfrew et al (2019: 1) propose that this is due to “the intersectionality of gender, social, professional and economic disempowerment, fuelled by powerful precedents and perverse incentives’. Other solutions to dehumanising care (such as showing compassion and respect) seem obvious; however evidence that the problem is ongoing is reflected in the continued findings of disrespect and abuse of women during childbirth in all settings (World Health Organization [WHO] 2014; Bohren et al 2015; Reed et al 2017; Vedam et al 2019). Questions we need to be asking ourselves as midwives are: Why is dehumanised care still happening? and What are we going to do about it?

SERIES FOCUS In this series of papers, we will be exploring more deeply what is humanisation of childbirth, how to progress humanisation, and how we might address the significant challenges to its implementation. Coming back to the research on which this series of papers is based, some of the issues that arise in the project of humanising childbirth are: to question whether large institutions are actually appropriate as birth settings for most women – if we continue to use them, we must pay attention to ‘deep humanism’ (Davis-

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Floyd 2018), attending first and foremost to the needs of the woman and her birth physiology (including time and environment); a change in approach to pain in labour, and the way that childbirth is understood culturally; a sustained critique and evaluation of technology and how its use is situated within medical belief systems; an emphasis on the importance of relationships, including specific elements of relational care, such as love, compassion and respect.

LOOKING TOWARDS THE FUTURE Humanisation is about whole-system and whole-world transformation in attitudes and care around birth. Although it is not solely about scaling up midwifery, educated, skilled and compassionate midwives in high-performing systems of care are critical to this transformation. However, humanisation is, at root, a political issue. It is about contributing to equity and respect for all human beings, no matter who they are, their circumstances and where they live. Humanising childbirth is fundamental to the future not only of childbirth practices but to the future of humanity (Page 2017). Overmedicalised and industrialised approaches to childbirth are harmful to individuals, populations and health services, and disregard the essence of birth: the profound human, physiological, psycho-social and also sacred and sexual nature of the childbirth experience. Humanised childbirth is not just about human rights and respectful care in childbirth; it is about reclaiming these aspects of birth, recognising what birth means to each woman, and situating her at the centre of care. It is about understanding the impact of new and emerging science, such as epigenetics and study of the microbiome, on birth and on long-term health and wellbeing. It is about a cultural shift to new ground, avoiding the polarisation of single issues and, instead, transforming to a new reality. Humanised childbirth goes beyond crude outcome measures and recognises the impact of birth on the infant, on the emerging/new mother, on the family into which the baby is being born, on the life-enhancing importance of secure attachments. This is an issue that affects society at its deepest level. We are talking about the creation of mothers, of fathers, of families – and if we get this right, we can make a substantial impact on the health and wellbeing of society.

REFERENCES Bohren MA, Vogel JP, Hunter EC et al (2015). ‘The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review’. PLOS Medicine, 12: e1001847. Davis-Floyd R (2018). Ways of knowing about birth: mothers, midwives, medicine, and birth activism, Long Grove: Waveland Press. ICM (2017). Discussion paper: midwives and the humanisation of birth, The Hague: ICM. Miller S, Abalos E, Chamillard M et al (2016). ‘Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide’. The Lancet, 388(10056): 2176-2192. Newnham E, McKellar L and Pincombe J (2018). Towards the humanisation of birth: a study of epidural analgesia and hospital birth culture, Basingstoke: Palgrave Macmillan. Page L (2017). ‘The birth of our humanity’. British Journal of Midwifery, 25(7): 1-3. Page L (2019). Keynote presentation: humanising birth, GOLD midwifery online conference, Feb 25th. https://www.goldmidwifery.com/conference/ speakers/closing-keynote-presentations-speakers Reed R, Sharman R and Inglis C (2017). Women’s descriptions of childbirth trauma relating to care provider actions and interactions’. BMC Pregnancy and Childbirth, 17 : 21. doi : 10.1186/s12884-016-1197. Renfrew MJ, Ateva E, Dennis-Antwi JA et al (2019). ‘Midwifery is a vital solution – what is holding back global progress?’ Birth, doi: 10.1111/ birth.12442. Vedam S, Stoll K, Taiwo TK et al (2019). ‘The giving voice to mothers study: inequity and mistreatment during pregnancy and childbirth in the United States’. Reproductive Health, 16: 77. doi 10.1186/s12978-019-0729-2. WHO (2014). The prevention and elimination of disrespect and abuse during facility-based childbirth, Geneva: WHO.

CHAPTER 1: THE HUMANISATION OF CHILDBIRTH 09

CHAPTER 2

THE CIRCLE OF TRUST Dr Elizabeth Newnham

INTRODUCTION In this second chapter Dr Elizabeth Newnham discusses one of the key findings from the book Towards the humanisation of birth: a study of epidural analgesia and hospital birth culture. The ‘circle of trust’ model illustrates the importance of the mothermidwife relationship within the context of women’s understanding and experience of childbirth. Focusing primarily on one of the two primary themes of the ‘circle’ – Trust in the body-self – and drawing on extant literature, Newnham discusses the role of the midwife in providing support for women in labour, which must include the support of birth physiology as a vital step towards humanising birth.

A STUDY OF EPIDURAL ANALGESIA AND HOSPITAL BIRTH CULTURE As discussed in the first chapter, a focus-point of this is the earlier published book Towards the humanisation of birth (Newnham et al 2018), which describes an ethnographic study of epidural use in labour. The aim of the study was to examine the personal, social, cultural and institutional influences on women in their choice regarding epidural analgesia, and by investigating the use of epidural analgesia in labour, to identify other current cultural meanings and practices in childbirth. Data collection included participant observation on a hospital labour ward, including informal interviews with midwives and doctors, and sequential interviews with 16 pregnant women. I interviewed each woman three times (twice antenatally and once postnatally) and attended as an observer, the labour of the six women who also consented to this. Hospital and policy documents were analysed as part of the study. As usual for a qualitative study, these findings are not generalisable, but they do alert us to social and cultural beliefs, understandings and practices about birth, and are therefore transferable. Robust, rigorously conducted qualitative research that draws on rich and deep data can advance our knowledge about the human condition and experience. The ideas and themes presented here are a result of in-depth analysis of the data and cross-referenced with current literature. 10 ALL4MATERNITY E-BOOK

THE ‘CIRCLE OF TRUST’ One of the main findings of the study was that of a ‘circle of trust’ (See Figure 1), which is needed between women and midwives for childbirth to be well supported. The ‘circle’ contains two key ideas: trust in the body-self and trust in the midwife. Related (sub-) themes are: birth as corporeal, ambivalence to pain, birth as unknowable and ambivalence to information. In this article I focus primarily on the idea of trust in the body-self and the significance of this finding to women’s experience of labour, as well as for midwifery practice.

Trust in body-self The women in the study described a trust in their bodies to give birth. They made frequent references to their bodies as knowing entities in their own right, that their bodies would ‘know what to do’ and that they could relax in this knowing. This was related to the idea of birth as corporeal – a primarily physiological, embodied experience that women throughout the millennia have experienced, and which was therefore also achievable for them. However, this confidence in birth as a physiological phenomenon did not necessarily lead to an idealised vision of birth – the women identified that just because their bodies could birth, this did not mean that they would – leading back again to an emphasis on trust in the midwife to help distinguish ‘necessary’ from ‘unnecessary’ intervention.

Trust in the midwife This sense of trust in birth, that their bodies were physiologically geared to do the work of birth, led to an expectation that the midwife’s role in labour support was not just emotional, but physiological. One woman, Anna, said of her first birth in a private hospital: There was a big bath there, but I didn’t ask and it wasn’t offered. So I don’t know whether it was available to be used or not… Nobody offered it. So I didn’t use it last time. I guess reliance is on the advice that was coming from the staff that were there on that day. And I figured if they thought it was a good idea, that they would offer it (Anna).

SIGNIFICANT OTHERS

TRUST IN BODY-SELF CONNECTION TO BABY

AMBIVALENCE TO INFORMATION

BIRTH AS CORPOREAL

BIRTH AS UNKNOWABLE

AMBIVALENCE

TO PAIN This was an interesting insight because in many maternity units, including the research site, birth physiology is not always well-supported. Hospital birth environments are set up to support the practitioner rather than the birthing woman, and space for TRUST IN MIDWIFE movement, privacy, access to water and continuous support, are not routinely available TRUST IN BIRTH to all women. In addition, not all midwives saw this as their role, and it was clear from the data that the ‘midwife in the room’ has a significant impact on a birthing woman’s decision about whether or not to have an epidural. This was seen directly in the Newnham E et al (2018). Reproduced with permission participant observation as well as from interviews with midwives and student midwives of Palgrave MacMillan. who divulged that they could often tell who would end up with an epidural, depending on the midwife who was attendant in labour, or that epidural rates would increase or decrease, shift-by-shift, depending on who was team leader on the labour ward. No matter what your beliefs about the benefits or risks of epidural, it is unlikely that any of us can say that this reflects a situation of bodily autonomy and genuine informed consent on the part of the woman. What it does reflect is the power of the midwife and the influence she has in providing or withdrawing support, which directly affects women’s ability to cope with childbirth. WORKING WITH PAIN

TRUST OR FEAR: HOW WOMEN EXPERIENCE BIRTH A couple of the women did not feel this sense of trust in their bodies, and this is reflected in other literature. Since birth is influenced by society and culture, and our belief systems about risk, pain, birth and medicine, women grow up with particular expectations of birth. For these women, fear of birth can be reconciled by the knowledge that medical intervention is close at hand. Some women do not want to take ownership of the birth process, and prefer to remain passive (Marshall et al 2011); however, for these women, midwifery knowledge and guidance is especially important, particularly as women’s interpretation of pain affects their experience of it, and the social birth environment, including support, can affect this interpretation (Whitburn et al 2017).

