Skilled Heartfelt Midwifery Practice: Safe, Relational Care for Alternative Physiological Births 3031436423, 9783031436420

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Skilled Heartfelt Midwifery Practice Safe, Relational Care for Alternative Physiological Births Claire Feeley

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Skilled Heartfelt Midwifery Practice

Claire Feeley

Skilled Heartfelt Midwifery Practice Safe, Relational Care for Alternative Physiological Births

Claire Feeley Nursing, Midwifery & Palliative Care King's College London London, UK

ISBN 978-3-031-43642-0    ISBN 978-3-031-43643-7 (eBook) https://doi.org/10.1007/978-3-031-43643-7 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Paper in this product is recyclable.

To Ethel for teaching me both the art and science of midwifery, the power of research and for your belief in me—a heartfelt thank you. To Mum and Bryan, I wouldn’t have been able to even complete my undergraduate degree without your support, without which none of this would have been possible—love you both.

Foreword

Safety in UK maternity care is an emotive topic. Over the past 10 years, a series of maternity reviews have exposed failures of care, resulting in distressingly poor outcomes for women and their babies. As review follows review, it feels as though we are no nearer getting to the bottom of the problem. Recommendations have tended to focus narrowly on physical safety, and the ‘risk management’ solutions that are proposed rarely take account of the broader components of safety, including emotional safety. But how does this sit with our own experiences of safety in healthcare? What is it that makes us feel safe in an encounter with a health professional, and how does a sense of feeling safe or unsafe affect our experiences? And as health professionals, how can we optimise an authentic sense of safety for the people we care for? There is so much more that we need to understand if we are to improve experiences and outcomes of care. This is where Claire’s book is so valuable, as it widens our conceptions of safety and offers important new insights into relational care which challenge the status quo. And it does so using actual examples from practice, in the words of midwives themselves. It is part of a new wave of thinking which views safety as a complex issue, affected by the interplay between individuals, systems and organisational culture. The central message of this important book is simple but radical: safety in maternity care is inextricably bound up with trusting, emotionally connected relationships, in combination with clinical expertise and respect for women’s autonomy. Emotional safety is not a luxury add-on, rather it is an essential element of skilled practice. Indeed, Claire argues that emotional safety is the precursor to all other aspects of safety. Without these trusting relationships between caregivers and receivers, it is unlikely that women and other birthing people will feel safe and supported. This in turn will impact on experiences and clinical outcomes. Indeed, some women may feel so unsafe that they will decide to opt out of NHS care altogether and free birth. As Claire proposes so eloquently, the core skill set of midwives is to combine these elements into ‘skilled heartfelt practice’, which integrates emotionally aware, relational practice with clinical expertise and a commitment to supporting and optimising women’s autonomy. And importantly, she provides real-life examples and case studies of how this can be achieved, together with reflective exercises to stimulate our thoughts. vii

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Foreword

I first became aware of Claire’s work 5 years ago, through her PhD, and was very excited by the freshness of her thinking. In this book she sets out the ideas she developed from her research, which explored how a sample of UK NHS midwives actively supported women in facilitating their ‘alternative’ birth choices (for example, where women wanted to birth ‘outside of the guidelines’ or against clinical advice). Stories from these midwives can be found throughout the book, illustrating in their own words the situations (often challenging) that they found themselves in and how they responded. Some of these midwives worked in supportive environments, but many worked in contexts where they were criticised and even ostracised. I found the midwives’ accounts compelling and insightful. They reminded me of similar dilemmas in my own practice many years ago, and the agility, creativity and emotion work that was needed to find solutions that kept women feeling and being safe. The flexible practice-based knowledge that midwives describe drawing on to best support women (‘skilled heartfelt practice’) is the essence of accomplished and expert midwifery. In the midwives’ accounts, we can see examples of holistic thinking and tacit knowledge, resonant with much earlier theorising by Patricia Benner [1] and Michael Polanyi [2]. Importantly it reveals the complex but often invisible work that midwives are doing when they may appear to be doing ‘nothing’. This book is a joy to read, as it articulates the ‘skilled heartfelt practice’ which is the essence of expert midwifery practice. Thank you, Claire, for giving us the words and stories to describe it. References 1 . Benner P (1984) From novice to expert: excellence and power in clinical nursing practice. Addison-Wesley, Menlo Park, CA 2. Polanyi M (1967) The tacit dimension. Anchor Books, New York School of Healthcare Sciences, Cardiff University Cardiff, UK Faculty of Health University of Technology Sydney (UTS) Ultimo, NSW, Australia Faculty of Health and Medical Sciences University of Surrey Guildford, UK August 2023

Billie Hunter

Preface

This book is about physiological birth, specifically, the midwifery care and practice involved when women make birthing decisions that sit ‘outside’ of maternity guidelines or recommendations (I call alternative physiological birth choices). These choices include a vast array of decisions from those with pre-existing medical disorders seeking midwifery-led care (home/birth centre) or perhaps those who prefer hospital but do not want specific routine medical care or interventions, to those with healthy ‘low-risk’ pregnancies declining aspects of care (and everything in between). Given the immense scrutiny physiological birth faces, decisions ‘outside’ of the guidelines can cause great consternation and even be seen as ‘deviant’. For midwives facilitating this care, my previous book shared insights into their experiences of doing so. They revealed polarised workplace environments that either radically hindered the care they could provide or were radically supportive, enabling midwives to provide the care birthing women and people were seeking. That book focused on the sociocultural-political contexts that influenced these polarised positions. However, this book is different. This book sought to strip away that context to get close to the midwives’ practice, why and how they supported ‘alternative’ physiological birthing decisions; to get closer to their skillsets and to illuminate their approach that can be applied to all birthing choices. This, I feel, is important as so much of midwifery skill and practice is invisible or hidden, so this was an opportunity to deep dive into specifics, to explore, unpack different components, and to try and articulate what it is midwives ‘do’. Based on research findings, this books draws on rich accounts from the 45 midwife study participants, bringing to life each chapter of the book to offer learning and reflection throughout. This has been a labour of love, love for the study participants, love for midwives working in challenging environments and most importantly love for all birthing women and people who deserve this type of care. Working towards improvements to maternity care is what drives me. While challenging to complete the manuscript given my new work life, I persevered as I feel strongly that the knowledge generated from this type of midwifery practice needs to be documented, shared and celebrated. I am so grateful to the midwives in the study who gave up their precious time to contribute, sharing intimate information about themselves and professional practice; they demonstrate courageous vulnerability. Furthermore, I have heartfelt gratitude for my support network, professionals, family and friends for yet another project that has kept me locked down and immersed! A big shout out to Prof. Gill ix

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Preface

Thomson, Dr. Stephanie Heys and Dr. Anna Byrom who have kept me going in this last push to get the book completed. And a special thank you to Jo Wright, Anna Madeley, Sheena Byrom, Soo Downe, Alicia Burnett and Lucia Rocca-Ihenacho who have graciously supported me throughout. Last but not least, a big thank you to my editor Marie Come-Garry who was very patient and supportive with shifting deadlines. London, UK

