The term midwife means to be with woman [Sweet, 1997], so what happens when that woman is a midwife?
This research project explores a midwife’s experience of having a baby herself using a phenomenological / relational approach. My aims of this piece of work are to give a voice to one particular midwife who went through this experience in a fairly structured interview in which I include antenatal, labour and the postnatal experience.
From analysis of the interview, three themes emerge; they are:
- Fantasy and Reality
- Judgement of Others / Expectations of Self, and
- Courage of conviction
However, a continual theme throughout the interview was a sense of “getting it right” and a desire to be in control in a professional capacity.
The midwife has a unique role which is complementary to, but different from, the role of other health professionals involved in care of mothers and babies. Not only does she support the women, she supports her partner for parenthood. She is the sole provider of care in normal childbirth and is therefore legally accountable for her actions.
After conducting a literature review I was not surprised to find no research on my topic, a midwife’s own personal experience of childbirth.
Therefore I began to contemplate how a midwife was perceived; were they not seen as vulnerable women going through a life changing experience? Have they been put on a pedestal by women, their families and the profession itself?
As a psychotherapist in advanced clinical training it became apparent how women look to the midwife for answers. No-one gives her permission to feel, a cultural script has evolved and subsequently the midwife has emerged.
I work in a large teaching hospital as a midwife, I have been practicing for over ten years. I became aware of a midwife’s “be perfect” driver: we have to get things right, not only does the mother depend on us, also the unborn child. We are forever vigilant looking for deviations from the norm.
I also became aware as I observed my colleagues going through the childbirth experience themselves. I often wondered how it was for them, having a greater depth of knowledge than the average woman, was that a blessing or a hindrance? Did it change the experience they had?
What also became apparent was the perception that midwives tended to have a complicated experience. How could this be so when a midwife is the champion of normality?
I would often hear comments like “she’ll end up as a rotational forceps in theatre” or “is it me or have we had at least four midwives recently having a forceps or a caesarean, we just don’t do normal.”
With these comments in mind I wanted to explore and get a feel of what the birth experience was like for a midwife. I also wanted to see how the “be perfect” driver played into this. Being a midwife I am all too aware of this and the needs to “please others”
A midwife wants a woman to have a positive experience and as a psychotherapist I am aware of how birth experiences shape who we are (our script).
On a personal level I don’t have any children, but I hope one day I will and therefore for this research project, perhaps? I subconsciously chose for my subject a midwife with a similar thought process to get a feel of what it would be like for me.
As part of my psychotherapy training I have undertaken a research topic from a phenomenological perspective. I have collaboratively explored a midwife Sue’s lived experience of becoming a mother for the first time. The transcript of the relatively unstructured literature has been closely analysed. From this I have developed three common themes to illustrate Sue’s experience.
Firstly I will clarify the meaning of phenomenological research:
It provides a rich resonant textured description of the lived experience [Finlay, 2006]
therefore giving greater meaning and depth to the data.
The research I have gathered offers my own interpretation from the interview.
Any one analysis can only be presented as one perspective with many possible interpretations [Finlay and Evans, 2009]
Co-researcher and ethical considerations
Sue is a midwife who works in the same hospital as me. We have often worked shifts together and I would consider her a friend. I initially contacted Sue to see if she would take part in my study when she was approximately 28 weeks pregnant. She has always shown an interest in my psychotherapy training and when I started talking about my research design, it became apparent that when Sue was doing her midwifery training, which involved research, she preferred phenomenological research and she even gave me some articles to read.
Sue was 37 when she found out she was pregnant and 38 when she had the baby. She had just recently got married. This was her second pregnancy; prior to this one she’d suffered an early miscarriage which was devastating to Sue.
Sue had grown up with midwifery in her family as her older sister had been a midwife for the previous 15 years. Sue came into the profession wanting something more from her job. She has been a practising midwife for 4 years, working predominantly on the midwifery-led unit.
Once Sue had agreed to my proposal I remember feeling anxious. “What happens if it’s a negative experience? If something goes wrong?” (Perhaps this was the cultural script of the midwife or some parallel process I was going through with Sue)
Obviously I had to wait for Sue to have the baby. I discussed with Sue for the purposes of my research that I would not be involved with her care, as this may change the outcomes. Sue was happy with this, and I left the interview until Sue was ready in the postnatal period.