Influencing factors The context and social environment are dynamic and can also change throughout labour. In their study about pain relief choices and beliefs about childbirth, Heinze and Sleigh (2003) found that women’s birth ideology was a motivating factor for specific choices determining analgesia use in labour. Women’s ideologies of birth were, in turn, influenced by the psychological factors of locus of control (internal or external) – seeing themselves as active or passive participants in the process of childbirth – and fear of childbirth. Levels of fear about birth were more significant in women’s choices than actual experience of pain in labour (Heinze and Sleigh 2003). Denis Walsh (2009) has identified that increasing epidural use might be as much due to technorationalist and risk discourses, midwives working within a ‘pain relief paradigm’, fragmented care and alienating birth environments, as actual pain relief requirements – and this research would support his claim. When the women spoke to me about fear of birth, they spoke about fear of intervention (including epidural or instrumental birth), fear of physical damage, fear of the unknown and of loss of control

CHAPTER 2: THE CIRCLE OF TRUST 11

(of the environment, of their bodies). Fear of birth was therefore associated with pain, but pain was not an exclusive or primary cause of birth fear. Pain was a bigger consideration for some, and four women planned, during pregnancy, to use epidural analgesia for labour. However, fear of pain was not the only reason for wanting an epidural. Reasons also included prior experience of long labour or complications; wanting to retain some physical control (not being ‘out of control’ with pain); and longstanding fear of birth.

Caregiver support Interestingly, women who discussed needing an epidural due to being unable to cope with pain, actually described, in their interviews, a lack of support or lack of access to planned coping mechanisms: I’d asked for the ball, the medicine ball and a mat, and the medicine ball came out and it was flat and it was useless. So that was one of my strategies gone… I just felt really like I needed someone to step up and say, ‘This is what you need to do’. The epidural came at 7 o’clock or something. Because… I just felt… I can’t do this by myself (Lily). This is also where trust in the midwife comes in. Caregiver support is clearly documented in the literature as having a positive influence on a woman’s experience of birth and how she copes with pain (Halldorsdottir and Karlsdottir 1996; Hodnett 2002; Leap et al 2010; Lundgren and Dahlberg 1998; Parratt and Fahy 2003; Van der Gucht and Lewis 2015; Whitburn et al 2017). Hodnett (2002) has identified that a woman’s personal expectations, the support she receives, her relationship with her care provider and contribution to decision-making are more influential on the woman’s overall satisfaction with childbirth than pain, continuity of care, physical environment or intervention. The focus moved to pain and/or its relief only if expectations were not met (Hodnett 2002).

TOWARDS HUMANISATION: SUPPORTING BIRTH PHYSIOLOGY As midwives, it is important to think about how we come to our own understandings and assumptions and beliefs about childbirth. The findings from this study show that although women have complex and competing input into their individual ideologies of birth, many women hold that birth is a fairly normal corporeal experience, and that their bodies will somehow manage it. They expect midwives to support them, both emotionally and physiologically. If midwives are to work towards humanising birth, then attention needs to be paid to identifying and promoting practices and environments that first and foremost promote birth physiology.

REFLECTION ON PRACTICE This research shows that the individual midwife has an influence on women’s decision to use epidural in labour. Thinking about your recent practice, reflect on your own experience of this. How does this relate to your own practice/setting? Is there more information or learning you need? Is there anything you can do in your practice setting to improve the environment to support birth physiology?

REFERENCES Halldorsdottir S and Karlsdottir SI (1996). ‘Journeying through labour and delivery: perceptions of women who have given birth’. Midwifery, 12(2): 48-61. Heinze S and Sleigh M (2003). ‘Epidural or no epidural anaesthesia: relationships between beliefs about childbirth and pain control choices’. Journal of Reproductive and Infant Psychology, 21(4): 323-333. Hodnett E (2002). ‘Pain and women’s satisfaction with the experience of childbirth: a systematic review’. American Journal of Obstetrics and Gynecology, 186(5s): S160-S172. Leap N, Sandall J, Buckland S et al (2010). ‘Journey to confidence: women’s experiences of pain in labour and relational continuity of care’. Journal of Midwifery and Women’s Health, 55(3): 234-242. Lundgren I and Dahlberg I (1998). ‘Women’s experience of pain during childbirth’. Midwifery, 14(2): 105-110. Marshall J, Fraser D and Baker P (2011). ‘An observational study to explore the power and effect of the labor ward culture on consent to intrapartum procedures’. International Journal of Childbirth, 1(2): 82-99. Newnham E, McKellar L and Pincombe J (2018). Towards the humanisation of birth: A study of epidural analgesia and hospital birth culture, Basingstoke, UK:Palgrave Macmillan. Parratt J and Fahy K (2003). ‘Trusting enough to be out of control: a pilot study of women’s sense of self during childbirth’. Australian Journal of Midwifery, 16(1): 15-22. Van Der Gucht N and Lewis K (2015). ‘Women’s experiences of coping with pain during childbirth: a critical review of qualitative research’. Midwifery, 31(3): 349-358. Walsh D (2009). ‘Pain and epidural use in normal childbirth’. Evidence Based Midwifery, 7(3): 89-93. Whitburn L, Jones L, Davey M et al (2017). ‘The meaning of labour pain: how the social environment and other contextual factors shape women’s experiences’. BMC Pregnancy and Childbirth, 17: 157.

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CHAPTER 3

RE-ENVISAGING LABOUR PAIN – A HUMANISTIC APPROACH Dr Elizabeth Newnham, Ass Prof Sigfríður Inga Karlsdottir and Ruth Sanders

INTRODUCTION In this third chapter the authors explore the topic of pain in labour. They address the ‘women’s paradigm of pain’, how this relates to midwifery support, and ways of approaching labour pain in practice, using pain theories. Humanising birth calls for re-imagining old ideas in new ways. Although there has been a long history of labour pain being medicalised, pathologised and seen as too much for women to bear, there has been an even longer history of women witnessing the power of birth and acknowledging the role of support – and now that midwives are also enaging in research, emerging evidence supports this.

OUR OWN EXPERIENCES OF PAIN: EXPERIENTIAL KNOWLEDGE As women who have all given birth and practised as midwives, we come to the idea of labour pain with experiential, practical, but also theoretical knowledge. We have felt and witnessed the power of giving birth, watched in awe as women enter the ‘zone’ – as the hormones of birth dance through their bodies. All three of us, in our experience, reading and research, see a relationship between pain and joy in birth (although this relationship is not always straightforward and, of course, is individualised to each woman’s experience; intense and relentless labour pain can also lead to birth trauma – we are not suggesting that women should be denied analgesia). There is a physiological reason for this joy, as the hormones of birth – primarily oxytocin and the betaendorphin response – also lead to feelings of calm, connectedness and euphoria (Buckley 2015). This potential for birth to be joyous and salutogenic, increasing the wellbeing of women and babies and families, is a vital aspect of humanising birth. In this article, we discuss some of our thoughts and research findings.

THE WOMAN’S PARADIGM OF PAIN One of us (SIK) has suggested that previous knowledge, attitude and practice around labour pain came from either a medical or midwifery paradigm, and that we now need to focus on the ‘woman’s paradigm’ (Karlsdottir et al 2014). As we discover more about how women actually feel about and approach labour pain, it allows us as midwives to reflect on and change our practice.

CHAPTER 3: RE-ENVISAGING LABOUR PAIN – A HUMANISTIC APPROACH 13

Although labouring women will describe the journey of birth as difficult and demanding (Karlsdottir et al 2014), most will see this work as an expected part of the process of having a baby. The fact that women are accepting of labour pain is a point that needs more attention, because throughout much of the medical literature, it has been assumed that women either do not want to, or are unable to cope with labour pain (Newnham et al 2018). We now know that this is not the whole story, as universally women expect, prepare for and find coping strategies for labour pain (Karlsdottir et al 2014; van der Gucht and Lewis 2015). Revisiting the ‘Circle of trust’ model (see chapter 2) and associated research, all women expected to feel some level of pain, even those who were planning to use pharmacological analgesia. Overall, the women’s attitude towards pain was ambivalent, and included ideas of pain as ‘necessary’ or pain as a ‘significant’ part of the transition to motherhood (Newnham et al 2018).

I need to feel it. I think it is part of becoming a mum…why numb that? I think it’s like – it’s an initiation, I think for me, into motherhood (Annie) (Newnham et al 2018: 218).

MIDWIFERY SUPPORT As well as changing our understanding of how women view labour pain, an important part of this paradigm is the role of the midwife. Midwifery support plays a vital role in how a woman is able to think about, process and manage labour pain. Women have emphasised how a caring and competent midwife can affect their experience, how important it is for them to get individualised care, and to have a good connection (Leap et al 2010; Karlsdottir et al 2014).

I could give birth in any circumstances…if I had a midwife with me. That was what counted. It was so important. They talked me through the labour and birth, and they…encouraged me (Daniela) (Karlsdottir et al 2014: 321). Regardless of the pain management choice a woman makes, her perception of its effect is related to the quality of the mothermidwife relationship in labour (Thomson et al 2019). It is therefore crucial to take the woman’s own paradigm (attitude, expectations and experience) into account when planning midwifery care (Karlsdottir et al 2014; Karlsdottir et al 2018), with a focus firstly on supporting birth physiology, and the strength of each and every childbearing woman, rather than on abnormality or risk (Leap and Hunter 2016), but knowing that all women, regardless of mode of analgesia, require continuous support.

