Emotions in Midwifery and Reproduction

Billie Hunter, Ruth Deery

• Publisher: Bloomsbury Academic
• Year: 2008
• ISBN:
  9781350310766
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

With contributions from a range of leading international authors, this 'stop and make you think' book explores the many contemporary issues surrounding emotion work in reproductive healthcare. The editors, forerunners in their field, have brought together both theoretical and clinical aspects to challenge readers to consider the significance of this important topic in their day-to-day work. Using examples of maternity care and infertility settings from the UK and beyond, and with an emphasis on personal reflection throughout, the book explores the subjects of:
- Emotional well-being
- Client-practitioner relationships
- Infertility
- Loss
- Breast feeding
- Motherhood Emotions in Midwifery and Reproduction underlines the importance of emotions and how they are managed, experienced and negotiated in clinical settings, addressing issues that are frequently overlooked in the drive for efficiency and effectiveness in the health service. It is stimulating reading for all midwifery and nursing students and practitioners looking to understand their patients' and their own emotional needs.

PART I

Emotion Work in Maternity Care

1

Relationship and Reciprocity in Caseload Midwifery

Chris McCourt and Trudy Stevens

Introduction

This chapter explores ways in which the organisation of midwifery care may be seen to affect the emotional work that is central to childbirth. It is drawn from a study of caseload practice that was implemented in the UK, following the publication of the Changing Childbirth report (Department of Health 1993), designed to support woman-centred care.

The traditional, Old English, meaning of the word ‘midwife’ is said to be ‘with woman’. Such meaning and values are clearly held by midwives and the importance of being ‘with woman’ is strongly articulated by midwifery students and practitioners as a defining characteristic of midwifery. However, a number of studies have suggested a considerable gap between such core values and those revealed in much of midwifery practice. For example, ethnographic (Kirkham 1989) and observation-based (Methven 1989) studies have indicated that midwives in practice spend relatively little of their time in work that could fairly be described as directly supporting or working with women.

A key focus of our evaluation was whether the new model of care would actually be woman-centred in practice, and whether it was experienced positively by those who were providing care as well as those receiving it. A structured review (Green et al. 1998) concluded that while there was evidence of women’s satisfaction with new models of care, there was little evidence on midwives’ experiences; they questioned whether the importance of continuity of carer to women justified the possible ‘costs’ to midwives. A large-scale analysis of midwives’ stress and burnout, however, found that high levels of both were associated with team rather than caseload midwifery (Sandall 1997).

In a study of emotional labour, Hunter (2004) found that midwives viewed the basic work of midwifery as a positive form of such labour, but experienced considerable distress through other, less anticipated, forms. These centred on managing institutional and work-related demands, intra- and inter-professional tensions and conflicts, and hierarchical and horizontal forms of oppression (see also Deery 2005). Such studies echoed the themes of a considerable wider literature on the nature of institutional work, on the experiences and behaviour of oppressed groups and on work-related stress and burnout. The study we draw on here offers a different perspective, indicating that midwives carrying personal caseloads experienced considerable job satisfaction and reward (Stevens and McCourt 2001, 2002a, 2002b, 2002c; Stevens 2003).

During our analyses it was noted that conceptual links could be drawn between the two aspects of the evaluation that examined the experiences of women and those of midwives. The first study explored women’s responses to maternity care through a longitudinal survey and interviews; the second was an ethnographic study of the impact of the change on midwives. This chapter sets the analysis of each alongside the other and highlights ways in which each group’s narratives echoed those of the other, particularly in relation to the emotional aspect of preparing for, and caring for, birth.

The key themes

The key themes identified in each analysis were set alongside each other, as shown in Table 1.1. We discuss these in turn, considering both the women’s and the midwives’ perspectives on each.

