Transcript Families, midwives and social policy - ISPA

Families, midwives and social policy:
In search of the secret agents
Anne Matthews,
Professor P Anne Scott
School of Nursing, DCU
Outline of presentation
Setting the scene(s)
Locating childbirth and midwifery within social policy
Models of childbirth
Rediscovering midwifery
What is a midwife?
Midwives as advocates?
Midwives as partners?
Midwifery in Ireland
Context of current situation for midwives
Research findings (Scott et al 2003, DCU)
The proposal of a model of empowerment in midwifery
Discussion: Achieving empowerment in midwifery
Families (with/without children),
midwives and social policy?
 An unlikely juxtaposition?
 Not so unlikely if childbirth is seen as a family and a
social concern rather than an individual/private concern
(or to a midwife whose academic study has been of
social policy!)
 Natural if childbirth and midwifery issues are situated
within a social policy context
 The context which will be outlined is
unarticulated “maternity policy/ies” invisible within
social policy
midwives invisible within maternity policy
thus midwives are invisible (secret?!) and often
unwitting (unwilling?!) agents of social policy
Midwives as secret agents?
“Maternity
policies”?
Social
policies
Health
policies
Social
welfare
M
i
d
w
i
v
e
s
Families
Models of childbirth
Social model
Sees birth as a natural, (rather than medical),
holistic, woman-centred event
Sees birth as a social/public health/family issue
Involves community-based and accessible maternity
services
Medical model
Childbirth as a medical event, normal only in
retrospect, risk-laden
hence active management is logical- to get it over
with- Postemotional birth- the mcdonaldisation of
maternity services (after Herdman 2004)
What is a midwife?
 A midwife is someone who is “with woman”- with “women”,
with “birthing women”- their babies, families
 WHO (1997): midwives are the most appropriate and costeffective caregivers in normal pregnancy and birth (skills
and attitudes)- “guardians of normal birth”
Midwives as advocates?
Widespread acceptance that midwives have an advocacy
role- individual and social level- but in practice?
Midwives as partners?
literature challenges whether partnership is realised in
practice (e.g. Fleming 1998)
Midwifery in Ireland
Historically the profession has been invisible without
a clear and distinct identity from nursing
(With nursing) controlled by medical doctors since regulation 1918
No Midwives’ Board since 1950; 1950 Act: the “definition of a nurse
includes a midwife”
1985 Nurses’ Act: dissolved the post-1950 Statutory Midwifery
Committee
Commission on Nursing 1998: recommended statutory Committee,
new legislation
 “The role of midwives caring for mothers and babies in
Ireland” pamphlet developed by NMPDUs of Health Boards
Appears to espouse the social model
The medical model of maternity
services in Ireland
60,000 births p.a. (CSO 2003)
Hospital-based consultant-led services- explicit policy
Lack of choice and continuity
Active management of childbirth (lack of control?)
High intervention rates (up to 90% epidural rate!)
Recent pilot midwifery-led schemes…
->Midwives on the margins of maternity services
Midwives have not challenged the system in the mainseen as “accessories” to it, there for the medical side of
things (Murphy-Lawless)
Exception is independent midwifery (not institutionally
bound) and individual midwives
Research evidence on midwifery in
Ireland
Begley’s (1998) longitudinal study of student
midwives (n=125) during their 2 year training
Industrial or economic model of maternity care in
Ireland- process-centred care
strict hierarchy in maternity units/hospitals
hierarchy makes development of autonomy and
professionalism impossible
act as obstetric nurses rather than midwives
professional socialisation- behave in way they
criticise
horizontal violence against juniors as cannot
express anger to oppressors
“shocking” level of bullying
National survey on empowerment in
nursing & midwifery
National two-phase study commissioned by
DoHC/ Steering Group on Empowerment through
HRB.