Claire Feeley

About the Book

This book delves into the art, craft and science of expert midwifery care. While the focus is on ‘alternative physiological births’ that are those ‘outside’ of guidelines, the contents can be, and should be applied to any birthing choices. Drawing upon the findings of a PhD that captured the experiences of midwives who proactively supported alternative physiological births while working in the National Health Service, their practice was conceptualised as ‘skilled heartfelt practice’. Skilled heartfelt practice denotes the interrelationship between midwives’ attitudes and beliefs in support of women’s choices, their values of cultivating meaningful relationships, and their expert practical clinical skills. It is the combination of these qualities that give rise to what ‘full-­scope midwifery’ is, as defined by the Lancet Midwifery Series. This book illuminates why and how the midwives facilitated safe, relational care. Using a combination of emotional intelligence skills and clinical expertise grounded in attitudes in favour of women’s bodily autonomy, they ensured safety was constructed holistically. Therefore, this book offers insights to move beyond ‘rule-based’ practice, to notions of expert practice within relational models of care. Furthermore, these insights reflect skilled heartfelt practice in both continuity and fragmented maternity systems. Midwives facilitating ‘alternative’ physiological births epitomise evidence-­ based practice, which centres the woman or birthing person as the expert in their life; the midwife meets them where they are with expert skills to support them. But what does this look like in clinical practice, particularly for those employed by institutions, those ‘working within the system’ who have constraints that private or self-employed midwives don’t have? How does a midwife cultivate those skills within a culture and climate that devalues both relationships, midwives and women’s autonomy? This book aims to provide a roadmap for those seeking to cultivate these skills. The core focus will be the midwife-mother relationship from the perspectives of the midwives, rather than the midwives wider working relationships or workplace contexts. This is purposeful so to offer a deep dive into the nuanced and varied ways of delivering this type of care. However, the realities of practice are also firmly embedded with the book, tensions will be explored and limitations acknowledged.

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Contents

1

Introduction������������������������������������������������������������������������������������������������   1 1.1 Skilled Heartfelt Midwifery Practice��������������������������������������������������   1 1.2 Midwifery in Context��������������������������������������������������������������������������   2 1.3 Physiological Birth in Context������������������������������������������������������������   4 1.4 Alternative Physiological Birth and the Research������������������������������   6 1.5 Moving from a Rule-Based Practice to Skilled Heartfelt Midwifery: A Roadmap����������������������������������������������������������������������  13 References����������������������������������������������������������������������������������������������������  14

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Recognising Ourselves: The Role of Beliefs, Values, Attitudes and Philosophy on Birthing Choices��������������������������������������������������������  21 2.1 Introduction����������������������������������������������������������������������������������������  21 2.2 Different Lenses, Different Perspectives��������������������������������������������  21 2.3 Beliefs, Values and Attitudes Underpinning Skilled Heartfelt Midwifery ������������������������������������������������������������������������������������������  25 Maternal Autonomy as Paramount and the Boundaries of Responsibility ������������������������������������������������������������������������������������  26 A Healthy Baby: The Minimum Expectation ������������������������������������  28 You Have to See It, to Believe It: Women’s Bodies Work������������������  29 Birthplace and Birth Attendants’ Matter: Influencing Birth Outcomes ����������������������������������������������������������������������������������  30 Loving Women, Loving Birth ������������������������������������������������������������  31 2.4 With-Woman Philosophy and Practice ����������������������������������������������  32 2.5 Cultivating Self-Awareness: Exploring Our Beliefs, Values and Attitudes����������������������������������������������������������������������������  34 2.6 Conclusion������������������������������������������������������������������������������������������  34 References����������������������������������������������������������������������������������������������������  36

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Cultivating Emotional Safety, the Cornerstone of Safe, Relational Care������������������������������������������������������������������������������������������  39 3.1 Introduction����������������������������������������������������������������������������������������  39 3.2 ‘Safety’ in Maternity Care������������������������������������������������������������������  40 3.3 Widening Conceptions of Safety in Maternity Care��������������������������  43 Understanding as Safety ��������������������������������������������������������������������  44 Support as Safety��������������������������������������������������������������������������������  46 xiii

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Contents

3.4 Relational Care Is Safe Care ��������������������������������������������������������������  49 3.5 Cultivating Self-Awareness: Exploring and Managing our Fears����������������������������������������������������������������������������������������������  52 3.6 Conclusion������������������������������������������������������������������������������������������  53 References����������������������������������������������������������������������������������������������������  54 4

 Moving from a Rule-Based Practice to Expert Clinical Midwifery Practice��������������������������������������������������������������������������������������������������������  61 4.1 Introduction����������������������������������������������������������������������������������������  61 4.2 Rule-Based Versus Autonomous, Professional Practice ��������������������  61 4.3 Expert Midwifery Practice������������������������������������������������������������������  66 Knowledgeable�����������������������������������������������������������������������������������  67 Proactive����������������������������������������������������������������������������������������������  69 Technical ��������������������������������������������������������������������������������������������  71 Responsive and Adaptable������������������������������������������������������������������  72 Intuitive ����������������������������������������������������������������������������������������������  74 4.4 Safe Care Is Not Routinised Care ������������������������������������������������������  77 4.5 Cultivating Self-Awareness: Exploring Our Experiences of, and Exposure to Physiological Birth ��������������������������������������������  78 4.6 Conclusion������������������������������������������������������������������������������������������  79 References����������������������������������������������������������������������������������������������������  80

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 What Midwives Need to Provide Skilled Heartfelt Practice������������������  85 5.1 Introduction����������������������������������������������������������������������������������������  85 5.2 Midwives’ Wellbeing: A Crucial Component of Safe, Relational Care������������������������������������������������������������������������������������  86 5.3 The ASSET Model������������������������������������������������������������������������������  88 A: Autonomy and Access, Assess and Apply EBM����������������������������  89 S: Skills, Skill Development ��������������������������������������������������������������  90 S: Systems Approach, Support������������������������������������������������������������  94 E: Empathy and Compassion��������������������������������������������������������������  98 T: Trusting Relationships��������������������������������������������������������������������  99 5.4 Safe, Relational Care as a Collective Responsibility�������������������������� 100 5.5 A Conclusion, and a Heartfelt Thank You������������������������������������������ 102 References���������������������������������������������������������������������������������������������������� 104

Appendix: Case Studies ������������������������������������������������������������������������������������ 109 Chapter 2������������������������������������������������������������������������������������������������������������ 111 Chapter 3������������������������������������������������������������������������������������������������������������ 113 Chapter 4������������������������������������������������������������������������������������������������������������ 115 Chapter 5������������������������������������������������������������������������������������������������������������ 119

List of Tables

Table 1.1 Participant demographics Table 1.2 Alternative birthing decisions the midwives reported

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About the Author

Claire Feeley  Qualifying as a midwife in 2011, earning an MSc in 2015, PhD in 2019; Claire has worked clinically in all areas of midwifery, in all settings, and across different organisations, across all birthplace settings—specialising in physiological birth across the risk spectrum, water immersion, advocacy and change implementation. Claire’s primary research focus has been on the sociocultural-political interactions upon women’s access to, engagement with and experiences of maternity care. Grounded within interests of health inequalities, childbirth choices, autonomy, rights and care provision issues; a core research focus is on ‘full-scope’ midwifery skill, competence and enabling (or not) working environments as the solution to overcoming many of the issues. Claire has published numerous peer-reviewed articles, book chapters, a monograph and many professional articles, in addition to presenting nationally and internationally on these key topics. Now a lecturer and researcher at King’s College London and a freelance consultant, Claire can be contacted at www.clairefeeley.com.