Knowing and being known

Knowing each other emerged as an important theme in both analyses and clearly held significance for the well-being of mothers and midwives. The women’s accounts indicated that ‘knowing the midwife’ was more complex than simply having met the person more than once; it was about the midwife knowing them. This was not the same as the intimacy of friendship or kinship, since the relationship was circumscribed by the experience of maternity; midwives were not seen as friends but were often seen as like friends or like kin:

Table 1.1 Women’s and midwives’ perspectives

Key theme	Women’s perspectives	Midwives’ perspectives
Knowing and being known	Knowing the midwife; ‘my’ midwife; being known by the midwife.	Relationship with the woman; ‘my’ woman; reciprocity.
Person-centred care	Care focused on me as a person; someone there for you.	Being a person not a role; personal orientation; being there.
Social support	Social support.	Support from partnerships and groups.
Reassurance, confidence and development	Reassurance, sense of confidence.	Confidence and development.
Informed choice, control and autonomy	Informed choice and decision making; sense of control (locus of control).	Autonomy; decision making; control over own work.
Holistic and flexible care	Flexible care, not a production line; time to listen and give care; place – hospital to community; medical and social care.	Time orientation; flexibility; place – with the woman; using all skills; integrated.

… my midwife and myself got on well. She was like my family there. (Caseload care 116)

When compared with conventional care, the difference in relationship was illustrated by the pronouns used by both women and midwives: ‘my’ rather than ‘the’ midwife, and ‘my’ women.

Such terms could signify some kind of professional territorialism or desire for control and, in attempting to be all things to all women in their care, might create a disempowering sense of dependency. However, their use here appeared to signify a sense of obligation and responsibility primarily to the care of the women on their caseload:

I’m definitely more in tune with the women that I look after and I certainly respect [the] women – because I know them and I’ll do the best to help them make the choices they want – you know, to help them achieve what they’ve said to me that they’re hoping from the birth. (Caseload midwife 6)

The importance of being known was emphasised by some women for its contrast with a fragmented system where you could not be known, where who you were was forgotten, where your history had to be told over and over, where you did not feel listened to, except in a superficial way. One woman, for example, described wanting to tell midwives about the effect of domestic violence. She had hoped that someone would ask her how things were at home:

… and I would probably have broke down and let the whole thing out. But they’ve got a hard job to do as well so I must appreciate that, because there are a lot of women having babies. (Conventional care 370)

However, she found that apart from visits to her GP, she saw different people every time, and was made to feel a nuisance if she tried to talk about how she felt. Nevertheless, the depth of relationship that appeared necessary before some mothers disclosed such intimate situations surprised the caseload midwives:

I was really shocked the other day when a woman reached 34/40 pregnant before she was able to tell me that she had been sexually abused. It would never have come out in the conventional service. As it was I could be sensitive to every nuance. (Focus group of caseload midwives)

The emphasis on the relationship was equally important for the midwives, who felt they gained from the relationship with women in their care, rather than just giving. We suggest that this sense of reciprocity offered an important defence mechanism that helped prevent the ‘burnout’ that could be thought to be a danger of working in this way (Stevens 2003).

The midwives felt known – and valued; they talked about ‘actually being a person again, not just a cog in a wheel’, and highlighted the way women related to them as individuals. The implication was that they had not been considered and valued as people when working in the hospital service, merely pairs of hands to get the work done. They also considered that they used many of their personal skills in their daily work that they had not found utilised in the hospital system. No longer tied by the routines and immediate workload pressures that dominated hospital practice, caseload midwives reported being creative in their practice, responding to the needs of their women in a more imaginative way than they had experienced working in the ‘confines’ of the hospital. They were able to practise the ‘art’ as well as the ‘science’ of midwifery in a manner that drew on their individual skills and strengths, not just their technical abilities. This feature was facilitated by their sense of ‘ownership’ of their caseload in accepting responsibility for care provided.