Carried out 2001/2 by a team in School of Nursing,
DCU led by Professor PA Scott
Context of national and international calls for the
empowerment of midwives and women (and
nurses)
Literature suggests that empowered midwives will
positively affect birthing women’s experiences
(Too 1996, Edwards 2000/2001, Halldorsdottir &
Karldottir 1996)
The survey examined…
Beliefs about the meaning of empowerment
(Meaning of empowerment scale- Scott et al
2003)
Levels of structural empowerment (Laschinger
1996)
Levels of job satisfaction (Warr et al 1979)
Level of affect commitment (Meyer & Allen 1984
Beliefs about locus of control (Levenson 1981)
(demographic profile)
Sample and response rate
Live Register of An Bord Altranais used as
sampling frame for phase 2- national survey
Stratified sample by division of Live Register
4,050 questionnaires posted, follow-up mail
1,781 replies
1,340 completed questionnaires
441 not in practice
95 midwives in current practice (though 562
have midwifery qualification)
>half practised outside Ireland, across Ireland, >
part-time.
DCU survey results
Midwives reported:
Low levels of support, resources, information
<10% have “ a lot” of feedback
<3% have a lot resources (temporary help)
14% had a lot of information about organisation
Low levels of informal and formal power
17% have “a lot” of collaboration with doctors
9% have “a lot” of reward for innovation
33% felt that the workplace is an empowering
environment
DCU survey results
63% satisfied (global item)
Low satisfaction- organisation managed, chance of
promotion
High satisfaction- fellow workers, variety in job
79% satisfied with amount challenge in their jobs
High level of affective commitment
Higher sense of internality than a sense that
powerful others or chance control their lives
Developing a model of
empowerment in midwifery
Developed through factor analysis of responses of
practising midwives to Meaning of Empowerment
Scale (Scott et al 2003)
Scale developed through focus groups, literature
Pilot-tested and revised
Exploratory factor analysis
Principal Components Analysis, Varimax rotation
4 factor solution, loadings >0.55, missing values replaced
by means, explains 54% of total variance 9factor 1
explains 30% variance)
23 (of possible 24) items included (excluded the one item
not judged to be involved in empowerment by respondents
“performing tasks doctors no longer perform”)
Model: Domains of
empowerment in midwifery
Working for
women
Skilled
practitioners
Respected
employees
Professional
partners
Factor analysis results
Empowering my patients/clients
Having access to resources for staff education and training
Being an advocate for my patients/clients
Having access to resources for patients
Having autonomy in my practice
Being able to say no when I judge it to be necessary
Having the skills to carry out my role
Knowing what my scope of practice is
Being recognised as a professional by the medical profession
Being recognised for my contribution to patient care by the medical profession
Being involved in nurse/midwife-led practice
Being valued by my manager
Being recognised for my contribution to patient care by my manager
Having the back-up of my manager
Having a supportive manager
Factors and loadings
1
2
3
4
0.8
0.7
0.6
0.6
0.6
0.6
0.8
0.6
0.8
0.7
0.6
0.7
0.7
0.6
0.6
Domains of empowerment
Working for women
Advocacy, empowering women, accessing resources,
autonomy, saying no when necessary
Skilled practitioners
Having requisite skills, knowing scope of practice
Professional partners
Midwife-led practice, recognition as a professional and
for contribution to care from medical profession
Respected employees
Having support, back-up and recognition from manager;
being valued by manager
 Model reflects existing literature on empowerment
(regarding support etc), but is specific to midwifery
Discussion
 Within the current system, it is unlikely that midwives
can undertake their role of “working for women”
 To facilitate empowerment in midwifery, a supportive,
respectful environment is required for the continuous
development of skilled midwives
 Need for national and local midwifery leaders and
leadership- traditionally very hierarchical structures
 Need for opportunities for involvement in decision-making
within planning and delivery of maternity services for
midwives- and that midwives take up those opportunities.
Discussion
Need to facilitate the wider social role midwives could
play would enhance the experiences of the women for
whom they work- key to family support. Needs
continuity and community based midwifery services
Explore possibilities for consumer and midwifery
alliances
Choice and integration within maternity services would
better serve a diversity of women’s needs.
