Copyright Hunter Valley Midwives Association (HVMA) Journal, where first published Nov/ Dec 1994, Vol 2, No 6. HVMA Journal, P.O. Box 411, New Lambton, NSW Australia, 2305 Phone: 61-49-214-693 Fax: 61-49-214-394 E-mail: firstname.lastname@example.org
Since the beginning of the twentieth century, Western society has undergone massive shifts in attitudes toward childbearing. The development of medicine as a science, the emergence of obstetrics, and the shift from home to hospital as the usual place of parturition, all contributed to an increasing medicalisation of childbirth. While these strategies were seen to be successful in improving the safety of birth, many believed they were also responsible for the disintegration of women's sense of dignity, f ulfilment, and autonomy.
Oakley (1992:186) stated:
It is a well known observation that institutional structures and systems can often be subversive of the goals they were set up to meet.
This paper endeavours to expand upon this point of view in the context of the role of social support in midwifery practice and research. It will firstly provide a brief overview of the history of childbirth and its institutionalisation. This will be fol lowed by a discussion of the goals that institutional structures and systems were set up to meet. The next section of the paper will demonstrate how the achievement of these goals has inadvertently been destructive in the area of social support for the w omen around the time of childbirth. This paper will focus specifically on the period of antenatal care. Finally, the importance of research for midwives will be discussed, in recognising the needs of women in relation to social support and how midwives can most effectively meet those needs.
Before continuing on, it might be useful to define the notion of social support. This is a very difficult and complex task. Oakley (1992:26) noted that there are almost as many definitions as there are studies researching the concept. What must be empha sised is that it is a subjective notion. For instance, it would be idealistic and inappropriate to consider family as a "support system" in every situation (Oakley, 1992:28). Further, as Leavey (1983, in Oakley, 1992:28) states, "Having support is one t hing; being satisfied with it is another".
For the purpose of this paper, social support as applied to pregnancy, is defined as ...social relationships... information, nurturance, empathy, encouragement validating behaviour, constructive genuineness, sharedness and reciprocity, instrumental help, or recognition of competence. (Brown, 1986, in Oakley, 1992:27)
Prior to the late 1800's, the area of childbirth belonged to women. In his book, History of childbirth, Jacques Gelis (1991) refers to the alliance of women during confinement as "feminine solidarity". Pregnancy was a "collective experience" in which t he woman was never alone (Gelis, 1991:45). "Being with child" was considered to be a state of normality and it was nearly always female relatives, neighbours or friends who surrounded the woman in confinement. For centuries the idea of calling outside h elp was totally alien to the minds of the village women (Gelis, 1991:99).
Changes were evident by the First World War. The opinion generated was that women's health should be "safe-guarded in the interests of family and nation" (Reiger, 1985:86). By the 1920's a major effort was being made to promote maternal welfare. There w as a surge of research interest in maternal morbidity and mortality. The importance of antenatal care was advocated. In Melbourne, clinics were established at the Women's, Queen Victoria and Alfred Hospitals. Kobrin (1966, in De Vries, 1989:146) observ es that obstetricians early in this century "argued again and again that normal pregnancy and parturition are exceptions and that to consider them normal physiological conditions was a fallacy". Reiger (1985:89) points out that these developments did alt er public attitudes and behaviours regarding childbirth and women turned to hospitalisation and anaesthetised labour to avoid the risks associated with giving birth.
Even at this early stage medically dominated childbirth was having a detrimental effect on women. Where once women shared their birthing experiences, passing information from mother to daughter, and obtaining material needs from community midwives, indus trialisation brought about increased mobility of the nuclear family, depriving women of their "traditionally strong, informal networks of support and education" (Simkin and Enkin, 1989:318).
From the historical analysis so far, it would appear that the goals that institutional structures and systems were set up to meet were essentially aimed at reducing infant and maternal mortality and to generally promote the safety of birth. However, the opinions of other authors cannot be ignored. Friedman (1987:76) suggested that the introduction of maternity institutions provided a steady supply of patients, usually working class, for physicians to practice upon and improve their skills. Dr. Joseph P rice (in Friedman, 1987:76) reasoned that by using "the pauper element of society...for educational purposes" would result in "more finished doctors". Another theory is offered by Willis (1983:123) who believes that institutional settings was a major str ategy toward gaining male control over childbirth and stamping out the occupation of independent midwifery. Versluysen (1981:18-9) agrees with this theory and points out that infant and maternal mortality did not significantly decrease with prenatal admi ssion to hospital, indicating that the underlying reason for the introduction of such institutional structures was more likely to establish male control rather than to make therapeutic advances in medicine (Versluysen, 1981:21-2).
The reasons discussed above are all relevant and are worthy of discussion too complex for this paper. What must be stressed here, however, is that in the eyes of the public the main emphasis on institutional care was the promise made by medicine to contr ol and reduce, perhaps eliminate, the risks of birth (De Vries, 1989:145). Whatever the reasoning one can be certain that the efforts experienced in achieving these goals has brought about medicalisation and in return, a decline in the area of social sup port for women.