Three months after the birth experience I arranged to meet Sue at her home. Her baby was present with her during the interview; she slept intermittently throughout the interview and was not a distraction.
Sue had agreed to the recording of a one-hour in-depth interview about her lived experience of childbirth through a midwife’s eyes.
I would then transcribe and analyse the interview phenomenologically. After the interview we had chance to feed back how the interview had impacted upon us but also develop the research dialogue and outcomes.
Sue was very open about her very personal experience but it was made clear at the beginning that if there was anything that she didn’t want to disclose then I would totally respect her wishes. I ensured confidentiality relating to this project. This project would be kept at my home in a secure place. Sue was given a copy of the transcript, which she signed to indicate that she was happy that it accurately reflected the interview and that she was happy for me to use it in my research project. However, Sue stated that she did not want the transcript or this project to be made publically available.
I was also wary that Sue had only recently had her baby, aware of hormonal changes in her body that could affect emotions. I offered, if needed, to refer her to an appropriate source of help if she felt it necessary during the time we worked together.
Data Collection & Analysis Procedure
On the day of the interview, as stated previously, we met at Sue’s house. We spent some time getting comfortable and letting go any anxieties or nervous tension by going over the aims of the interview. The only structure I gave was from an antenatal, labour and postnatal perspective. We started recording and what came up in those areas was spontaneous. I had aimed to ask open-ended questions in order to enable Sue to freely express herself and tell me how it was for her.
After the interview had finished I offered Sue some feedback. She then began linking themes herself about her experience which were then recorded and added to the transcript.
The feedback I got from Sue was positive. She felt she had time to put things into perspective and make sense of her experience, and for that she thanked me.
The second phase of data collection was the lengthy task of transcribing the interview whilst re-living the experience and making notes, highlighting quotes to back up the themes I pulled from the narrative.
Three inter-connected themes emerged from the interview:
- Fantasy and reality
- Judgement of others / expectations of self, and
- Courage of conviction
These are described in more detail and illustrated via quotations of Sue’s own experience.
Fantasy and Reality
From the start of the interview Sue made it clear that she had wanted a baby for a very long time. Her sister is a midwife who has had children, so pregnancy/childbirth was often discussed. Sue had an idealised view of what she wanted and what it would be like to be pregnant:
“I’d always said, and I’ve said for years, ‘cos I’ve wanted a baby for so many years, that I would love being pregnant. I’ve always said I would, you know, really milk being pregnant and wanting my feet massaged, and being pampered and being looked after by my husband/partner; being, you know, a typical pregnant woman that can’t do housework and, you know, want to be looked after in pregnancy.”
She loved the idea of being pregnant, the concept filled her with joy. However, when the pregnancy was confirmed it became the opposite. She was no longer the ‘typical pregnant woman’. Sue could not be pampered or taken care of because she became consumed by anxiety: anxious about having another miscarriage.
“But being a midwife, from the absolute onset there was every possibility that could happen was going through my mind… And I do think that was exacerbated by being a midwife… I found something all the way though the pregnancy. I found a reason to be stressed, and to worry”
Because of the knowledge she was constantly thinking at every milestone in her pregnancy “what will go wrong next?”. She describes feeling constantly ‘on edge’. Was this her need for control due to the knowledge she had which contrasted with the unpredictability of pregnancy? I could really feel the internal struggle she was describing. Her midwife status, in her words, tainted the experience she’d longed for, about which I felt a real sadness.