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Abbreviations

AMU BMI CEFM COC FMU

Alongside maternity unit (birth centre within hospital grounds) Body mass index Continuous electronic foetal monitoring Continuity of carer Free standing maternity unit (birth centre that situated away from the hospital) GBS/GBS+ Group B streptococcus HVBAC Homebirth after caesarean section HWVBAC Home waterbirth after caesarean section ICM International Confederation of Midwives IOL Induction of labour MDT Multi-disciplinary team OU Obstetric unit/hospital P1/P2/P3 etc. Number of births the woman has had PET Pre-eclampsia toxaemia PPH Post-partum haemorrhage PRSOM Prolonged rupture of membranes (definitions vary between 12 and 48 h) RCM Royal College of Midwives RCOG Royal College of Obstetricians and Gynaecologists SOM Supervisor of Midwives SROM Spontaneous rupture of membranes VBAC Vaginal birth after caesarean section VBAC2 Vaginal birth after two caesarean sections VBAC3 Vaginal birth after three caesarean sections VE Vaginal examination WHO World Health Organization WVBAC Water vaginal birth after caesarean section

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Introduction

1.1 Skilled Heartfelt Midwifery Practice Skilled heartfelt midwifery practice is the integration of a midwife’s attitudes, beliefs and philosophy in support of women’s autonomy, aligned with values of relational care and expert clinical skills [1]. It centres the concept of safety through relational care; which is an ongoing trusting therapeutic relationship between caregiver and receiver [2–5]. Relational care has been well documented across healthcare and has a strong evidence base in favour of improved biopsychosocial outcomes [2, 4, 6, 7] and in maternity care demonstrates numerous key benefits [8, 9].1 Relational care typically arises from continuous relationships (continuity of carer) across an extended period between care provider and receiver—in maternity, across the childbearing continuum. Skilled heartfelt midwifery practice extends our understanding of relational care with an exploration of the qualities and skills required of midwives (and any maternity professional)2 to practice ‘relationally’ but is not necessarily contingent on the continuity of relationships (although certainly, continuity magnifies the benefits and makes it easier for both parties). To practice relationally requires attention to our personal attributes and qualities such as attitudes, beliefs, philosophies and emotional intelligence—for what we bring into our caregiving can affect the depth and quality of the caregiving–receiving relationships. A ‘heartfelt’ practice seeks to emotionally connect and attune with those in our care cultivating a therapeutic relationship [10, 11]. Therefore, attending to the personal attributes  Women who received continuity of care from a midwife they know during the antenatal and intrapartum period (compared to women receiving medical-led or shared care) are 24% less likely to experience preterm birth, 19% less likely to lose their baby before 24 weeks gestation, and 16% less likely to lose their baby at any gestation. Women were also more likely to have a vaginal birth, and fewer interventions during birth (instrumental birth, amniotomy, epidural and episiotomy) [8, 9]. 2  While this book focuses on midwifery practice, the core messages are transferrable to other maternity professionals. 1

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. Feeley, Skilled Heartfelt Midwifery Practice, https://doi.org/10.1007/978-3-031-43643-7_1

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required to practice relationally, also includes a willingness or desire to connect emotionally. For midwives, emotional intelligence, personal qualities and attributes must, however, sit within robust clinical skillsets [5]. For kindness, respect and dignity whilst essential, are redundant in this context, if clinical skills are substandard— therefore, both a mindset and skillset are required to safely support all births. A fundamental remit of a qualified midwife relates to supporting and facilitating the physiological processes across the childbearing continuum [12, 13]. Safe practice also includes robust knowledge and the skills to identify, manage and/or escalate deviations known to cause harm and/or are life threatening. Moreover, expert clinical practice rests on the ability to apply a wide range of knowledge sources to clinical situations whilst honouring the specific needs of individuals within our care. Furthermore, it does not rely on a ‘rule-based’ approach to care [14–16], rather, utilises an evidence-­informed approach based on the core principles of ‘patient preference, clinical judgement and the latest evidence’ [17, 18]. Moreover, expert clinical midwifery practice applies a judicious approach to care—not intervening too quickly, or too late [19]—whilst also maintaining principles of maternal autonomy where women are the core decision maker irrespective of the professionals’ preferences or recommendations [19, 20]. As such, skilled heartfelt midwifery practice is a coalescence of all three elements, personal attitudes, meaningful relationship building (with a desire to emotionally connect) and technical clinical skills. Together they provide the essence of safe care, where I use safety within its broadest context—physically, mentally, emotionally, culturally and spiritually [21]. Accordingly, the qualities and skills to cultivate a skilled heartfelt midwifery practice are the core focus of this book. Skilled heartfelt midwifery practice brings into focus what is needed within ourselves to centre the needs of birthing women and people and to enact the ‘caring’ within our caregiving profession. Such a practice can be and should be, applied to all pregnancy and birthing choices, irrespective of the midwife’s personal opinions regarding a particular choice. This is fundamental to respectful, dignified and humanised care [22]. As such, it transcends particular decisions and should be seen as a practice, a way of being, and a way of caring for women during the childbearing continuum. Although the concept of skilled heartfelt midwifery practice was developed from research findings that focused on midwives who facilitated ‘out of guidelines’ physiological birth choices (as this is in the direct remit of professional midwives and is the space in which midwives should have expertise [13, 19]); I advocate that the principles set out in this book can be applied to any pregnancy or birthing decision.

1.2 Midwifery in Context A qualified, regulated midwife is a responsible and accountable health professional working in partnership with women to provide support, care and advice across the childbearing continuum, to facilitate births, to detect, manage and/or escalate complications to appropriate medical care, and to provide antenatal education and

1.2 Midwifery in Context

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preparations for parenthood [13, 23]. They can practice in any setting including home, birth centres and hospitals and for women deemed to have complicated pregnancies that require obstetric or paediatric input, midwives work alongside other health professionals within a ‘coordinator role’ to ensure women’s needs are met [13, 23, 24]. Fundamental to the definition, the role and philosophy of midwifery resides the notion that care operates within a ‘partnership’ model with women, i.e. woman-centred care [25, 26]. A partnership model seeks to cultivate trusting relationships, an important feature of quality midwifery care, women have repeatedly reported as essential [3, 27]. Moreover, birthing women and people want to be treated with respect, dignity and with compassion—again, core features of good quality midwifery care and partnership working [22, 28, 29]. All these aspects highlight that midwifery holds multiple simultaneous roles within an overarching role as public health professionals [24, 30].3 Capturing these multiple roles, ‘full-scope’ midwifery is defined as: Skilled, knowledgeable and compassionate care for childbearing women, newborn infants and families across the continuum throughout pre-pregnancy, pregnancy, birth, postpartum and the early weeks of life. Core characteristics include optimising normal biological, psychological, social and cultural processes of reproduction and early life, timely prevention and management of complications, consultation with and referral to other services, respecting women’s individual circumstances and views, and working in partnership with women to strengthen women’s own capabilities to care for themselves and their families ([19, p. 3]).

This definition of full-scope midwifery was generated by the pioneering Lancet Midwifery Series [19]. This series examined 13 meta-syntheses and 173 systematic reviews that determined midwifery as ‘a vital solution to the challenges of providing high-quality maternal and newborn care for all women and newborn infants, in all countries (p. 8)’. The extensive reviews found that over 56 maternal and neonatal outcomes could be improved by the care that is within the scope of midwifery practice, including: Reduced maternal and newborn mortality, reduced stillbirth, reduced perineal trauma, reduced instrumental birth, reduced intra-partum analgesia or anaesthesia, less severe blood loss, fewer preterm births, fewer newborn infants with a low birth weight, and less hypothermia. The analyses also found increased spontaneous onset of labour, greater numbers of unassisted vaginal births and increased rates of initiation and duration of breastfeeding. Increased referrals for pregnancy complications, fewer admissions to neonatal intensive care units, and shorter stays in neonatal units are examples of outcomes that indicate both improved care and resource use. Importantly, women reported a higher rate of satisfaction with care in general and with pain relief in labour in particular, and improved mother–baby interaction was also identified [19, p. 5].