WORKING WITH PAIN Midwives who are reflexive of their own feelings about pain, who see the normality and power of labour pain, and can therefore take a ‘working with pain’ approach (Leap and Hunter 2016) are better able to support women through their labour and birth journey. The ‘working with pain approach’ is pivotal to the ‘trust in the midwife’ theme of the ‘Circle of trust’ model (Newnham 2019), as midwives need to reflect back to the woman her own sense of trust in her body to give birth (Karlsdottir et al 2014; Leap and Hunter 2016; Newnham et al 2018). A recent literature review supports our discussion here, finding that three main factors contribute to a woman experiencing labour pain as transformative and non-threatening: ongoing belief in the purposeful nature of labour pain (we suggest that this belief needs to come from both the woman and the midwife); that pain is perceived as productive; and feeling supported and safe (Whitburn et al 2019).

FUNCTIONAL DISCOMFORT Another of us (RS) has been studying language around pain. Women are bombarded with images from popular culture about the management of labour pain (Sanders and Crozier 2018). One discourse follows the physiological, biophysical route, often depicting a dramatic ‘horror story’ narrative showing the hazardous potential of bodies to malfunction. The other shows the biomedical, anaesthetised path of the calm woman, seemingly comfortable yet disconnected from their labouring state. Women’s experiences may be formed by an uneasy blend of these two perceptions (Walsh 2010). The physicality of labour is not comfortable – it is an embodied, corporeal experience that many women consider integral to becoming a mother (Newnham et al 2018; Power et al 2017; van der Gucht and Lewis 2015). Language is at the core of a different approach to labour. To transform it into a positive experience – a discomfort which is physiologically normal and expected – labour and birth need to be reimagined before the woman enters the birthing room. For example, much of the language used by professionals situates pain sensations outside the body, using seemingly unrelated metaphors to explain the experience (Sanders 2015). Although some women might relate to these metaphors, using words like ‘waves’, ‘surges’ and other nature-based metaphors can also place women outside their bodies during labour. Language which situates the discomfort within the body, helps women to understand that they are able to cope with labour and enables them to reconnect with the physiological changes of birth. A focus on pain as a function of normal birth physiology has the potential to ease women’s fear. Discussing pain as functional discomfort is a way of negotiating women’s ambivalence and acknowledged recognition of the inevitable yet unknown process of birth. Drawing psychological focus away from labour ‘pain’, which has been medically contextualised as pathological and 14 ALL4MATERNITY E-BOOK

unmanageable, and emphasising the purposeful and functional nature of labour pain removes the pathology, while retaining its importance. Recontextualising labour pain from pathology and suffering, into a profound purposive and functional experience, becomes essential in enhancing women’s belief in their ability to birth (Whitburn et al 2019). The humanistic midwife needs this different approach to enable women to navigate the discomfort of labour (Sanders 2015).

HUMANISM AND MIDWIFERY PRESENCE Although we all strive to create a space where women are experts of their own experience, it is crucial to recognise our role as gatekeepers to pain-management solutions – in philosophical outlook, environmental influence and access to pharmacology. Women, mostly, want a meaningful birth experience – avoiding drugs and intervention (Downe et al 2018; Newnham et al 2018) and they rely heavily on the presence of the midwife to support them through this. If we are to practise humanistic midwifery, we must first understand the physiological function of labour pain; how it supports birth physiology; and the hormonal cascades that can lead to joy and euphoria at birth. While many of you will already be practising this way, we hope that reading this paper will inspire you to think more deeply about how to work with women’s pain, to talk about it with others, or to reflect on potential future ideas for knowledge or practice development.

REFLECTIONS FOR PRACTICE Are you able to prioritise facilitating a connection with a woman and her partner/support person? Are you always aware of how important your presence is for a woman in labour? How do you think your own experience/feelings about labour pain influence your practice? Reflect on your own decisionmaking strategies when determining whether you think women are coping in their labours. Is there anything you can do in your practice setting to improve the way that labour pain is approached? Is there more information or learning you need?

REFERENCES Buckley S (2015). Hormonal physiology of childbearing: evidence and implications for women, babies, and maternity care, Washington, DC: Childbirth Connection. http://www.nationalpartnership.org/our-work/resources/health-care/maternity/hormonal-physiology-of-childbearing.pdf Downe S, Finlayson K, Oladapo OT et al (2018). ‘What matters to women during childbirth: a systematic qualitative review’. PLOS ONE, 13(5): e0197791. https://doi.org/10.1371/journal.pone.0197791 Karlsdottir SI, Halldorsdottir S and Lundgren I (2014). ‘The third paradigm in labour pain preaparation and management: the childbearing woman’s paradigm’. Scandinavian Journal of Caring Sciences, 28(2): 315-327. doi.org/10.1111/scs.12061 Karlsdottir SI, Sveinsdottir H, Kristjansdottir H et al (2018). ‘Predictors of women’s positive childbirth pain experience: findings from an Icelandic national study’. Women and Birth, 31(2): 178-184. doi.org/10.1016/j.wombi.2017.09.007 Leap N and Hunter B (2016). Supporting women for labour and birth: a thoughtful guide, Oxon: Routledge. Leap N, Sandall J, Buckland S et al (2010). ‘Journey to confidence: women’s experiences of pain in labour and relational continuity of care’. Journal of Midwifery and Women’s Health, 55(3): 234-242. http://dx.doi.org/10.1016/j.jmwh.2010.02.001 Newnham E (2019). ‘Humanisation of childbirth. 2: The circle of trust’. The Practising Midwife, 22(9): 15-19. Newnham E, McKellar L and Pincombe J (2016). ‘A critical literature review of epidural analgesia’. Evidence Based Midwifery, 14(1): 22-28. Newnham E, McKellar L and Pincombe J (2018). Towards the humanisation of birth: a study of epidural analgesia and hospital birth culture, Basingstoke: Palgrave Macmillan. Power S, Bogossian F, Sussex R et al (2017). ‘A critical and interpretive literature review of birthing women’s non-elicited pain language’. Women and Birth, 30(5): e227-e241. http://dx.doi.org/10.1016/j.wombi.2017.02.001 Sanders R (2015). ‘Functional discomfort and a shift in midwifery paradigm’. Women and Birth, 28(3): e87-e91. http://dx.doi.org/10.1016/j. wombi.2015.03.001 Sanders R and Crozier K (2018). ‘How do informal information sources influence women’s decision-making for birth? A meta-synthesis of qualitative studies’. BMC Pregnancy and Childbirth, 18: 21. doi: 10.1186/s12884-017-1648-2 Thomson G, Feeley C, Moran VH et al (2019). ‘Women’s experiences of pharmacological and non-pharmacological pain relief methods for labour and childbirth: a qualitative systematic review’. Reproductive Health, 16(1): 71. doi: 10.1186/s12978-019-0735-4 van der Gucht N and Lewis K (2015). ‘Women’s experiences of coping with pain during childbirth: a critical review of qualitative research’. Midwifery, 31(3): 349-358. https://doi.org/10.1016/j.midw.2014.12.005 Walsh D (2010). ‘Childbirth embodiment: problematic aspects of current understandings’. Sociology of Health and Illness, 32(3): 486-501. doi: 10.1111/j.1467-9566.2009.01207.x Whitburn L, Jones LE, Davey M et al (2019). ‘The nature of labour pain: an updated review of the literature’. Women and Birth, 32(1): 28-38. doi: 10.1016/j.wombi.2018.03.004

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CHAPTER 4

THE PARADOX OF THE INSTITUTION Dr Elizabeth Newnham

INTRODUCTION In this fourth chapter Dr Elizabeth Newnham describes more of the research from the ethnographic study that is outlined in Towards the humanisation of birth: a study of epidural analgesia and hospital birth culture. The background to the study was described in the second chapter, whereas this chapter focuses on the concept of the paradox of the institution – which incorporates analysis of the beliefs and practices observed within the hospital labour ward, set against the behaviour of the hospital itself – the institutional momentum which added yet another component to the already contested space of birth. The institutional paradox also describes the way in which the hospital defines itself as a site of safety, yet behaves as a site of risk, and the way that technological, interventionist practices, which themselves may carry several risk factors, are perceived as safe, whereas practices that support birth physiology are constructed as risky. isk factors, are perceived as safe, whereas practices that support birth physiology are constructed as risky. The concept of the paradox of the institution (illustrated in Figure 1) forms part of an ‘intermediate social’ level of ethnographic analysis – which focuses on institutional policy and decision-making processes and how these impact on clinical practice and professional interactions. This level of analysis aims to highlight dominant cultural institutional beliefs – that may not even be obvious to those within it (recalling Marsden Wagner’s [2001] oft-cited ‘fish can’t see water’) – and how they influence practice. On each side of the paradox model is a distinct concept: organisational technology and midwifery technology, each of which contains its own internal paradox, and both of these contribute to the larger paradox of the institution. 16 ALL4MATERNITY E-BOOK