A social model of childbirth would facilitate midwives to
be midwives!-
Conclusion
Since the literature suggests that
having empowered midwives working
for them is beneficial to birthing
women, then relocating and
empowering these secret agents of
social policy is of importance for
families and society
References (1)











An Bord Altranais (2001) Guidelines for Midwives. 3rd ed. Dublin: An Bord Altranais. September.
Begley, C (1998) Midwives in the making. A longitudinal study of the experiences of student
midwives during their two-year training in Ireland, PhD Thesis. Dublin University.
CSO (2003) Vital Statistics www.cso.ie
Edwards, N P (2000) Women Planning Homebirths: Their own views on their relationships with
midwives. In Kirkham, M (ed.) The Midwife-Mother Relationship. Houndsmills: Macmillan Press.
Edwards, N P (2001) Women’s experiences of planning homebirths in Scotland. Birthing
autonomy. PhD Thesis University of Sheffield.
Fleming, V. E. (1998) Women and midwives in partnership: a problematic relationship? Journal of
Advanced Nursing, 27(1): 8-14.
Fleming, V (2000) The midwifery partnership in New Zealand: Past history or a new way forward?
In Kirkham, M (ed.) The Midwife-Mother Relationship. Houndsmills: Macmillan Press.
Halldorsdottir, S & Karldottir, S (1996) Empowerment or discouragement: women’s experience of
caring and uncaring encounters during childbirth. Healthcare for Women International 17(4): 36179
Herdman, E A (2004) Nursing in a postemotional society. Nursing Philosophy 5: 95-103
Hyde, A (1997) The medicalisation of childbearing norms: encounters between unmarried
pregnant women and medical personnel in an Irish context. In Cleary, A & Treacy, M P (eds.) The
Sociology of Health and Illness in Ireland. Dublin: UCD Press
Hyde, A & Roche-Reid, B (2003) Midwifery practice and the crisis of modernity: implications for
the role of the midwife. Social Science & Medicine (Article in Press)
References (2)













International Confederation of Midwives (2003) Mission statement. www.internationalmidwives.org
Kennedy, P (2002) Maternity in Ireland: a women-centred perspective. Dublin: The Liffey Press.
Kitzinger, S (2003) The politics of birth. Letter from Europe. Birth 30(3)
Laschinger, H. K. S. (1996) A theoretical approach to studying work empowerment: A review of studies
testing Kanter’s theory of structural power in organisations. Nursing Administration Quarterly, 20(2): 2541.
Levenson, H. (1981) Differentiating among internality, powerful others and chance. In Lefcourt, H. M.
(Ed.) Research with the locus of control construct. New York: Academic Press.
Meyer, J. P. & Allen, N. J. (1984) Testing the test-bet theory of organisational commitment: some
methodological considerations. Journal of Applied Psychology, 69: 372-378.
Murphy-Lawless, J. (1998) Reading birth and death. A history of obstetric thinking. Cork: Cork University
Press.
Scott, A., Matthews, A. & Corbally, M. (2003) Nurses’ and Midwives’ Understanding and experiences of
empowerment. Final Report. Dublin: Department of Health and Children.
Too, S-K (1996a) Do birthplans empower women? A study of midwives’ views. Nursing Standard 10(31):
44-48.
Too, S-K (1996a) Do birthplans empower women? A study of women’s views. Nursing Standard 10(32):
33-37.
Walsh, D & Newburn, M (2002a) Towards a social model of childbirth: part one. British Journal of
Midwifery 10(8): 476-481
Walsh, D & Newburn, M (2002b) Towards a social model of childbirth: part two. British Journal of
Midwifery 10(9): 540-544
Warr, P., Cook, J. & Wall, T. (1979) Scales for the measurement of some work attitudes and aspects of
psychological well-being Journal of Occupational Psychology, 52: 129-148.