The Lancet Series [19] identified key aspects of midwifery care that have been demonstrated to optimise women and babies’ outcomes including, midwife-led continuity models, continuous support during childbirth, alternative institutionalised birth settings (birth centres), supporting upright positions in the first stage of  For an extensive overview of the multiple roles of a midwife see [24].

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1 Introduction

labour, relaxation techniques for pain relief in labour, immersion in water in the first and second stages of labour etc. As such, the authors determined that qualified midwives were best placed to deliver cost-effective safe care globally [19]. However, despite these significant benefits, globally, midwifery remains an under-resourced and undervalued profession—highlighted in 2021, The State of the World’s Midwifery [31] found a global shortage of 900,000 midwives. They also found should there be universal access to quality midwifery care, by 2035, 4.3 million lives could be saved—maternal, neonatal and stillbirths [31]. Whilst the burden of workforce shortages and poor maternal-neonatal outcomes sits within low-income countries, workforce and capacity issues exist in most countries [31]. Moreover, evidence demonstrates that access to midwifery models of care and practices (identified above) is inconsistent, even within high-income and well-resourced countries. For example, access to water immersion for labour and/or birth has strong evidence for favourable maternal-neonatal outcomes burns [32] yet is underutilised in obstetric units (OU) [33]. Similarly, access to non-obstetric birth settings (home, midwifery-­led units) is underutilised and lacks prioritisation or resourcing—despite strong evidence in favour of positive maternal-neonatal outcomes (where there is good infrastructure) in these birth settings [34–36]. Poor or inconsistent implementation of these midwifery-led interventions (and many others) limits childbearing women and people’s access to the beneficial biopsychosocial outcomes they offer.

1.3 Physiological Birth in Context A core competency and the specific remit of qualified midwives is the support, facilitation and optimisation of normal physiological processes across the childbearing continuum [19, 37]. Whilst this is relevant and extremely important during the antenatal and postnatal periods, it is during the intrapartum period in which the unique midwifery skillset is paramount for safe and optimal biopsychosocial outcomes [19, 37]. Such skilled intrapartum care matters to women—a systematic review that included 35 studies from 19 countries determined that what mattered most to women was a positive birth experience within a psychologically and clinically safe environment, and the majority wanted a physiological labour and birth: …was a positive experience that fulfilled or exceeded their prior personal and socio-cultural beliefs and expectations. This included giving birth to a healthy baby in a clinically and psychologically safe environment with practical and emotional support from birth companions, and competent, reassuring, kind clinical staff. Most wanted a physiological labour and birth, while acknowledging that birth can be unpredictable and frightening, and that they may need to ‘go with the flow’… [38, p. 1]

Whilst in the UK, the notion of ‘normal’ birth has been recently contested [39, 40],4 it remains a crucial aspect of good midwifery care and is vital for delivering  For more insights regarding the polarisation, contentions and debates regarding the concept of ‘normal’ birth see Feeley, 2023 [21], whereas this book will focus on the practical components of delivering physiological birth care that women are seeking and is not promoting ‘normal birth at any cost’. 4

1.3 Physiological Birth in Context

5

the safe care that women are seeking [13, 19, 41, 42]. ‘Normal’ birth is an internationally recognised term, however, here, I use the term physiological birth to circumvent concerns around moralistic values of ‘normal vs. abnormal birth’ and use the following definition—physiological birth is one where labour starts spontaneously, proceeds without incident (problem or emergency), nor requires intervention, and results in a spontaneous birth, with mother and baby well.5 The optimisation of physiological processes (across the continuum) and in particular during birth requires sound knowledge informed by a wide range of sciences including the basic sciences, anatomy, physiology, biomechanics, epidemiology, observational and intervention studies. Moreover, expert midwifery practice must apply the plethora of evidence to a range of clinical situations (including those unexpected), and also recognises, manages and/or escalates deviations of pathology as required. Importantly, even where labours or births require medical intervention and/or management, expert midwifery practice draws on the evidence to maintain optimal physiological processes, e.g. skin-to-skin following an instrumental or caesarean birth [45, 46]. As such, the optimisation of physiological processes does not neglect women who want or need medical births but seeks to retain or regain homeostasis wherever possible to support positive maternal-neonatal outcomes. Physiological labour and birth have significant biopsychosocial benefits for mothers and babies [19]. These include increased experiences of positive birth [47, 48], reduced complications such as serious perineal tears or post-partum haemorrhages [19], greater levels of maternal–infant attachment [49], fewer infant complications such as respiratory or other chronic metabolic illnesses [50], higher breastfeeding initiation and continuation rates with significant maternal–infant health benefits [49]. Moreover, physiological birth reduces complications more likely to occur with operative births and safeguards against risks in subsequent pregnancies [51, 52]. For example, evidence now suggests that a caesarean section carried out during the second stage of labour (full dilatation) increases the risk of a subsequent miscarriage or preterm birth [53]. Moreover, physiological birth, by definition, does not include routine interventions that are commonly carried out such as induction of labour, augmentation of labour, continuous electronic monitoring, episiotomies, instrumental births or caesarean sections [54, 55]. These interventions have a role in specific circumstances to facilitate the wellbeing of mothers and babies, where on balance of risk/benefit, the intervention benefit outweighs its harm; and are lifesaving in the right circumstances. However, when overused, routinely and injudiciously, the risks of using the interventions outweigh the benefits

 There are some variations across the globe regarding the definition of a physiological birth whereby the ‘risk’ status of the woman may be used to define a normal physiological birth, i.e. low risk at the onset of labour (and remaining low risk) and/or where the fetus is head down rather than breech presenting [43, 44]. However, those with obstetric or medical complexities can and do go into spontaneous labour, proceed without complication or intervention to have a spontaneous physiological birth and as the subject of this research study, I’ve opted to use this broad definition to encompass these variations. 5

6

1 Introduction

[56] and place a significant (and inequitable)6 biopsychosocial and economic health burden [59]. Therefore, it is vital to retain and/or regain both the skills required to optimise physiological labour and birth and to identify emerging pathology requiring escalation and/or lifesaving medical intervention because to understand pathology, maternity professionals must understand physiology. The significant increase in childbirth interventions internationally, specifically the dramatic increased rate of caesarean sections corresponds with a significant decline in physiological birth rates [52, 59].7 Numerous complex factors influence whether the physiological processes of labour and birth are enhanced or inhibited. Whilst arguments exist that the increasing complexity of women’s demographics is a significant factor in the rise of medical interventions in high-income countries (e.g. increased rates of obesity, pre-existing morbidity and older nulliparous women) [60, 61] other evidence suggests place of birth and care models are also significant factors [33, 62, 63]. For example, the findings from the UK Birthplace Study [33] demonstrated a relationship between the intended place of birth and maternal birth outcomes, where similar cohorts of women (healthy, low-risk) were much less likely to have a physiological birth in OU settings—58%, compared to; 76% for planned births at a birth centre attached to a hospital, 83% for planned births at a free-standing birth centre, 88% for planned births at home. Other studies have found that despite the popularity of alongside maternity units (AMU), the closer they are situated to an OU, their outcome profile is more similar to that of the OU, thus, negating their beneficial effects [33, 62]. ‘Therefore, birthplace makes a significant difference in outcomes even when accounting for women with similar demographics suggesting care models and practices are influential factors regarding the likelihood of a physiological birth’. Within an obstetric unit, practice is particularly influenced by a complex interplay of medicalisation, institutionalisation, bureaucratic, guideline-centred, risk-averse and litigious-­centred maternity care [21]. This environment is less conducive to the optimisation of physiological labour and birth whereby institutionalised birth practices and routinised care risk superseding individualised, evidence-based care [64, 65]. Whilst some interventions are necessary and lifesaving and if carried out with due care, respect and compassion do not necessarily lead to trauma [66–68]—it is the overuse of routine clinically non-indicated interventions that is problematic [37, 52].