ORGANISATIONAL TECHNOLOGY My use of the word ‘technology’ here refers to the more common understanding of technology as a scientific or artificial device, and I also draw on Foucault’s use of the word, which classified technologies as collections of techniques and practices. The organisational technology of the institution was based in a predominantly medicalised view of birth as inherently risky and needing to be managed. This industrial-level management of birth required institutional-level surveillance, and the surveillance contributed to the ‘institutional momentum’ – or the throughput of women through the system. Institutional surveillance Although more subtle surveillance techniques were observed in the study, surveillance was overtly achieved through the visual mechanism of the ‘journey board’, which was situated on the rear wall of the midwives’ station. The journey board, divided vertically by bed number and horizontally by columns dedicated to various pieces of clinical information, is a relatively common and simple hospital tool, designed to prevent error and near-miss events (and influenced, I might add, by tools designed for factory and industrial settings). It is also a highly effective surveillance tool, providing various layers of surveillance, including of individual women and the progress of their labour, of midwives and their practice, of staffing and workload, and bed management. It became a visual representation of the safety of the ward itself – a green board (green marker pen signified postnatal) brought a sense of relief both because the ‘danger’ period of labour and birth was over, and because Figure 1 The paradox of the institution the woman would soon be discharged, leaving the bed free. Part of the necessity of institutional surveillance was to try and avoid the ward becoming over Organisational technology Midwifery technology full, and thereby putting women (and clinicians) at ‘risk’. Women were pushed through the system on a timeline that supported the institution and its need to rush women through (and out), despite Guarding Institutional normal birth surveillance many midwives and some doctors equals safety equals safety Midwifery Institutional practice momentum attempting to resist it. increases risk

constructed as risky

Institutional momentum This timeline, or ‘institutional momentum’ was influenced by institutional surveillance. It sped up when the ward was busy, and slowed down when things were quiet. Interestingly, Newnham et al (2018). Reproduced with kind permission of Palgrave MacMillan. if real emergencies were occurring, it slowed the momentum for other women in labour, who would fall under the radar in comparison to what else was going on, and women who might have had intervention on another day would quietly get on and have a baby. If the ward/board was full of women in labour, then measures would be taken to expedite birth in women who were in late stages of labour in order to keep from the very real danger of bed block. Once women were caught in the institutional momentum, it was very difficult to swim against its current. Interventions would continue once they had started, even if the reason for them was no longer valid or of concern. Institutional momentum is shored up by other dominant discourses such as the safety of all/any medical technology/intervention versus the perceived risk of normal birth. However, the unfortunate irony of the paradox is that forcing women to conform to the institution’s timeline (in its attempt to keep them safe) actually puts women at risk – only this risk is not acknowledged within the system because of the dominant belief in birth management and technological intervention as safe. Paradox of the institution

MIDWIFERY TECHNOLOGY Although we think of ‘technology’ as referring to mechanised or technological inventions, the origins of the word reveal another meaning. The Greek root for technology – ‘techne’ – refers to the arts, and artisanal skill and activity. The suffix ‘ology’ refers to the knowledge about techne – technology as ‘the knowledge of art and skill’ – which signifies human beings’ engagement with their craft. There is a seduction with new technologies that drives the ‘technological imperative’ – the compulsion to use technological devices just because they are there (whether or not they are actually of benefit). Whilst selective use of technology is no doubt useful, the reliance on industrial technologies and factory-like rhythms within institutional birth has eroded midwifery ‘knowledge of art and skill’. And many midwives in this study were trying their best to keep hold of it. Guarding normal birth equals safety Something that initially surprised me was that, embedded within the institutional culture, was an underlying premise that midwives were in fact responsible for ‘normal birth’. Doctors would make light-hearted reference to midwives’ skill at disappearing into

CHAPTER 4: THE PARADOX OF THE INSTITUTION 17

a room and ‘getting a baby out’. At first, I thought I had identified support for midwifery technology within the obstetric unit. However, on closer analysis it was revealed as another form of institutional surveillance. Within the paradox of the institution, midwives were expected to ‘perform’ midwifery. Facilitating normal birth where possible supported the institution by decreasing obstetric workload and pressure on other hospital resources (such as the operating theatre and neonatal unit) as well as by aiming for what was a genuine clinical acknowledgement of normal birth as an optimal outcome, not just for the woman but also for the system itself. And yet, against the pressure of the institution’s momentum to ‘push women through’ this became yet another onus on midwives – to be individually responsible for the outcome of the labour, and whether or not the baby was born vaginally. Despite this, midwives attempted to sustain midwifery technology by ‘relishing the normal’: telling each other stories about normal birth when it occurred. Normal birth was imbued with a sense of scarcity and rarity and midwives took great pleasure in the experience of attending women having a physiological, intervention-free labour and birth, and would share their own joy and delight in this with their colleagues. These stories, and other reminders about the unique pattern of women’s individual labours, or midwifery support strategies, provided an oral discourse that kept normal birth and midwifery technology alive within the institution. Midwifery practice constructed as risky The internal paradox of the midwifery technology concept that emerged from the study was that, although being held somewhat responsible for normal birth outcomes, there was a corresponding ridicule, disapproval or disciplining of midwives who attempted to incorporate practices that actually support normal birth physiology. Midwives were expected to abide by risk-oriented protocols of medically-managed birth and interventions based on the institutional timeline. Language used to describe midwives who attempted to use or talk about midwifery technologies invoked images of the ‘hairy-armpit hippie’: the non-conformist, the feminist, the witch. Whilst most of the resistance to institutional technology is in terms of trying to buy more time or decrease intervention, the idea of normal birth as risky becomes a foundation of the medical model of birth, filtering through all levels of hospital discourse, from policy to practice, to midwives and to women. This puts midwives in the predicament of having to follow industrial-level (non-individualised) policies and accepted practices that contradict their professional philosophy, and which may not be supported by high-quality evidence.

CONCLUDING THOUGHTS Antithetical to institutional momentum is a woman labouring and giving birth in her own time. What is most alarming about everything I have just described is how often women say they want to ‘go with the flow’ in labour. Almost all of the women in my study said something to that effect, and women say similar things all over the world (Downe et al 2018). However, because of the momentum within the institutional paradox, women in large, acute-care hospital obstetric units who want to ‘go with the flow’ are far more likely to go with the flow of the institution than with the flow of their bodies’ physiological labour responses. And, given that all of these practices are hidden behind a powerful discourse of safety (of hospital birth, of medical intervention, of technology), the danger of going with the institutional flow is a difficult concept to explain. The paradox of the institution provides a cultural explanation for the quantitative findings of the UK Birthplace study (Brocklehurst et al 2011) and subsequent update of the National Institute for Health and Care Excellence (NICE) guidelines (2014), which recommended that women be informed of the increased risk of intervention (and decreased risk of normal birth) when birthing in an obstetric- compared to a midwifery-led unit. One of the recommendations of my research is that birth should be moved out of large institutions as a matter of priority – and this is even more significant when you consider that the move to hospital was never one of safety to begin with. Hospital birth has, from its outset, posed risks to women. This is not to say that intensive obstetric support and intervention is never needed, but to say that in general, birth as a physiological process with important social and psychological elements is not supported within large institutions that need to manage labour according to industrial technologies and timelines.

REFERENCES Brocklehurst P, Hardy P, Hollowell J et al (2011). ‘Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study’, British Medical Journal, 343(7840): d7400. Downe S, Finlayson K, Oladapo OT et al (2018). ‘What matters to women during childbirth: a systematic qualitative review’. PLoS ONE, 13(4): e0194906. https://doi.org/10.1371/journal.pone.0194906 NICE (2014) [updated 2017]. Intrapartum care: care of healthy women and their babies during childbirth (CG190), London: NICE. https://www.nice. org.uk/guidance/cg190 Newnham E (2019). ‘Humanisation of childbirth. 2. Circle of trust’. The Practising Midwife, 22(9): 15-19. Newnham E, McKellar L and Pincombe J (2018). Towards the humanisation of birth: a study of epidural analgesia and hospital birth culture, Basingstoke: Palgrave Macmillan. Wagner M (2001). ‘Fish can’t see water: the need to humanize birth’, International Journal of Gynaecology and Obstetrics, 75: s25-s37.

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CHAPTER 5

HUMANISING POLICY – THE CURIOUS CASE OF EPIDURAL Dr Elizabeth Newnham

INTRODUCTION In this chapter Dr Elizabeth Newnham looks at policy and practice documents – specifically on epidural and water use – in the ethnographic study site featured in Towards the humanisation of birth. She examines how social beliefs, which run broad and deep and are often unquestioned, affect science, policy and practice. By putting two documents side by side – information pamphlets for women about epidural analgesia and waterbirth – she makes these dominant discourses visible, and discusses them in relation to practice. The document analysis discussed in this chapter formed part of a larger critical discourse analysis predicated on a critical literature review of epidural analgesia.1 This review identified powerful ideas being told and retold about epidural analgesia in the scientific literature – ideas of pain relief as ‘progress’ (technological determinism), as a human right, or at any cost, and that the relief of labour pain is of the utmost importance to women (which we now know it is not: see chapter 3 of this series). The significance of pain related to medical intervention (such as caesarean section), or of the intervention itself, was not acknowledged. So, although early research showed increased caesarean-section (CS) rates, and ongoing research shows increased instrumental-birth rates, the effect of these interventions on women were not discussed. When early research into epidural analgesia showed clear evidence of a causal relationship to CS, epidural analgesia continued to be researched, and described as both safe and efficacious within the scientific literature, even as it identified the risks.

MEDICAL DISCOURSE TRANSLATED INTO INFORMATION PAMPHLETS Epidural analgesia is associated with higher rates of instrumental birth2 (and therefore third- and fourth-degree tears3,4) and intravenous synthetic oxytocin2; requires commencement of continuous electronic fetal monitoring (EFM) (both EFM and synthetic oxytocin are individually associated with increased risk of CS5); and brings other risk factors such as intrapartum fever, hypotension,2 and decreased breastfeeding rates.6,7 Although epidural analgesia is no longer identified as causing increased rates of CS, observational studies continue to show correlation.8,9 It is hard to tease out where exactly in the ‘cascade of intervention’ the

CHAPTER 5: HUMANISING POLICY – THE CURIOUS CASE OF EPIDURAL 19

epidural fits, but it is definitely a component. Despite these, and other risks associated with the anaesthetic itself, the belief in the safety of the epidural that begins in the scientific literature was perpetuated in hospital policy and information pamphlets. In contrast, water immersion in labour – a practice that is low-tech, supports physiology and allows privacy (placing the woman ‘outside’ of medical management or control) – was framed as risky. The state health department had written a policy for water in labour and birth, which in one sense legitimised this relatively alternative practice and made it more mainstream but, in another, contributed to it being presented as a restricted option. The information pamphlet given to women was based on the policy and had to be read and signed while the woman was still pregnant – implying that the decision was too important to be made during labour. On the other hand, epidural analgesia had no such policy and verbal consent was often obtained in labour, with the woman signing a consent form after the epidural had been put in and she was more comfortable.10 When looked at objectively – from outside of the sometimes irrational ‘water’ of obstetric belief – this is actually quite astounding, and highlighting it has provoked animated discussion from midwifery audiences on more than one occasion. The astounding fact is this: that getting into a bath – something that women can do by themselves, at home, without signing anything – required detailed, documented consent before labour commenced, while a procedure for which you need to be in hospital, attended by a highly trained medical specialist, who introduces a needle, catheter and drugs into the spinal fluid – with possibilities of infection and paralysis, let alone the aforementioned obstetric risks to labour – required only verbal consent at any stage during the labour process.