When discussing how knowledge is a good thing, Sue saw herself very differently:
“being a midwife I’d gone beyond that. I’d gone beyond antenatal classes, I’d gone to ‘everything bad’s gonna happen to me, it’s bound to’. Not just because I’m a midwife but because of the things I’ve seen, and the experiences and the women that’ve come through the doors where I’ve worked ”
Because Sue works in a large regional midwifery unit, there are a large number of complicated pregnancies. I wonder that if she had worked in a smaller low-risk unit whether she would still feel like this. It would seem not just knowledge that changed her experience, but the high-risk nature of the pregnancies in the hospital where she worked. The extent of Sue’s worry for herself and her unborn child can be illustrated in her behaviour, especially concerning her baby’s movements:
“It was sort of an obsession that I would say escalated to being an obsession”
She knew the importance of baby movement, but still this would not console her. Another midwife who had just had a baby offered her a sonic aid (a listening device to hear the baby’s heartbeat). She described how she would sneak off and listen while she was at work; at home she would hide what she was doing from her husband. She was aware she was fuelling her anxiety. She would listen every day several times and if she did not feel the baby move, it gave justification to her obsession.
She describes her rationale for all her anxiety:
“because she’s such a wanted baby… it’s Sod’s Law it’ll [foetal death] happen to me”
This to me was a powerful statement which could be see to illustrate Sue’s lack of entitlement to have a positive childbirth. I think she truly believed that she was not worthy.
Judgement by Others / Expectation of self
After reading the transcript several times, these two themes were connected. She was worried what other people would think about her and her choices. She became extremely hard on herself which I will discuss in greater detail. She recalled not telling anybody at work about her pregnancy until she was 20 weeks, her reasons being risk of miscarriage and due to her age she elected to have an amnio (an invasive test to screen for Down’s Syndrome)
“I didn’t want to be telling people because I didn’t want people judging me”
Concerned that midwives would ask why she was having an amnio, I think that at that time in her pregnancy she was unable to cope with having to justify her actions.
There is a sense of containment, to keep hold of the pregnancy and information relating to it, while her internal world was stressful. When I questioned what her fantasy was of the judgements/viewpoints held by her colleagues, she replied
“because being a midwife – I thought people would think you’d have much more of a sensitive and probably empathetic view that babies are born with abnormalities and you should deal with it”
For me it highlights Sue’s critical voice in her head. I thought she was incredibly hard on herself and put a lot of pressure on herself. I got the feeling she felt she had to do the right thing because she was a midwife, but this conflicted with what she actually wanted as she states:
“I thought I can’t deal with a baby with an abnormality”
I think she felt some shame because she has, in the past, counselled women who have had babies with abnormalities and had for them tried to provide a positive outlook. However, the reality for Sue and her own baby was different, and she thought that people would think:
“ ‘how can she be a caring sensitive midwife but not want a baby with an abnormality?’ ”
I remember at this point in the interview being impacted by her struggle; I had a genuine strong urge to rescue Sue. I offered another way of viewing this, i.e. she was being responsible and sometimes facing up to what she believed was a weakness actually showed honesty and strength.
In relation to Sue’s labour, she was aware of the pressure she had put on herself; she didn’t want the situation to be to be out of her control.
“I certainly didn’t want to come in, and I think there would probably be for me that notion of people saying ‘for god’s sake, you’d think she’d be able to cope, or you think she’d know what to do, you’d think she’d be able to cope with it better at home’ because you’ve got knowledge of how to deal with things, and I thought people may have that judgement of me”
I wondered where all this negativity came from that put extra pressure on her to behave in a certain way. Surely knowledge is the last thing on your mind when you are in pain and vulnerable. I thought it may have to do with shame as she had her baby in the same hospital in which she worked. How could someone go from being a professional midwife one minute to being a labouring woman the next? However, it became more clear as the interview progressed.
Sue had a normal birth but had a perineal tear that needed stitching in theatre under general anaesthetic. Two days later Sue had to return to theatre for a blood patch (to alleviate the side effects of the epidural). News of Sue’s birth was public knowledge on the unit – there are no secrets! But Sue was annoyed by the comments of some midwives:
“ ‘I believe you’ve had a horrendous birth, a horrendous birth experience’ and it’s still being said four months down the line… people latch onto the fact not that I’ve had a nice normal delivery, being cared for by people that meant the world to me”
She was angry that they could only focus on the negatives, saying that she’d had a typical midwife’s birth where something had to go wrong. In the antenatal period, midwives predicted negative things for Sue’s birth which, when you’re anxious and vulnerable, can sow seeds of doubt about having a positive experience.