The medical profession's preoccupation in reducing maternal and infant mortality is evident when one considers the medical classification for the definition of normal labour. It can only be applied in retrospect and unlike the midwifery classification, t he woman's labour is treated as actually or potentially abnormal until normality (or otherwise) is confirmed following birth (Silverton, 1993:261-2). Thus, it may be assumed that women receiving antenatal care are treated in the same manner, i.e. ill or potentially abnormal. As Eliot Friedson (1970:251 in Oakley, 1980:18) explains, it is characteristic of our culture that the medical profession "has first claim to jurisdiction over the label of illness and anything to which it may be attached, irrespect ive of its capacity to deal with it effectively".
To "deal with it effectively" is a controversial issue surrounding the medicalisation of reproduction. While one cannot argue that the quest to improve the safety of birth has been successful, it must be recognised that it has been inadvertently responsi ble for the lack of social support available to women around the time of childbirth. Graham and Oakley (1981) discuss the different ways in which doctors and mothers view pregnancy. While obstetricians are concerned with perinatal and maternal mortality rates and strive to achieve a healthy baby and mother, women view childbearing in a more holistic way. Not only does she want a live birth of a healthy infant, the mother strives for a satisfactory personal experience (Graham and Oakley, 1981:54-5). Thi s applies not only to the pregnancy and birth but to the subsequent mother-baby relationship and to the way in which motherhood is integrated with the rest of a woman's life (Graham and Oakley, 1981:55).
Reid and Garcia (1989:133) claim that women expect personal care during pregnancy, an expectation that often remains unfulfilled by institutionalised antenatal care. Research indicates that women feel undervalued as individuals in hospitals. Contributin g factors include long waiting times, poor clinic facilities, different caregivers at each visit, and very little opportunity to ask questions and receive appropriate information (Reid and Garcia, 1989:133).
Graham and Oakley (1981:66) compare a visit to the antenatal clinic like being on a conveyor belt and, often, a very dehumanising experience. In an atmosphere such as this, health professionals tend to ignore the problems perceived by pregnancy women and , instead, focus on the care of the foetus and the newborn child. Elbourne, Oakley and Chalmers (1989:221) point out that from the moment conception is contemplated, women are expected to re-arrange their way of life in the "supposed interest of the fetu s". As the research midwives (in Oakley, 1992) discovered, it was impossible for many women to take the advice of health professionals and go home to rest when they were unmarried, and socially and financially isolated with three other children to care f or. The research midwives said their eyes had been opened through the research and visiting women's homes was vital to this altered vision (Oakley, 1992:185-6).
Because the social, psychological, and physical problems experienced by pregnancy women are often substantial, care during pregnancy and childbirth cannot be as effective as it might be if those providing it are insufficiently aware of the particular prob lems experienced by individual pregnant women and uninformed about the wider social circumstances in which these are occurring. (Elbourne, Oakley & Chalmers, 1989 :222).
By undertaking research, midwives are in an ideal position to learn about these "wider social circumstances" which influence the outcome of pregnancy and childbirth. Robinson (1989:177) believes that midwives play a major role in achieving good perinatal outcomes and in providing women with a satisfying experience of pregnancy and childbirth. However, she does point out that this role has been hindered by medical involvement. Although differing between countries, research has generally shown that the mi dwife's skills are under-utilised, particularly in the area of assessment and decision-making (Robinson, 1989:167).
Implications for these restrictions are many and varied, but most significantly, is the type of care available to women. When medical staff assess normal pregnancy, care tends to be fragmented into a number of tasks undertaken by different personnel. In this situation, midwives have neither the time nor the opportunity to develop the kind of supportive and continuous relationship within which women feel able to discuss their pregnancy and any problems or concerns they may have (Robinson, 1989:168).
According to accepted definitions of the role of the midwife, he/she has a central place in the provision of care in pregnancy and childbirth. The midwife's role is based on an integrated and holistic approach where clinical assessment and monitoring, an d the provision of advice and support are combined (Robinson, 1989:162). If midwives are to practise in accordance with these definitions, they must overcome the constraints placed upon them. This may be best facilitated through research. Robinson (198 9:175) agrees that:
midwifery practice should be based on research and should be constantly evaluated rather than being based on custom and tradition or being dictated by other health professionals. According to Oakely:
It is a well known observation that institutional structures and systems can often be subversive of the goals they were set up to meet (1992:186).
In a bid to decrease maternal and infant mortality, childbirth has become medicalised. While it cannot be denied that this has reduced the risks associated with childbirth, it has ultimately brought about a decline in the area of social support for women .
Midwives must recognise the important role that social support for women plays in achieving effective care during pregnancy and childbirth. By utilising current research as well as carrying out research of their own, midwives can determine what it is a wo man wants or needs with the goal of providing more holistic care with an individual approach. It is in this way that midwives will facilitate the restoration of women's sense of dignity, fulfilment and autonomy.
Melinda is currently undertaking the Graduate Diploma of Nursing (Midwifery) at the University of Newcastle, NSW, Australia.
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Simkin, P. and Enkin, M. 1989. "Antenatal classes". In Chalmers, I., Enkin, M. and Keirse, M. (Eds). Effective care in pregnancy and childbirth. Volume 1. Oxford University Press, Oxford.
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Willis, E. 1983. Medical dominance. George Allen and Unwin, Australia.
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