LANGUAGE OF RISK AND SAFETY There is not enough room here to publish the table that compares the two documents and which can be found elsewhere.10,11 However, there was a distinct difference in the tone of the two information pamphlets and the way each practice was framed as ‘risky’ or ‘safe’. The first sentence on the waterbirth pamphlet was that ‘Hospitals, doctors and midwives… generally do not advocate waterbirth’ (this is completely anecdotal and in fact not true – at least not the part referring to midwives, in my experience). This would be enough to put some women off completely, given the pressure to conform to social norms of medical acquiescence and responsible motherhood. The risk tone continued throughout; although citing evidence of the benefits of waterbirth, there was also mention of ‘rare events such as drowning’, the strict conditions under which water use could occur, and how and when access would be restricted. The epidural pamphlet had none of these warnings, beginning with ‘Epidurals are commonly used in labour for pain relief… Epidurals provide very good pain relief, and you may want one when you are in labour.’ Although obstetric and anaesthetic risks were mentioned, they were downplayed and there was no mention of any possible effect on the baby, instead, stating ‘an epidural may be better for your baby than other types of pain relief as it minimises the effects of painful labour’, echoing the themes in the scientific literature. The overall tone was pleasant and conciliatory, compared to the paternalistic warning tone of the waterbirth pamphlet. Women planning a waterbirth were told ‘you must…, you can’t…, you can only… if, you cannot…’. Women planning an epidural would only be ‘advised’ if there was some reason for which she could not have one. In both pamphlets the incidence of rare events was discussed (drowning for waterbirth, paralysis for epidural) but only in waterbirth were these events said to ‘cast a cloud’ over the practice. Rare epidural events (maternal paralysis, death due to error or infection) did not appear to attract such a cloud.

HOW RISKS ARE IDENTIFIED AND MAINTAINED IN MEDICAL DISCOURSE The institutional paradox identified how risks of medical intervention are commonly not acknowledged, birth intervention therefore being construed as safe, while physiological birth is believed to be dangerous, and therefore practices associated with it are construed as risky. Evidenced by the language of scientific beliefs that filtered down through policy, into practice; detrimentally affecting women’s choices. The extra paperwork associated with the use of water was restrictive, and meant that women missed out on this option. Also restrictive was the fact that midwives needed to be accredited to attend waterbirth (an education package and witness to three waterbirths) before being able to attend one. As there was no real support for this from the hospital management, progress was slow and there were relatively few midwives accredited to facilitate waterbirth. Midwives were not required to be accredited to attend a woman with an epidural (despite the extra observation and susceptibility to risk that epidural analgesia entails). This restriction was filtered down to the woman, with midwives saying, ‘You can use the bath, but… you have to sign the consent; there has to be a midwife on who is accredited; the rooms with the baths have to be free.’

CONCLUDING THOUGHTS – HUMANISING POLICY So, what is the problem here, and how can we move towards a solution? These policy and practice impositions meant that water, an essentially low-risk, effective form of analgesia for labour, had inordinate restrictions for use. However, when looked at in terms of danger rather than risk, evidence points to the epidural as the more ‘dangerous’ of the two practices.

20 ALL4MATERNITY E-BOOK

THE CURIOUS CASE OF EPIDURAL ANALGESIA AND WATER IMMERSION

Bryers and van Teijlingen12 talk about the idea of tolerable risk, where individual perceptions of what constitutes a risk, based on prior experience and beliefs, are weighed up and some freedoms surrendered or compromises made in order to feel safe. Women therefore fashion an interpretation of risk and safety according to their own parameters, although these, too, may be influenced by broader social and cultural discourse. Epidural analgesia, as a medical intervention and therefore perceived as safe, comes across clearly as a tolerable risk for the obstetric institution, whereas water immersion does not. Dominant conceptualisations of risk are perpetuated by medical authority (and the belief that birth is dangerous and needs to be managed) and not necessarily drawn from evidence. If we are going to humanise childbirth policy then such hidden agendas need to be made visible and policies written that are informed not only by evidence, but also have input from women. Such policies also need to be flexible to individual needs and circumstances rather than prescriptive to the whole birthing population.

Reflections for practice How are the policies in your local area of practice developed? On what evidence are they based? How is the risk or safety of a particular practice conceptualised within policy? Are midwives/women invited to be part of policy development? Are policies easily adapted to the needs of individual women? What other information or learning about this do you need?

REFERENCES 1. Newnham E, McKellar L, Pincombe J. A critical literature review of epidural analgesia. Evidence Based Midwifery; 2016;14(1):22-28. 2. Anim-Somuah M, Smyth RMD, Cyna AM, Cuthbert A. Epidural versus non-epidural or no analgesia for pain management in labour. Cochrane Database of Systematic Reviews; 2018;May 21st,5: CD000331. doi: 10.1002/14651858.CD000331.pub4. 3. Jha S, Parker V. Risk factors for recurrent obstetric anal sphincter injury (rOASI): A systematic review and meta-analysis. International Urogynecology Journal; 2016;27(6):849-857. 4. Ramm O, Woo VG, Hung Y, Chen H, Ritterman Weintraub ML. Risk factors for the development of obstetric anal sphincter injuries in modern obstetric practice. Obstetrics & Gynecology; 2018;131(2):290-296. 5. Smith V, Gallagher L, Carroll M, Hannon K, C B. Antenatal and intrapartum interventions for reducing caesarean section, promoting vaginal birth, and reducing fear of childbirth: an overview of systematic reviews. PLoS ONE; 2019;14(10):e0224313. https://doi.org/10.1371/journal.pone. 6. Adams J, Frawley J, Steel A, Broom A, Sibbritt D. Use of pharmacological and non-pharmacological labour pain management techniques and their relationship to maternal and infant birth outcomes: Examination of a nationally representative sample of 1,835 pregnant women. Midwifery; 2015;31:458-463. 7. Jordan S, Emery S, Watkins A, Evans J, Storey M, Morgan G. Associations of drugs routinely given in labour with breastfeeding at 48 hours: analysis of the Cardiff Births survey. BJOG; 2009;116:1622-1632. 8. Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Listening to mothers III: Pregnancy and birth: childbirth connection. The Journal of Perinatal Education; 2014;23(1):17-24. 9. Lucovnik M, Blajic I, Verdenik I, Mirkovic T, Stopar Pintaric T. Impact of epidural analgesia on cesarean and operative vaginal delivery rates classified by the Ten Groups Classification System. International Journal of Obstetric Anesthesia; 2018;34:37-41. 10. Newnham E, McKellar L, Pincombe J. Towards the humanisation of birth: epidural analgesia and hospital birth culture. Basingstoke, UK: Palgrave MacMillan; 2018. 11. Newnham EC, McKellar LV, Pincombe JI. Documenting risk: a comparison of policy and information pamphlets for using epidural or water in labour. Women and Birth; 2015;28(3):221-227. 12. Bryers HM, van Teijlingen E. Risk, theory, social and medical models: a critical analysis of the concept of risk in maternity care. Midwifery; 2010;26(5):488-496.

CHAPTER 5: HUMANISING POLICY â&#x20AC;&#x201C; THE CURIOUS CASE OF EPIDURAL 21

CHAPTER 6

MIDWIFERY TECHNOLOGY – MIDWIFERY PRACTICE FOR THE HUMANISATION OF BIRTH Dr Elizabeth Newnham

INTRODUCTION In this chapter Dr Elizabeth Newnham talks more about the concept of midwifery technology – knowledge of the art and skill of midwifery – introduced in the fourth chapter of the series. Given the wide-ranging public health problem of over-medicalisation, high intervention rates, and current trends of combating one intervention with yet another instead of looking back to physiology, it is vital that midwives continue collecting, sharing and researching midwifery knowledge and practice. Different to obstetric knowledge, or practice guidelines, midwifery knowledge needs to include knowledge of the ebbs and flows of birth physiology, of women’s experiences and of keeping out of the way of birth as much as knowing when to step in. ar e perceived as safe, whereas practices that support birth physiology are constructed as risky. Previously, I talked about the conceptual structure of the paradox of the institution. From this conceptual structure, I described the embedded concepts of organisational technology and midwifery technology. Here I want to explore this notion of midwifery technology more fully; it is important to understand how these technologies have emerged, and to explore the role of midwifery technology in humanising birth. First, it is important to note that in referring to obstetrics and midwifery, I am referring to knowledge systems, rather than individual practitioners, and some midwives operate within an obstetric knowledge system, while some obstetricians subscribe to a midwifery one. There is a need for these systems to be bridged so that women can access the best and most relevant care for their needs, and I do not dichotomise them lightly. In fact, humanisation of birth provides a way forward in the bringing together of these two systems. However, in order to do this, it is vital to discuss the history of birth knowledge and the power dynamics that enable one kind of knowledge to supersede another.