“Nothing went wrong for me. And I’ve surprised myself with that thought, I have surprised myself because you do think it’s a lot worse than it actually is”
I think Sue thought she could not possibly have a good outcome. In view the notion of a typical midwife’s birth being negative, this then leads on to my final theme: that Sue needed to prove to herself and others that it does not need to be that way.
Courage of Conviction
I got a real sense throughout the interview that Sue had something to prove; maybe to herself, to her colleagues and to women she has looked after in the past, or will look after in the future. When she was in the later stages of pregnancy, she found out the baby was breech (bottom first), for which women are offered a caesarean section or external cephalic version (ECV), where the doctor manually turns the baby to be the in the correct position of head-down, which is what Sue opted for.
“I wanted the experience, I wanted to go through the pain. I wanted… which sounds a bit sadistic… but I didn’t want a cop-out, I wanted to go through it to at least say ‘well I’ve had a go and I’ve tried’ ”
I thought it was interesting that she used the phrase “cop-out” in relation to caesarean section. Was this what a midwife thought? Not to go through normal birth which midwives are all champions of. I got the feeling that Sue would have felt cheated out of the fantasy she had always wanted to experience.
Sue had a big fear of coming into hospital, the place where she worked, being out of control and not coping. She admitted to having “high expectations” of herself. The pressure seemed to be coming from her professional head of behaving in a certain way. I would have thought that this would be Sue setting herself up to fail, forgetting that she would be vulnerable like any labouring woman. She may have knowledge, but intense pain such as that experienced in labour, really affects adult rational thinking. Sue explained this pressure:
“we see a lot of women coming in, in those very early stages, and some midwives can be quite negative: ‘oh god, not her again, she’s back and she’s only, you know, only a centimetre’ and I think certainly, possibly that’s more so for midwives who’ve not had babies. And I’m guilty of it myself ”
I then began to understand why it was really important for Sue, as a midwife, to go through labour, experience pain, to be a more authentic and passionate midwife. I asked her whether this experience would change her midwifery practice to which she answered:
“I’ll be able to probably give that little bit more reassurance, offer reassurance because you’ve been there, and you’ve experienced it… hopefully more supportive”
Sue thought before having that experience that her practice could not change, and a regular question is always asked by women to their midwife: “do you have children?”
She recalls one of her lecturer’s advising student midwives to tell women that they had children and they knew that it hurt. But I admire Sue’s honesty for not lying to women about not having children. She needed that birth experience to complete her as a midwife.
So for Sue her job had given her the knowledge of the kind of birth she wanted: the perfect birth, labouring in the pool, having a normal birth, and adamant that she would breastfeed.
“I’ve always, always said from being probably quite young, I would breastfeed a baby”
She experience negative comments “well what if you can’t?”. Her reply was “I will, I will do this”.
Again, right from first meeting pregnant women, breastfeeding is discussed, it’s the best for mother and baby. But with Sue, she did not feel pressurised into doing it, it was something she was compelled to do, to experience the womanly art of breastfeeding.
Even though I was unable to find any supporting literature relating to a midwife’s experience of childbirth, I decided to look at the cultural script of midwives in the hospital where I work. It is a large tertiary unit. They have a midwifery unit, but specialise in complicated obstetric histories with a specialist neonatal and surgical unit.
As times have changed and women have been given more choice, women who were once advised by their doctor not to have children due to poor medical histories, are now being supported by new research and technologies. Therefore we now see more complex cases.
Since the hospital where Sue and I work has seen a lot of changes, there is an obvious divide: the midwives who like normal low-risk non-intervention births and those who prefer high-risk complicated births.
To put this into perspective, I was aware of this general theme of a typical midwife’s birth. Sue also was aware of this, and confirmed that she had experienced negative comments about her forthcoming birth.
I think a contributing factor was the environment in which we both work. As a midwife, we have to act on deviations from the norm and we are hyper-vigilant due to significant cases we have all been aware of. The midwives’ documentation is a legal document that is kept for 25 years for potential malpractice litigation.
Midwives who work mainly with the high-risk cases, and therefore are more reliant upon technology for health-monitoring, become de-skilled in the more natural caring aspects of midwifery, and therefore I wondered whether this was the source of the negative comments towards childbirth.