1.4 Alternative Physiological Birth and the Research Within this broader context of the tensions surrounding physiological birth, we turn to women’s decisions that challenge mainstream birth practices. The premise of this research and book is the concept of ‘alternative’ physiological birth choices which I  Consistently, global studies find there is a disparity and inequity to life-saving interventions for those from the Global Majority living in white-dominated countries—these include access to the beneficial preventative midwifery models of care previously discussed and life-saving interventions when they are needed [57, 58]. 7  With some notable exceptions such as Scandinavia. 6

1.4 Alternative Physiological Birth and the Research

7

defined as ‘birth choices that go outside of local/national maternity guidelines or when women decline recommended treatment of care, in the pursuit of a physiological birth’ [1].8 Making choices ‘outside’ of guidelines and/or delivering care for those women can be another site for tension and conflict [69–71]. The dominance of institutionalised practices, where guideline-centred care wields authority over decision-­ making, can negatively influence women’s access to their preferred choices [72–74]. Birthing decisions deemed as culturally non-normative (i.e. in hospitals with routine medical interventions and/or with pharmacological pain relief) can create moralistic opposition and restrictive care provision by maternity professionals [69, 70, 75]. For example, women with raised BMIs might be excluded from birth centres or birthing pools [72], or women declining a routine induction of labour for postdates may face pressure and coercion with repetitive conversations with health professionals regarding the ‘risk’ of being overdue [71]. In severe cases, maternity professionals may refer women to social services for ‘unwise’ decision-making [73, 76, 77]. In all these situations, such coercive strategies deny birthing women and people’s agency, bodily autonomy and are a violation of their human rights [20]. However, for maternity professionals working in institutional settings (which is most), they too face pressure to conform to local guidelines for fear of disciplinary action from their employers [16, 78]. Therefore, by centring on this aspect of maternity care, the research was an examination of these complex sociological issues [21] whilst developing practice-based evidence regarding midwives’ facilitation of such births [79]. This book focuses on the practice-based evidence generated from the study to inform everyday clinical practice—the ‘how’ midwives enacted authentic and ‘full-scope’ midwifery practice.9 The research was carried out in the UK which has strong legislation and governmental policy in support of women’s bodily autonomy, including the right to decline healthcare [20, 80–84]. Additionally, the UK has a strong professional midwifery workforce embedded within a robust maternity care system across all birth settings (home, birth centres and hospital), with timely access to medical or paediatric care should the need arise. Therefore, the UK maternity system should, in theory, generate high rates of safe physiological births and positive childbirth experiences. However, data from England for 2020–2021 [85] showed 47% of labours were spontaneous onset (down from 67% 10 years previously) with 54% documented as spontaneous births (down from 62% 10 years previously). However, these statistics do not capture typical interventions such as augmentation during labour, whereas the National Maternity and Perinatal Audit (NMPA) found the UK spontaneous birth rate, without any intervention, was just 36.9% in 2016–2017 [86]. However, the researchers opted not to capture birth without intervention for 2018–2019 [87]. The report citing problematic datasets and concerns about applying value-based judgements to intervention-free births, however, other data was included with no  This definition excluded birth choices that go outside of maternity guidelines for increased medical surveillance and/or medical interventions such as elective induction of labour or caesarean. This was purposeful to get closer to midwifery practice within this contentious space and because supporting physiological birth is a core midwifery skillset. 9  To explore the sociological issues from the study please see [21]. 8

8

1 Introduction

concerns regarding neutrality such as regarding caesarean sections and instrumental births [87]. All of these issues mirror the fraught political maternity landscape the UK faces. Within a backdrop of austerity, Brexit, the COVID-19 pandemic and significant maternity workforce challenges, several public inquiries have highlighted several failing maternity services [88–91]. Such failures of care have been misattributed to an ideology of ‘normal birth at any cost’ [39, 42, 92, 93] rather than the chronic, systemic, institutional failures the reports revealed [88–91].10 As such, women seeking physiological birth and midwives supporting them face even greater tensions and challenges than at the time of this study’s data collection. More recently, further issues have been raised such as frequent closures of homebirth, birth centre and waterbirth services, and continuity teams are being disbanded [94], further reducing women’s access to midwifery-led models of care. Despite these ongoing challenges and tensions, those using maternity services want and expect skilled caregivers to support and optimise their birthing experience [38] and many continue to seek physiological birth (alternative or otherwise) care. To do this safely (within the broadest sense of safety—physically, psychologically, culturally and spiritually), skills need to be acquired and strengthened. Therefore, the research insights within this book still have relevance and are also transferrable to other settings and countries. This research captured narrative accounts and interviews from NHS-employed midwives, who were self-defined as facilitative of alternative physiological birth choices.11 Forty-five midwives participated, sharing their practice-based stories and experiences of delivering this type of maternity care. The core focus was to collect these stories that related to any physiological birth choice deemed outside of the guidelines to take a broader approach rather than focusing on specific decisions (e.g. home vaginal birth after caesarean or waterbirth for those with raised BMIs). Instead, the aim was to develop practice-based knowledge and insights that could be applied to any birth choice, to elucidate the principles of midwifery practice in this context—from which, were developed into the core concept of this book ‘skilled heartfelt midwifery practice’.12 The midwives recruited for the

 A further issue is any vaginal birth including induction of labours, augmentation during labour and instrumental births have been conflated with physiological birth (spontaneous onset of labour and spontaneous birth). Long inductions and augmentations (each carrying their own risks) were frequently identified in these reports as core areas of failings, yet ‘normal’ physiological birth which precludes these interventions has been cited as an ideology that has risked mothers and babies’ lives [42, 93]. 11  For methodological insights this study was based on, please see [1]. 12  The research included three research questions—to find out how midwives delivered this care so that practice-based evidence could be used for other midwives and maternity professionals within their practice. I also wanted to understand their experiences of doing so, and to examine the intersection, influence and impact of social, cultural and political discourses on their practice and experiences in delivering care. To answer these three research questions, three different narrative analyses were carried out, one building on the other. This book is focused on the insights generated from research question one: ‘how did midwives support and facilitate alternative physiological birth choices?’ The other two questions formed the basis of my previous book [21]. 10