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GENEALOGY: THE STUDY OF DISCOURSE There is increasing alarm across the world about the over-medicalisation of birth, and rising birth intervention rates, especially caesarean section.1,2 It can be useful, in order to understand current practices, to spend some time tracing their history. Michel Foucault, a French philosopher I draw on heavily in Towards the humanisation of birth,3 called this process ‘genealogy’. Genealogical research essentially examines the ‘struggle’ between competing knowledge systems. Foucault explains that the status quo – what appears as reasonable or right, or simply as taken for granted or unquestioned within any society – is not necessarily reasonable, or right. It is the end result of numerous power/knowledge struggles, where those who access and lay claim to power/knowledge (otherwise known as ‘discourse’) get to create this status quo, and therefore the current ‘truths’ of the epoch. The fact that dominant discourses often present themselves as beyond doubt, makes it all the more necessary to question them.4 On examining obstetric and midwifery practice, including situating hospital as the primary place of birth, from a genealogical perspective, it becomes evident that much of the argument about the safety of both obstetric practice and of the hospital is due to a dominant obstetric discourse, rather than because it is true. This discourse is upheld in various ways, such as ridiculing and shutting down dissenting voices, and basing points of argument on authority and belief, not evidence.4 Therefore, knowledge of practices that support birth physiology, including those that might have been passed down through generations of midwives, is being lost or may not have been gathered in the first place. This point was made eloquently in last month’s TPM issue by Jo Gould in her paper on storytelling and midwifery knowledge, saying that ‘the generation and promotion of midwifery knowledge must be at the heart of a concerted action to reverse the declining trend in physiological birth’.5 (p.13) The need to collate midwifery – and women’s – birth knowledge is a recurrent theme across decades of midwifery and social science literature, and it is imperative that we do so.

KNOWLEDGE AND POWER Much of the information that has been collected over the centuries about birth and women’s bodies was produced by male philosophers and scientists and bears the marks of historical gender assumptions. This first traversed ideas of women’s bodies as opposite (though unequal) to, then as completely ‘other’ than the male body, and eventually regarded as generally pathological and untrustworthy, needing to be regulated or fixed.2 This mistrust and regulation of women’s bodies is the basis for the mechanised system of institutional birth. Such assumptions have shaped the (dominant) discourse of medicine and obstetrics. However, obstetrics’ assertion of authority was not informed by any greater knowledge – in fact far less so – than the local midwife, who had the benefit of empirical knowledge, passed down through generations. University medical training – which women were prohibited to attend – until the turn of the 17th century, was still based on the theories of Galen, a second-century Greek doctor. Medical students had little practical experience, and common cures included bloodletting, balancing humours, prayer and amulets. Although some of these folk practices would have also been used by village healers and midwives, their greater practical knowledge was evident; many midwives had use and knowledge of herbs such as ergot and belladonna, the chemical derivatives of which are now in use medicinally.2 What medical practitioners had – and why their knowledge came to be dominant –was access to education, the status of their gender, the support of the Church (which was opposed to midwives, especially during the centuries of the witch-craze), and their later alignment with the scientific discourse (although obstetrics was, and remains, slow to get on the evidence-based train).6 In establishing itself as the dominant discourse, the obstetric system failed to disclose or acknowledge the high mortality rates from puerperal fever in lying in hospitals, or from overuse of obstetric forceps, and continued to perpetuate a mythology of obstetric intervention as safer than midwifery.4 The system of obstetrics continues to maintain its dominant birth discourse (often at the expense of midwives), with claims to authority, as rescuers of women, as responsible for all that is safe about birth in the modern era, rather than actually providing robust evidence to support its case.4 It is important to remind ourselves of the extensive public opposition to midwives by the medical profession and the church over several hundred years. Well documented, it rarely seems to enter current birth discussions, yet its influence is ongoing. Although we may have moved on in terms of gender equity, the ramifications of centuries of expurgation, oppression and mass slaughter during the witch-craze (of which midwives were a target) cannot be underestimated.

MIDWIFERY TECHNOLOGY Knowledge of midwifery art and skill is therefore, often, still anecdotal, empirical or experiential. Midwives pass on stories, they observe the process of labour, use intuition and are guided by the women in their care. There is also more and more research in this area, primarily since midwives have been undertaking their own research – although, knowledge associated with normal physiological birth does not necessarily need to be generated by midwives. Again, it just needs to sit within a philosophy of trust in women’s bodies and birth physiology. Let us use the progress of labour as an example. Midwife Ina May Gaskin talks about the concept of ‘pasmo’, a Spanish word that describes the halting of established labour, and midwives’ empirical knowledge of ‘reverse’ dilatation of the cervix.7 She gives many

CHAPTER 6: MIDWIFERY TECHNOLOGY – MIDWIFERY PRACTICE FOR THE HUMANISATION OF BIRTH 23

examples of obstetric textbooks from the 19th century that state that the medical practitioner should take care entering a birth chamber as a sudden shock or encounter with a stranger could stop contractions, for hours, or even days. Perhaps this knowledge was passed on by midwives, as they often make reference to the midwife who is already in the room with the woman. And yet, as birth moved into hospitals, obstetric discourse brought in practices that opposed this knowledge: Friedman’s curve, frequent vaginal examinations, lack of privacy, active management of labour. Obstetric discourse expected women to dilate at 1 cm per hour and fixed those who did not with intervention. Midwives, on the other hand, even those who worked in obstetric units, know that women’s cervices do not dilate like that: that labour can be interrupted, that it can speed up or slow down (or stop), that there are hormonal and subconscious factors at play. A recent prospective cohort study adds to recent research that questions decades of this practice.8 What the authors found was that cervical dilatation was ‘non-linear’; that cervical dilatation was slower if women came into hospital before 4 cm dilatation, that women could spend four hours or more progressing from 3-4 cm, with faster dilatation after 6 cm. In the 95th percentile range, women could take anywhere between three to eight hours to dilate from 4 to 5 cm, or between one to six hours to dilate from 5 to 6 cm. Some women never dilated at the speed of 1 cm per hour and these differences did not necessarily lead to adverse outcomes.8 This study, and the related work, breaks new ground from an obstetric point of view. Seeing this research presented at the Normal Birth conference one year was a memorable moment. I was delighted – excitedly taking photos of the presentation slides to share with my students. The study is brilliant and beneficial; it will change practice and hopefully prevent unnecessary intervention from occurring. And yet, I felt like getting up and shouting ‘Yes! Yes, midwives knew this all along!’

CONCLUSION If hospitals and obstetrics were robust systems that were based in evidence, they would be redesigned to actually support birth physiology. Even with the knowledge we now have – of intricate and interlinked hormonal and psychological responses – most obstetric units do not attempt to reduce practices that can interfere with women’s labour, such as bright light, noise, interruption and lack of privacy. Quite apart from the incorporation of evidence, in a mechanised, linear, time-managed view of labour, there is not much allowance, if any, for nuance, for individuality, for connection, for love or for humanity in the birth room. It is time we changed this; a focus on rebuilding midwifery technology – knowledge of midwifery art and skill – can help us achieve it. Reflections for practice 1. Do you have your own ‘midwifery technologies’ that you use in practice? How do you share these with other midwives? 2. Think about your place of work. Is there a place for the development or sharing of midwifery technology? 3. If so, think about how this can be used to improve practice or policy. 4. If not, is there a way you could begin this? 5. Reflect on the practice guidelines in your place of work. On which knowledge/evidence are they based? 6. Think about some of the ‘routine’ interventions that sometimes still occur in maternity settings. How did these practices start, what was their origin, and on which knowledge are they based?

REFERENCES 1. Miller S, Abalos E, Chamillard M, Ciapponi A, Colaci D, Comandé D, et al. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. The Lancet. 2016;388(10056):2176-92. 2. Cassella C. The World Health Organisation Has Called For a Reduction in C-Sections. Science Alert. 2018. https://www.sciencealert.com/whoglobal-caesarean-rates-double-15-years. Accessed December 1st 2019. 3. Newnham E, McKellar L, Pincombe J. Towards the humanisation of birth: epidural analgesia and hospital birth culture. Basingstoke, UK: Palgrave MacMillan; 2018. 4. Newnham EC. Birth control: Power/knowledge in the politics of birth. Health Sociology Review. 2014;23(3):254-68. 5. Gould, J. Storytelling, midwifery knowledge and physiological birth. The Practising Midwife. 2019;22(11):9-13. 6. Grimes DA. Discovering the need for randomized controlled trials in obstetrics: a personal odyssey. JLL Bulletin: Commentaries on the history of treatment evaluation. 2007. https://www.jameslindlibrary.org/articles/discovering-the-need-for-randomized-controlled-trials-in-obstetrics-apersonal-odyssey/. Accessed December 1st 2019. 7. Gaskin I. Going Backwards: The Concept of Pasmo 2019. https://inamay.com/going-backwards-the-concept-of-pasmo/. Accessed December 1st 2019. 8. Oladapo OT, Souza JP, Fawole B, Mugerwa K, Perdoná G, Alves D, et al. Progression of the first stage of spontaneous labour: A prospective cohort study in two sub-Saharan African countries. PLoS Medicine. 2018; 15(1): 1-30.

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CHAPTER 7

THE ROLE OF CRITICAL PEDAGOGY IN MIDWIFERY EDUCATION Janice Bass, Dr Lois McKellar and Dr Elizabeth Newnham

INTRODUCTION In this chapter the authors discuss the importance of using critical pedagogy as a pathway to transforming maternity care and humanising childbirth. We have a responsibility to students in terms of what and how we teach future generations of midwives. Midwives are guardians of normal birth, and they are also teachers, passing on midwifery technology (knowledge of the art and skill of midwifery) to midwifery students. Midwifery academics in particular, as educators and researchers, are guardians of the discipline and its knowledge base. The authors of this paper, all of whom work in higher education, see education as transformational â&#x20AC;&#x201C; transformational on a personal level, as well as encompassing the transformation from student to midwife, the transformation of the profession itself and, ultimately, the transformation of society.