Can midwifery knowledge be a hindrance as well as a help? Sue said:
“Information is a good thing, antenatal classes are very good, but being a midwife I’d gone beyond that. I’d gone beyond antenatal classes, I’d gone to ‘everything bad’s gonna happen to me, it’s bound to”
This was partly due to the high-risk unit she worked on; all the negative experiences would fuel her anxieties.
With regards to drivers, midwives want to get it right, they want a positive experience for the woman, be perfect and please others. These were definitely obvious during the interview with Sue. I was overwhelmed at times to the lengths she would go to self-soothe, e.g. listening to the baby’s heartbeat became an obsessive ritual that would consume her.
I found myself getting quite angry at midwives’ negative comments, and wondered if this subconsciously added to Sue’s need to get it right. I distinctly remember Sue saying:
“what if I get post-natal depression? What if…? I can’t have post-natal depression. I’ve got to carry on, I’ve got to be this super person and I can’t tell somebody that I’m feeling… I’m feeling crap… And again that was then me being hard on myself thinking I can’t be seen as this midwife who can’t cope with her baby. ”
I can feel as I write this the enormous amount of pressure that Sue put on herself. There was definitely a parallel process going on. I wanted to get this right for Sue to give her experience meaning. Another interesting discovery that was very evident during the interview was the amount of anxiety she felt during pregnancy and the need to be strong in labour and could not lose control. Once she saw her baby for the first time, what came after that didn’t matter; all the previous worries and concerns paled into insignificance once she saw her daughter’s face.
“It was amazing and still to this day I still look at her, she’s four months old, and I still look at her and think ‘my god, that’s my baby’. Or I sometimes look and think ‘whose is that baby lying over there? Is that actually mine?’ Because it was just such a wanted experience and wanted thing”
At this point we both became emotional and looked at Sue’s daughter gurgling and playing on her mat. At this point I felt deeply honoured and privileged to hear Sue’s experiences; it deeply touched me.
Possible drawbacks of this study are that it is only one midwife’s experience and therefore it may not be accurate to generalise and conclude that this is how it is for all midwives. I also wondered what my part was in this: I’m a midwife interviewing another midwife that I work with and who is also a friend. I felt very protective of her, which I think may have possibly influenced the findings.
I identified with Sue’s anxieties, the transference in the interview were my anxieties of wanting to get the interview right. I also have similar ideas about my preferences to having a normal low-risk birth. Was I subconsciously seeking to prove my own hypothesis?
I also considered what the findings would have been if the researcher completing this project was not a midwife. I think there may have been a lack of subjectivity on my part.
On the whole I think Sue described her experience from a “be strong” driver. I think she found it difficult being vulnerable whilst being in a professional capacity; there was shame in her vulnerability.
I believe that the predominant ego state presented in the interview was Sue’s critical parent: “I must do this, I can’t have postnatal depression”. I think Sue was quite aware of this process which ties in with her professional capacity as a midwife.
As main researcher in this project, I realise I’ve had a large part to play in this construction of knowledge appropriate for this study. I became very aware of my bodily responses in the interview, especially when she talked about midwives who haven’t had children being harsh on labouring women, and they were less sympathetic. I remember feeling a strong sense of guilt and panic for a fleeting moment, disconnected from Sue whilst I checked out my own care of women, questioning myself. Was I like that?
Was my parallel process with Sue about being authentic? Does it make you a better midwife having had children yourself? Surely a nurse looking after cancer patients does not need to have had cancer to be a good nurse. Was I trying to justify myself as a midwife?
Finlay, L. (2006) The embodied experience of multiple sclerosis; an existential-phenomenological analysis. In Finlay, L and Ballinger, C. (2006)(Eds.) Qualitative Research for Allied Health Professionals. Sussex: Wiley-Blackwell
Finlay, L and Evans, K (2009) Relational-centred Research for Psychotherapists, Chichester, West Sussex: Wiley-Blackwell
Sweet, B (1997) Mayes’ Midwifery: A Textbook for Midwives: Bailliere Tindall