1.4 Alternative Physiological Birth and the Research

9

study were mostly employed by different organisations (known as hospital Trusts)13 from across the UK. This provided data and analyses to generate broader insights and perspectives, beyond that of a localised organisational culture, to extrapolate wider, transferrable findings. The 45 midwife participants were diverse in several ways (see Table 1.1), e.g. working in different settings (community, birth centres, hospital), working in different roles, in different models (continuity or fragmented), with different levels of experience (30) and levels of seniority (junior/senior/management). Such diversity strengthened the findings and facilitated the development of transferrable principles whilst providing breadth and depth to the knowledge base regarding both relational care and supporting a wider range of physiological births safely. The midwives could either write a reflective account (self-written narrative) or be interviewed, with many opting to do both. Starting with an open question, the midwives either wrote or told me about a specific alternative physiological birth they had facilitated; thereafter, interviews were ‘conversational’ and covered a wide range of clinical and personal experiences related to the topic. Across the 65 pieces of data, the midwives reported facilitating a wide range of alternative physiological birth choices. Some a ‘nudge’ outside of the guidelines, i.e. women with healthy pregnancies declining an aspect of care; others a ‘giant leap’, i.e. women with multiple complexities and/or co-morbidities seeking midwifery-led birthplace settings such as home or free-standing birth centres. Table  1.2 shares the range of birth choices but notes to preserve the anonymity of the women (who were not involved directly in the study), the ‘risk’ factors were separated and tabulated individually. However, many of the practice-based stories involved multiple complexities. In all the interviews and some of the written accounts, the midwives wove in stories about their workplace environments and how their caregiving approach was received by their colleagues and organisations. Some were heartbreaking accounts of isolation, ostracization and bullying and others were uplifting accounts of workplace friendship, camaraderie and support [21]. Whilst explored at length elsewhere, it is pertinent to acknowledge that the midwives’—workplace cultures positively or negatively influenced the degree to which the midwives support alternative physiological birth choices. For those within environments that did not value women’s autonomous decision-making and were ‘guideline-centric’—the midwives reported obstacles and battles to deliver this care [21]. In extreme circumstances, midwives were vilified for their practice which included referrals to their regulatory body,14 as  In the UK, the NHS is divided into ‘hospital Trusts’ which are commissioned to deliver services in specific geographical areas. A ‘Trust’ providing maternity services typically includes hospital settings (the dominant place), community midwifery services for homebirth provision, antenatal/ postnatal care (sometimes in conjunction with GP surgeries) and may include birth centre provision (free standing or adjoined within the hospital). Therefore, a ‘Trust’ is responsible for all maternity service provision, employment of the staff across the different areas, and operate under the same employment contracts, policies, guidelines etc. 14  Nursing and Midwifery Council—although all were cleared of wrongdoing and/or negligent practice, their experiences were extremely distressing and traumatising. 13

10 Table 1.1 Participant demographics

1 Introduction Sex Female Male Age 18–24 25–34 35–44 46–54 >55 Ethnicity British African-Caribbean White British White Welsh White Irish White American Region North East England North West England Yorkshire and Humber East Midlands West Midlands Greater London East of England South East England South West England Wales Northern Ireland Scotland Education Diploma Degree Postgraduate certificate Master’s PhD Year’s qualified 20 >30

44 1 45 1 11 19 8 5 44 1 39 2 2 1 45 1 8 4 3 2 8 4 8 4 2 1 0 45 4 24 3 12 2 45 2 5 14 16 7 1 45

1.4 Alternative Physiological Birth and the Research Table 1.1 (continued)

Employment status Full-time Part-time Bank Current clinical band Band 5 Band 6 Band 7 Band 8 Other Job role Hospital Rotational midwife Core midwife Labour Ward Coordinator (shift leader) Community Community midwife Integrated midwife (community and birth centre) Birth centre Homebirth Team Leader Community Manager Across all settings Specialist (i.e. mental health) Supervisor Consultant midwife Other Research Education Those with additional roles Secondary Tertiary Type of additional role Supervisor Specialist Research

11

32 12 1 45 2 21 14 5 3 45

4 6 2 8 2 5 4 1 5 1 4 1 2 45 7 3 10 4 1 1 6

12

1 Introduction

Table 1.2  Alternative birthing decisions the midwives reported Broad decisions Declining vaginal examinations during labour Declining postdates induction of labour (IOL) Declining recommended IOL for ‘risk’ factors, i.e. IVF pregnancy, >40 years old, previous caesarean Declining antenatal screening/scans Declining all monitoring during labour Freebirth Hospital Declining antibiotics in labour for GBS+ or PRSOM Declining augmentation for PSROM WVBAC (with telemetry) WVBAC—declining CEFM VBAC3 Declining recommended medical interventions (not emergency) Declining medical interventions in emergency situations Twin waterbirth Physiological third stage—PET Breech births outside of guidelines Waterbirth—gestational diabetes—no CEFM Homebirth >40 years old VBAC VBAC2 VBAC postdates Water VBAC Grand multipara P5–P10 PSROM>72 h GBS+ Diabetes (type 1 (n = 1) or GDM (n = 3) Polyhydramnios Hypothyroidism Mental health needs (various) Blood clotting disorder Epilepsy Blood-borne virus Low iron levels Raised BMI >35, >40, >50 Breech Twin breech Twin waterbirth Twins Previous history of PPH’s Previous history of shoulder dystocia Previous history of 3rd-degree tear

1.5 Moving from a Rule-Based Practice to Skilled Heartfelt Midwifery: A Roadmap

13

Table 1.2 (continued) Broad decisions Unusual locations Declining a recommendation of transfer for meconium liquor Declining transfer for PPH Declining transfer for the stalled second stage of labour Declining transfer to hospital during prolonged third stage (>3 h) Birth Centre Outside of ‘criteria’ (unspecified) >40 years old Blood clotting disorder Antidepressant medication Gestational diabetes Waterbirth GBS+ Raised BMI >35, >40 VBAC no CEFM Breech

such, many of the midwives worked in psychologically unsafe environments [21, 95]. Conversely, around half of the midwife participants worked in supportive, enabling environments. Their workplace cultures valued women’s autonomous decision-making and trusted the midwives to deliver alternative physiological birth care [21, 95]. Supportive environments were characterised by compassionate, inclusive leadership, visible and proactive support for women’s choices and midwives directly involved in care delivery, with positive working relationships with the multidisciplinary teams. Furthermore, these environments had high levels of ­psychological safety creating virtuous circles of positive cultures safely meeting the needs of birthing women and people [21]. There are crucial contextual insights for midwifery practice does not occur in a vacuum. However, for the purposes of this particular book,15 much of this important context is removed (but is revisited in Chap. 7), so to provide an in-depth examination of the qualities and skills required to deliver authentic personalised care.

1.5 Moving from a Rule-Based Practice to Skilled Heartfelt Midwifery: A Roadmap Returning to the start of this chapter skilled heartfelt midwifery practice was defined as the integration of a midwife’s attitudes, beliefs and philosophy in support of women’s autonomy, aligned with values of relational care and expert clinical skills [1]. Skilled heartfelt practice can be viewed as extending our understanding of what constitutes relational and woman-centred care. Accordingly, the key focus is on the  See my previous book for an in-depth examination of the sociocultural-political contexts of the midwives’ workplaces [21]. 15

14

1 Introduction

midwife-mother relationship, rather than the broader sociocultural-political contextual features already discussed. I do not wish to ignore those complexities and challenges, however, to offer a close examination of the qualities and skills required to practice authentic midwifery, much of that context will be stripped away for the purposes of this book, to provide a roadmap of safe and relational skilled heartfelt midwifery practice. Using examples, quotes and vignettes from the research participants, the different concepts will be illuminated and ways to cultivate them will be described through reflective exercises. Much of the content you may know intuitively, but hopefully the midwife participants’ articulation of these attributes will offer a new language and way to understand these practices. Each chapter will examine a different concept/attribute individually, however, remember that skilled heartfelt practice constitutes a coalescence of these concepts together.