THE ROLE OF EDUCATION IN HUMANISING MATERNITY CARE

The World Health Organization (WHO) asserts that central to the provision of quality maternity care is the need for women and their families to thrive, not just survive, and that this requires a strong and significant contribution by midwives who are educated to international standards.1 In order for families to thrive, the humanisation of childbirth must be at the heart of midwifery education globally. Midwifery education plays a critical role in the development of midwifery and curricula should be designed to reflect this. Key to this is the imperative to embed a set of core values at the heart of midwifery curricula, which reflect the qualities that will optimise a positive childbirth experience and, ultimately, humanise birth.2 In order to embed and enact the philosophy inherent in the humanisation of childbirth, midwifery education must draw on transformative learning theories, alongside experiential learning principles and attention to the reflection/action dialectic known as praxis. Transformative learning emphasises the role and responsibility of the educator to shape the educational experiences of the learner.3 Attention is given to power relationships with a specific focus on the student-teacher relationship4 and the educational process is underpinned by respect, with educators modelling the respectful care and communication that graduates will engage in with women. Drawing on experiential learning the student is intentionally situated at the centre of learning and becomes directly involved in the process of constructing knowledge.5 CHAPTER 7: THE ROLE OF CRITICAL PEDAGOGY IN MIDWIFERY EDUCATION 27

HUMANISING MIDWIFERY EDUCATION The movement towards a humanised birth culture is deeply rooted in the primacy of the midwife-woman relationship. Being woman-centred lies at the heart of a humanised approach to childbirth and represents a fundamental concept that guides the nature, philosophy, education and practice of midwifery. The paradigm shift from the current technocratic model to a humanised approach in childbirth requires a deep structural shift in attitudes regarding women and childbirth at an individual, institutional and societal level. Davis-Floyd describes this as deep humanism that seeks to balance the needs of each birthing person and the institution, in ways that respect each birthing person’s experience and the physiology of human birth.6 This structural shift requires fundamental changes in midwives’ attitudes, beliefs and willingness to provide woman-centred and humanised care in practice.7 It is concerning that, despite the role of the midwife as the guardian of normal birth and alignment with an individualised, holistic and woman-centred approach, the dominant technocratic hegemony continues to exert a profound influence on the professional socialisation of midwives. Central to this is the debate about how we can best facilitate the development of midwives who are capable practitioners and philosophically aligned with transforming maternity care through humanising birth. We suggest this is best achieved through a transformational, social emancipatory and holistic approach within midwifery education. The curriculum should be underpinned by a constructively aligned pedagogy that equally values personal and societal transformation alongside fitness for practice and preparation for employment.8

THE ROLE OF CRITICAL PEDAGOGY In transformative education, critical theory is used to raise consciousness, resulting in critical awareness of dominant ways of thinking and use of knowledge to assist self and others to live a more liberated life.9 Critical consciousness is more than a way of thinking or knowing, it is manifest as a way of being in the world.10 This is underpinned by critical pedagogy with a focus on realising the dominant paradigms of the age, understanding oppressive forces and taking action.9,10 The purpose of an emancipatory transformative approach within midwifery education is to facilitate a shift in human consciousness to make a difference as agents of change at a personal and societal level.11 Through social emancipation midwives are able to draw on diverse ways of knowing in an ethical manner how to advocate for social and political justice and equity for women and families in their care. In this way, midwives exercise critical thinking and reflexivity to inform both the development of best practice skills and attitudes aligned with humanistic dimensions of midwifery and childbirth.7 To facilitate this shift in human consciousness and transformation in practice, education of the whole person is essential. Transformative learning comprises a holistic human process that involves cognitive, emotional, social, cultural, physical and spiritual dimensions.12 Critical theory and emancipatory learning help us to situate ourselves in the centre of another’s experience, while recognising and respecting our differences – not as separate but as a reflection of the diversity of our shared human condition and unique experience.13 This enables the development of midwives who achieve transformation at a personal and societal level as self-determining, self-empowered and autonomous midwife practitioners.4,10

HOLISTIC APPROACH TO EDUCATION The use of holistic education approaches through exploration of the art and science of midwifery practice draws on personal, intuitive, empirical, aesthetic, midwifery and woman’s ways of knowing. This includes midwifery knowledge and practice drawn from the humanistic/holistic paradigm, rather than the technocratic/biomedical continuum.6 The unique relationship between the midwife and the birthing person represents a holistic perspective that involves opportunities for personal growth and development.14 Furthermore, midwifery care where midwives ‘work with’ rather than ‘for’ the expectant parent, paves the way for holistic care.15 Emotional, physical, spiritual and psychological presence in the relationship is central to the philosophy underpinning the concept of ‘being with women’ in midwifery care.14,15 This requires an integrative whole of midwifery program approach with translation of the humanised birth paradigm across the midwifery theory-practice continuum. Central to this is embedding midwifery meta-values throughout the curriculum to facilitate development of a midwifery values-aligned philosophy and strong sense of professional identity.16 This includes providing midwifery students with immersive learning opportunities in practice to experience woman-centred midwifery models of care. In a recent study, midwifery students described the experience of immersion in continuity of midwifery care as transformation that created a paradigmatic shift from a medicalised to a humanised view of birth.17

THE ROLE OF CRITICAL REFLECTION Embedding critical and reflective pedagogies within the curriculum is also essential to promote the paradigm shift associated with humanisation of birth. Critical thinking involves clinical judgements and decisions based on appropriate contextual evidence that reflects the birthing person’s holistic, individual circumstances.18 Critical reflection promotes self-awareness, deep personal learning and ability to identify the values and beliefs underpinning our practice. When we further reflect on the assumptions informing these values and beliefs, we reveal the influence of dominant discourses and power relationships inherent within our practice.19 Sharing insights and meanings generated through critical reflection with others as part of reflexive conversations is more likely to lead to shifts in perspective and changed ways of knowing and being in the world.20

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RESPONSIBILITIES OF EDUCATORS AND STUDENTS In this way midwife educators are challenged to aspire to facilitate the development of midwives who are more than technically competent, but whose practice is steeped in the values and ethics of humanism and caring as the disciplinary foundation and moral obligation of midwifery to society.21,22 Transformational learning requires a movement away from traditional didactic teaching styles into a context of learning where students are empowered to be active participants in their own learning and as agents of change in the healthcare system.

CONCLUDING THOUGHTS Ultimately, transformational education empowers learners to be active participants within their own learning and ultimately as practitioners within the healthcare system. Opportunities for personal introspection and shared discourse through interaction with others within a learning community need to be explored and included. Through this process they reflexively question the beliefs, assumptions and constraints of their understanding of the world, and to consciously transform themselves through learning.20 This in turn builds resilience, confidence and a love of learning at the same time as developing knowledge and skills. Embedding a social emancipatory and transformative education philosophy within midwifery curricula is essential to facilitate development of midwives who are values-aligned with the humanisation of birth.

REFERENCES 1. World Health Organization (WHO). Strengthening Quality Midwifery Education Framework for Action, Universal health Coverage 2030. Geneva: WHO; 2019. 2. International Confederation of Midwives (ICM). International Confederation of Midwives Global Standards for Midwifery Education. 2013. 3. Biesta G. What is Education For? On Good Education, Teacher Judgement, and Educational Professionalism. European Journal of Education. 2015;50(1):75-87. 4. Cranton P. Understanding and Promoting Transformative Learning: A Guide for Educators of Adults. San Francisco: Jossey-Bass; 2009. 5. Chorazy M, Klinedinst K. Learning by doing: A model for incorporating high-impact experiential learning into an undergraduate public health curriculum. Frontiers in Public Health Journal. 2019;7(31):1-6. 6. Davis-Floyd R. Ways of Knowing about Birth: Mothers, Midwives, Medicine, and Birth Activism. Long Grove, Illinois: Waveland Press; 2018. 7. Fontein-Kuipers Y, De groot R, Van Staa A. Woman-centered care 2.0: Bringing the concept into focus. European Journal of Midwifery. 2018;2(5):1-12. 8. Biggs J, Tang C. Teaching for quality learning at university: What the student does. 4th ed. Berkshire, England: Open University Press; 2011. 9. Friere P. Pedagogy of the oppressed. Hammondsworth: Penguin Books; 1972. 10. McAllister M. Transformative teaching in nursing education: leading by example. Collegian. 2005;12(2):11-16. 11. Cranton P. Understanding and promoting transformative learning: a guide for educators of adults. San Francisco: Jossey-Bass higher and adult education series; 2006. 12. Illeris K. Transformative Learning. In: Scott D, Hargreaves E eds. The SAGE Handbook of Learning. Thousand Oaks, US: Sage Publications Ltd; 2015:331-352. 13. Canales MK. Othering. Advances in Nursing Science. 2010;33(1):15-34. 14. Hunter B, Berg M, Lundgren I, Ólafsdóttir ÓÁ, Kirkham M. Relationships: The hidden threads in the tapestry of maternity care. Midwifery. 2008;24(2):132-7. 15. Kirkham M. How can we relate? In: Kirkham M ed. The midwife-mother relationship. New York: Palgrave Macmillan; 2000:227-50. 16. Sidebotham M, Fenwick J, Carter A, Gamble J. Using the five senses of success framework to understand the experiences of midwifery students enroled in an undergraduate degree program. Midwifery. 2015;31(1):201-7. 17. Sidebotham M, Fenwick J. Midwifery students’ experiences of working within a midwifery caseload model. Midwifery. 2019;74:21-8. 18. Carter A. Critical thinking. In: Jefford E, Jomeen J eds. Empowering Decision-Making in Midwifery: A global perspective. Oxon, UK: Routledge; 2019:64-76. 19. Fook J, White S, Gardner F. Critical reflection: A review of contemporary literature and understandings. In: Fook J, White S and Gardner F eds. Critical reflection in health and social care. Berkshire, UK: Open University Press; 2006:3-22. 20. Bass J, Fenwick J, Sidebotham M. Development of a model of holistic reflection to facilitate transformative learning in student midwives. Women and Birth. 2017;30(3):227-35. 21. Hills M, Watson J. Creating a caring science curriculum: an emancipatory pedagogy for nursing. New York, US: Springer Publishing Company; 2011. 22. Newnham E, McKellar L, Pincombe J. Towards the humanisation of birth: epidural analgesia and hospital birth culture. Basingstoke, UK: Palgrave MacMillan; 2018.