Also, importantly, they felt that knowing the woman meant they were not constantly starting over, and they could understand more. Prior knowledge meant some things were easier – such as supporting the woman in labour:

It’s very easy to look after women in labour when you know them … Because you’ve got to build up this relationship with them, got to know them [and they’ve] got to like you. You’ve gone through all that by the time they go into labour. It’s far easier … They are far more relaxed. (Caseload midwife 62)

Other issues could be more difficult, such as establishing limits to the care they should offer to a ‘needy’ woman. Nevertheless, this problem was recognised early by the midwives, who then learnt to define their role clearly in the early stages of the relationship, and to ‘educate’ their women, as they termed it. They also built up local knowledge and contacts, so that they could refer and connect women to other sources of social support. In many cases, the sense of relationship engendered a sense of mutual trust and obligation that was important to both the woman and the midwife:

And they really do tell you things. Very deep things. Very personal things. But it does make it easier to look after them because you can actually see why they’re behaving that way or going through it. (Caseload midwife 23)

The midwives also gained a sense of professional and personal satisfaction from feeling that they had seen a particular relationship through – the accepted conclusion being the end of postnatal care and the settling of the woman into new parenthood. Occasionally this proved longer-term as individual relationships were renewed in subsequent pregnancies, something warmly welcomed even when a childbearing experience had proved difficult. Recounting her experience of caring for a mother after a previous stillbirth, one midwife noted:

She had two others since then and she’s as happy as anything – because I went through that traumatic time with her and it helped her to grieve and it helped her to accept the other two pregnancies much more easily. Because I knew [what she had gone through] we could talk about it much more easily. (Caseload midwife 21)

Such relationships may hold psychological benefits for both the woman experiencing such traumas and the midwife supporting her.

Person-centred care

For both women and midwives, the organisation of care appeared more person-centred. This was reflected in the orientation of the midwives’ work and sense of responsibility, which appeared to shift from accountability to the institution towards accountability to the client and to the profession of midwifery. Autonomy of practice and expectation of continuity gave them space and time to get to know the particular circumstances of each mother; by recognising the individuality of each case the women became special because they were different and they demanded different responses. Emotions were engaged, but were ‘worked through’ by midwife and mother, not denied behind a professional ‘mask’.

Person-centred care was highlighted by the importance attached to the phrases ‘having someone there for me’ and ‘being there’:

… knowing that I could like pick the phone up and talk to someone on a one-to-one basis sort of, like really relaxed me and gave me the confidence to carry on. (Caseload care 717)

In practice, knowing that the midwife was ‘there for you’ did not engender greater dependency; the women reported that they rarely called as they had the confidence of knowing they could, if they really needed to.

For the midwives the ‘being there’ was an idea that was closely linked to the expectation of continuity and the autonomy the midwives experienced. Their work with an individual held a greater significance because they knew they would be following through a case and had the power to influence the situation.

During the booking visit you are investing time for the future. (Caseload midwife 8)

Providing continuity and having responsibility were seen to be categorical in the midwives being able to ‘invest in’ and ‘build on’ care provision for the future event of childbirth and subsequent motherhood. The disappointment they reported if they had not been present at the birth reflected the personal satisfaction this investment could give them. Comments made at such times were particularly illuminating:

You are with them for all that time and then miss out at the end – you’ve missed the bloody party! That’s what I feel. (Caseload midwife 18)

It’s like revising for an examination and then missing the result. You have put all the hard work in … and then you don’t know if what you have done has been appropriate. (Caseload midwife 34)

Caseload practice entailed the midwives becoming more deeply involved with their work than conventional midwifery practice permitted. Such form of engagement could go beyond an ‘investment’ of their professional skills to ensure a meaningful outcome. It also encompassed something of their individuality that they gave and something that they received in return. The midwives valued the reciprocal relationships established, experiencing enjoyment in the communication and receiving acknowledgement of their personal interests. They valued occasions when their individuality was considered, for example the coffee specially prepared for their visit, or the chats. And they talked of mothers who delayed phoning them because they were aware of some activity in the midwife’s personal life, or ‘waited’ to go into labour until the midwife returned from a weekend off or from holiday.

On a deeper level, the midwives appeared to gain some sense of approbation of their...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of Tables and Figures
• Foreword
• Preface
• Acknowledgements
• Notes on the Contributors
• Introduction
• Part I Emotion Work in Maternity Care
• Part II Emotion Work and Infertility
• Part III Developing Emotional Awareness in Health Care Practitioners
• Part IV Weaving It All Together
• Index