References 1. Feeley (2019) ‘Practising outside of the box, whilst within the system’: a feminist narrative inquiry of NHS midwives supporting and facilitating women’s alternative physiological birthing choices. PhD thesis, University of Central Lancashire. https://clok.uclan. ac.uk/30680/?template=default_internal 2. Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R (2003) Continuity of care: a multidisciplinary review. BMJ 327:1219–1221. https://doi.org/10.1136/ bmj.327.7425.1219 3. Perriman N, Davis D, Ferguson S (2018) What women value in the midwifery continuity of care model: a systematic review with meta-synthesis. Midwifery 62:220–229. https://doi. org/10.1016/j.midw.2018.04.011 4. Sandall J, Soltani H, Gates S, Shennan A, Devane D (2016) Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev 4:CD004667. https://doi.org/10.1002/14651858.CD004667.pub5 5. Downe S, Simpson L, Trafford K (2007) Expert intrapartum maternity care: a meta-synthesis. J Adv Nurs 57:127–140. https://doi.org/10.1111/j.1365-­2648.2006.04079.x 6. Freeman G, Hughes J (2010) Continuity of care and the patient experience. The King’s Fund. https://www.kingsfund.org.uk/sites/default/files/field/field_document/continuity-­care-­patient-­ experience-­gp-­inquiry-­research-­paper-­mar11.pdf 7. Pereira D, Gray J, Sidaway-Lee K, White E, Thorne A, Evans PH (2018) Continuity of care with doctors—a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open 8:e021161. https://doi.org/10.1136/bmjopen-­2017-­021161 8. Hatem M, Sandall J, Devane D, Soltani H, Gates S (2008) Midwife-led versus other models of care for childbearing women. Cochrane Database Syst Rev 2008:CD004667 9. Sandall J, Coxon K, Mackingtosh N, Rayment-Jones H, Locock L, Page L (2016) Relationships: the pathway to safe, high-quality maternity care report from the Sheila Kitzinger symposium at Green Templeton College October 2015. King’s College, London. https://www.gtc.ox.ac.uk/ images/stories/academic/skp_report.pdf 10. Bradfield Z, Duggan R, Hauck Y, Kelly M (2018) Midwives being ‘with woman’: an integrative review. Women Birth 31:143–152. https://doi.org/10.1016/j.wombi.2017.07.011 11. Bradfield Z, Hauck Y, Duggan R, Kelly M (2019) Midwives’ perceptions of being ‘with woman’: a phenomenological study. BMC Pregnancy Childbirth 19:363. https://doi. org/10.1186/s12884-­019-­2548-­4 12. NMC (2019) Future midwife: standards of proficiency for midwives. A Draft Jan 2019. https:// www.nmc.org.uk/globalassets/sitedocuments/midwifery/future-­midwife-­consultation/draft-­ standards-­of-­proficiency-­for-­midwives.pdf

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13. ICM (2018) Essential competencies for midwifery practice 2018 update. International Confederation of Midwives. https://internationalmidwives.org/assets/uploads/documents/ ICM%20competencies%20-­%20English%20document_final_Oct%202018.pdf 14. Downe S (2010) Toward salutogenic birth in the 21st century. In: Walsh D, Downe S (eds) Essential midwifery practice: intrapartum care. Wiley-Black, Oxford 15. Downe S, Simpson L, Trafford K (2006) Expert intrapartum maternity care: a meta-synthesis. J Adv Nurs 57:127–140 16. Griffith R, Tengnah C (2010) Law and professional issues in midwifery (transforming midwifery practice series). Learning Matters Ltd, Exeter 17. Sackett D (1997) Evidence-based medicine. Semin Perinatol 21(1):3–5 18. Kumah EA, McSherry R, Bettany-Saltikov J et  al (2019) PROTOCOL: evidence-informed practice versus evidence-based practice educational interventions for improving knowledge, attitudes, understanding, and behavior toward the application of evidence into practice: a comprehensive systematic review of undergraduate students. Campbell Syst Rev 15:e1015. https:// doi.org/10.1002/cl2.1015 19. Renfrew M, McFadden A, Bastos M et al (2014) Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. Lancet 384:1129–1145. https://doi.org/10.1016/S0140-­6736(14)60789-­3 20. Birthrights (2020) Consenting to treatment. https://www.birthrights.org.uk/wp-­content/ uploads/2021/08/Consenting-­to-­treatment-­FINAL-­1.pdf 21. Feeley C (2023) Supporting physiological birth choices in midwifery practice: the role of workplace culture, politics and ethics. Taylor & Francis Ltd, London 22. Newnham E, McKellar L, Pincombe J (2018) Introduction. In: Newnham E, McKellar L, Pincombe J (eds) Towards the humanisation of birth: a study of epidural analgesia and hospital birth culture. Palgrave Macmillan, London, pp 1–15 23. International Confederation of Midwives (2017) ICM definitions: definition of the midwife. https://internationalmidwives.org/our-­work/policy-­and-­practice/icm-­definitions. html#:~:text=The%20midwife%20is%20recognised%20as,the%20newborn%20and%20 the%20infant 24. Watkins V, Nagle C, Yates K et  al (2023) The role and scope of contemporary midwifery practice in Australia: a scoping review of the literature. Women Birth 36:334–340. https://doi. org/10.1016/j.wombi.2022.12.001 25. Maputle M, Hiss D (2013) Woman-centred care in childbirth: a concept analysis (part 1). Curationis 36(1):E1–E8. https://doi.org/10.4102/curationis.v36i1.49 26. ICM (2014) Core document philosophy and model of midwifery care. https://www.internationalmidwives.org/assets/files/definitions-­files/2018/06/eng-­philosophy-­and-­model-­of-­ midwifery-­care.pdf 27. Walsh D, Devane D (2012) A metasynthesis of midwife-led care. Qual Health Res 22:897–910 28. Birthrights (2013) The dignity survey 2013: women’s and midwives’ experiences of UK maternity care. http://www.birthrights.org.uk/wordpress/wp-­content/uploads/2013/10/Birthrights-­ Dignity-­Survey.pdf 29. Shakibazadeh E, Namadian M, Bohren MA et al (2018) Respectful care during childbirth in health facilities globally: a qualitative evidence synthesis. BJOG 125:932–942. https://doi. org/10.1111/1471-­0528.15015 30. McNeill J, Lynn F, Alderdice F (2012) Public health interventions in midwifery: a systematic review of systematic reviews. BMC Public Health 12:955. https://doi.org/10.1186/ 1471-2458-­12-­955 31. UNFPA, ICM and WHO (2021) The state of the world’s midwifery: 2021. https://www.unfpa. org/sites/default/files/pub-­pdf/21-­038-­UNFPA-­SoWMy2021-­Report-­ENv4302_0.pdf 32. Burns E, Feeley C, Hall PJ, Vanderlaan J (2022) Systematic review and meta-analysis to examine intrapartum interventions, and maternal and neonatal outcomes following immersion in water during labour and waterbirth. BMJ Open 12:e056517. https://doi.org/10.1136/ bmjopen-­2021-­056517