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CHAPTER 8

WHERE DO WE GO FROM HERE? Professor Lesley Page and Dr Elizabeth Newnham

INTRODUCTION In this final chapter the authors revisit the important tenets of the humanisation of childbirth and provide ideas for progressing this concept into the future of maternity care systems. Ideas discussed in this paper have been published in an article by Professor Lesley Page in Deutsche Hebammen Zeitschrift, titled (in English) Humanising birth: crucial for resilience sustainability and humanity for the future, and in German Die Humane Geburt: Zeit fĂźr den Wandel!1 and by Dr Elizabeth Newnham and colleagues in Towards the humanisation of birth: a study of epidural analgesia and hospital birth culture.2 e perceived as safe, whereas practices that support birth physiology are constructed as risky.

THE CRITICAL NEED TO HUMANISE BIRTH

In her recent article written for a German practicing midwife journal, Lesley Page made the comparison between childbirth dehumanisation and overmedicalisation, and the crisis of climate change. They are both issues of global importance, and yet there is scant awareness of the critical implications of the problems of dehumanised and overmedicalised care. Perhaps they are a part of the same crisis: reliance on outdated industrial models; on the belief that we can interfere with delicate and complex processes of physiology or ecology without disturbance; that we are all self-reliant individuals (a byproduct of capitalism and neoliberal politics); that we do not require fundamental social processes of support and community and allow commercial interests to dominate care. These late modern beliefs and practices are at the heart of the overmedicalisation of birth. However, the consequences of disturbing birth physiology are also becoming clearer,3 and may not only disrupt the immediate mother-baby dyad, but also impact on the health of future generations through epigenetic change.4 30 ALL4MATERNITY E-BOOK

REVISITING HUMANISATION OF CHILDBIRTH Humanising birth is a response to this problem. It is an approach, a way of thinking about birth, that moves away from medicalisation and institutionalisation – moves away by building systems of care that respect the complex processes of physiology and social support, that respect the need for true autonomy and justice, and that provide individualised compassionate and respectful care to all women and their families. The idea of humanising birth can be used by individual practitioners in their daily work to develop awareness to encourage critical and big picture thinking, to establish systems of care, and redesign healthcare services. According to the findings discussed in Towards the humanisation of birth,2 midwives should be aware that women do not necessarily come into labour with a specific plan: women expect support, comfort, suggestions for coping and identification of the abnormal. They expect that their bodies be respected. They expect that birth physiology will be supported. Women’s experiences of birth are strongly influenced by the attitude of the midwife and rely on the development of a trusting relationship (the ‘circle of trust’ – see the second chapter).5 This seemingly simple factor is complicated within institutional/ industrial birthplace because it puts midwives in a position where they are attempting to facilitate a trusting relationship on one hand and work within medicalised and prescriptive hospital policy on the other. It also undermines women’s expectations – as they are expecting to be offered choices that actually do encourage normal birth. This disruption of the midwife-woman relationship by the institution can be detrimental to both women and midwives.6

TRUST AND THE INDUSTRIAL MODEL The issue of trust – so central to childbirth – is complex. One of the fundamental principles of the medical model of childbirth is a lack of trust in the woman’s birthing body (and a corresponding faith in science and technology to ‘fix’ the faults). Add to this a longstanding gendered history of control over women and reproductive processes, and the end result is a flawed system that, generally, fails to see its own shortcomings. This situation leads to a lack of trust, by some women and some midwives, in the medical system. While this can lead to a reclaiming of birth space and knowledge production, and the provision of alternative models, other consequences include a complete lack of engagement with any health provider, or non-disclosure of complications, thereby increasing risk. The flipside is complete faith in a medical system that cannot always deliver on its promise of healthy mother, healthy baby, which introduces risk and iatrogenesis through overuse of intervention, and which cannot incorporate individualised care into its industrialised model. What is needed is for trust to build between the obstetric and midwifery professions. However, birth remains contested territory under dominant discourses of risk and safety. Policies that restrict ‘normal’ birth practices and facilitate ‘medical’ ones further embed these discourses. The paradox of the institution (see the fourth article in this series7) – the entrenched surveillance and momentum that seeks to keep women safe by pushing them through – potentially puts women at risk and puts midwives in a contradictory position as both guardians of normal birth and risky practitioners.

PRIORITISING PLACE OF BIRTH We suggest the critical revision of the assumption that a hospital labour ward should be the primary place of birth. Implementation of alternative birth settings should be prioritised and midwives the lead providers of maternity care for most women. Homebirth services need to be supported by infrastructure and positive interdisciplinary culture. In instances where women need to birth in hospital labour wards, practices that support physiological birth, such as continuous labour support and the use of water, should be viewed as best practice. Where normal birth is not possible, supportive trusting relationships should still be facilitated. This is not a narrow focus on ‘normal birth’ outcomes – it is about maximising the potential of physiology and paying attention to the process. Dahlen notes that ‘keeping birth normal is at the heart of building trust – building trust keeps birth normal’.8,p160 This will be the beginning of a humanised birth culture that attributes trust, power and respect to women’s bodies. One that places women at the centre of the birth process and prohibits unethical actions. Disrespectful and abusive behaviours in maternity settings frequently fly under the radar due to narrow definitions of ‘informed consent’ and ‘bodily autonomy’ that do not acknowledge discourses and relationships of power.9 In fact, humanisation is very much about confronting our illusions, or perhaps delusions, about what is safe. We cannot, given the evidence, continue to support the belief that hospital birth is safer than out of hospital birth, or that high caesarean section rates are safe. Hospital birth and caesarean birth might be safer for some women and some babies, but not all. So, the development of personalised care, or woman-centred care, is at the very heart of humanisation. The provision of individual care, which meets the personal and physical needs of each woman, her baby and family and responds to her preferences and life situation, requires a shift in systems of care in our institutions, to emphasise the importance of relationship formation over time (continuity of carer (CoC)). An essential part of the relationship is in the art of respectful conversations, always listening to the woman and responding to her needs and values. It is about being able to convey good information, understand and convey the evidence and help the woman apply it to her own situation and, ultimately, to make her own decision about her care. Therefore relationship-based CoC is key to humanised approaches.

CHAPTER 8: WHERE DO WE GO FROM HERE? 31

CONCLUDING THOUGHTS But perhaps above all, humanised birth is concerned with recognising the deep significance of the birth of a baby, the woman becoming mother, the partner becoming parent and a new family being formed. Pregnancy, birth and the weeks after are a critical sensitive period in which midwives may contribute to this strong relationship, which is the foundation to health, wellbeing and emotional resilience through life. A secure attachment is a building block, a cornerstone, to a life of more positive relationships, improved wellbeing and greater empathy and altruism. This support for a secure attachment comes not only from sensitive and responsive support of the woman and her partner, but also support of physiological processes and avoiding disruption to the physiological basis of love as much as possible.3 The birth of every baby is the birth of our humanity.10 The humanisation of childbirth is therefore, fundamentally, about the perpetuation of love and a more optimistic future for humankind.

FUTURE STEPS AND POINTS OF REFLECTION • The circle of trust can provide a useful model to understand the relationships and influences described by women and required of midwives and a template for humanised birth practice. Consider reading about the circle of trust model and incorporating an understanding of the model into your practice. • A renewed focus on ‘midwifery technology’ – with an emphasis on the continuing importance of research, education, documentation, dissemination and support of knowledge and practice that facilitate normal birth. Share your midwifery ‘knowledge of art and skill’ with each other. Talk to colleagues, organise interdisciplinary journal clubs or study days. • That midwives acknowledge their disruptive potential as the nexus between women and medical discourse. That they hold firm to the central mother-midwife relationship and notice if/when the institution gets in between this. Consider your interactions with women. Do they contribute to or question dominant medical discourse? Pay attention to the times if/when hospital policy causes conflict or disrupts the mother-midwife relationship. What affect does this have on trust, on ethical practice, on your feelings about your practice?

REFERENCES 1. Page L. Die humane Geburt: Zeit für den Wandel. Deutsche Hebammen Zeitschrift. 2019;(11)8-12. 2. Newnham E, McKellar L, Pincombe J. Towards the humanisation of birth: epidural analgesia and hospital birth culture. Basingstoke, UK: Palgrave MacMillan; 2018. 3. Buckley S, Uvnas Moberg K. Nature and consequences of oxytocin and other neurohormones in the perinatal period. In: Downe S, Byrom S, eds. Squaring the Circle: Normal birth research, theory and practice in a technological age. London: Pinter and Martin; 2019:19-31. 4. Downe S, Powell Kennedy H, Dahlen H, Craig J. Epigenetics in healthy women and babies: short and medium term outcomes. In: Downe S, Byrom S, eds. Squaring the Circle: Normal birth research, theory and practice in a technological age. London: Pinter and Martin; 2019:163-70. 5. Newnham E. Humanisation of childbirth series article 2: The circle of trust. The Practising Midwife. 2019;22(9):15-19. 6. Kirkham M. How can we relate? In: Kirkham M, ed. The midwife-mother relationship. New York: Palgrave Macmillan; 2000:227-50. 7. Newnham, E Humanisation of childbirth series article 4: The paradox of the institution. The Practising Midwife. 2019;22(11):16-19. 8. Dahlen H. Undone by fear? Deluded by trust? Midwifery. 2010;26(2):156-62. 9. Newnham E, Kirkham M. Beyond autonomy: Care ethics for midwifery and the humanization of birth. Nursing Ethics. 2019;26(7-8):2147-57. 10. Page L. The birth of our humanity. British Journal of Midwifery. 2017;25(7):1-3.

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