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1 Introduction

33. Brocklehurst P (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. BMJ 343:d7400. https://doi.org/10.1136/BMJ.d7400 34. Hodnett E, Downe S, Walsh D (2012) Alternative versus conventional institutional settings for birth. Cochrane Database Syst Rev 2012:CD000012. https://doi.org/10.1002/14651858. CD000012.pub4 35. Reitsma A, Simioni J, Brunton G, Kaufman K, Hutton EK (2020) Maternal outcomes and birth interventions among women who begin labour intending to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: a systematic review and meta-analyses. Lancet 21:100319. https://doi.org/10.1016/j.eclinm.2020.100319 36. Hutton E, Reitsma A, Simioni J, Brunton G, Kaufman K (2019) Perinatal or neonatal mortality among women who intend at the onset of labour to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: a systematic review and meta-­ analyses. EClinicalMedicine 14:59–70. https://doi.org/10.1016/j.eclinm.2019.07.005 37. World Health Organisation (2018) WHO recommendations Intrapartum care for a positive childbirth experience. https://www.who.int/publications-­detail-­redirect/9789241550215 38. Downe S, Finlayson K, Oladapo O, Bonet M, Gülmezoglu A (2018) What matters to women during childbirth: a systematic qualitative review. PLoS One 13:e0194906. https://doi. org/10.1371/journal.pone.0194906 39. Gutteridge (2022) Silence is never golden—midwives and women speaking out. https://www. maternityandmidwifery.co.uk/silence-­is-­never-­golden-­midwives-­and-­women-­speaking-­out/ 40. Beech (2017) The backlash against normal birth. 2022. AIMS. https://www.aims.org.uk/ campaigning/item/the-­backlash-­against-­normal-­birth 41. NMC (2018) Standards for competence for registered midwives. Nursing & Midwifery Council. https://www.nmc.org.uk/standards/standards-­for-­midwives/ standards-­of-­competence-­for-­registered-­midwives/ 42. Buchanan K, Newnham E, Geraghty S, Whitehead L (2022) Navigating midwifery solidarity: a feminist participatory action research framework. Women Birth 26(1):e169–e174. https:// doi.org/10.1016/j.wombi.2022.06.004 43. World Health Organization (1996) Care in normal birth: a practical guide. https://onlinelibrary. wiley.com/doi/abs/10.1111/j.1523-­536X.1997.00121.pp.x?sid=nlm%3Apubmed 44. International Confederation of Midwives (2014) Position statement keeping birth normal. International Confederation of Midwives. https://www.internationalmidwives.org/assets/files/ statement-­files/2019/06/keeping-­birth-­normal-­eng-­converted-­updated-­letterhead.pdf 45. Kahalon R, Preis H, Benyamini Y (2021) Who benefits most from skin-to-skin mother-infant contact after birth? Survey findings on skin-to-skin and birth satisfaction by mode of birth. Midwifery 92:102862. https://doi.org/10.1016/j.midw.2020.102862 46. Armbrust R, Hinkson L, von Weizsäcker K, Henrich W (2016) The Charité cesarean birth: a family orientated approach of cesarean section. J Matern Fetal Neonatal Med 29:163–168. https://doi.org/10.3109/14767058.2014.991917 47. Hildingsoon I, Johansson M, Karlström A, Fenwick J (2013) Factors associated with a positive birth experience: an exploration of Swedish women’s experiences. Int J Childbirth 3:153–164. https://doi.org/10.1891/2156-­5287.3.3.153 48. Olza I, Leahy-Warren P, Benyamini Y et  al (2018) Women’s psychological experiences of physiological childbirth: a meta-synthesis. BMJ Open 8:e020347. https://doi.org/10.1136/ bmjopen-­2017-­020347 49. Olza-Fernández I, Marín Gabriel MA, Gil-Sanchez A, Garcia-Segura LM, Arevalo MA (2014) Neuroendocrinology of childbirth and mother-child attachment: the basis of an etiopathogenic model of perinatal neurobiological disorders. Front Neuroendocrinol 35:459–472. https://doi. org/10.1016/j.yfrne.2014.03.007 50. Dahlen H, Thornton C, Downe S et  al (2021) Intrapartum interventions and outcomes for women and children following induction of labour at term in uncomplicated pregnancies: a 16-year population-based linked data study. BMJ Open 11:e047040. https://doi.org/10.1136/ bmjopen-­2020-­047040

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51. Sandall J, Tribe R, Avery L et al (2018) Short-term and long-term effects of caesarean section on the health of women and children. Lancet 392:1349–1357. https://doi.org/10.1016/ S0140-­6736(18)31930-­5 52. World Health Organisation (2018) WHO recommendations non-clinical interventions to reduce unnecessary caesarean sections. http://apps.who.int/iris/bitstream/han dle/10665/275377/9789241550338-­eng.pdf?ua=1 53. Watson HA, Carter J, David AL, Seed PT, Shennan AH (2017) Full dilation cesarean section: a risk factor for recurrent second-trimester loss and preterm birth. Acta Obstet Gynecol Scand 96:1100–1105. https://doi.org/10.1111/aogs.13160 54. ten Hoope-Bender P, de Bernis L, Campbell J et  al (2014) Improvement of maternal and newborn health through midwifery. Lancet 384:1226–1235. https://doi.org/10.1016/ S0140-­6736(14)60930-­2 55. The Lancet (2018) Stemming the global caesarean section epidemic. Lancet 392:1279. https:// doi.org/10.1016/S0140-­6736(18)32394-­8 56. 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. Lancet 388:2176–2192. https://doi.org/10.1016/S0140-­6736(16)31472-­6 57. Sheikh J, Allotey J, Kew T et  al (2022) Effects of race and ethnicity on perinatal outcomes in high-income and upper-middle-income countries: an individual participant data meta-analysis of 2 198 655 pregnancies. Lancet 400:2049–2062. https://doi.org/10.1016/ S0140-­6736(22)01191-­6 58. Khan Z, Vowles Z, Fernandez Turienzo C et al (2023) Targeted health and social care interventions for women and infants who are disproportionately impacted by health inequalities in high-income countries: a systematic review. Int J Equity Health 22:131. https://doi. org/10.1186/s12939-­023-­01948-­w 59. Euro-Peristat Network (n.d.) European perinatal health report, 2015–2019. EuroPeristat. https://www.europeristat.com/index.php/reports.html 60. Kelly E, Lee T (2017) Under pressure? NHS maternity services in England: IFS Briefing Note BN215. Institute of Fiscal Studies. https://ifs.org.uk/sites/default/files/output_url_files/ BN215.pdf 61. Panda S, Begley C, Daly D (2022) Clinicians’ views of factors influencing decision-making for CS for first-time mothers—a qualitative descriptive study. PLoS One 17:e0279403 62. Burns E, Boulton M, Cluett E, Cornelius V, Smith L (2012) Characteristics, interventions, and outcomes of women who used a birthing pool: a prospective observational study. Birth 39:192–202. https://doi.org/10.1111/j.1523-­536X.2012.00548.x 63. Scarf V, Rossiter C, Vedam S et al (2018) Maternal and perinatal outcomes by planned place of birth among women with low-risk pregnancies in high-income countries: a systematic review and meta-analysis. Midwifery 62:240–255. https://doi.org/10.1016/j.midw.2018.03.024 64. Davis D, Homer CSE (2016) Birthplace as the midwife’s work place: how does place of birth impact on midwives? Women Birth 29:407–415. https://doi.org/10.1016/j.wombi.2016.02.004 65. Behruzi R, Hatem M, Goulet L, Fraser W, Misago C (2013) Understanding childbirth practices as an organizational cultural phenomenon: a conceptual framework. BMC Pregnancy Childbirth 13:205. https://doi.org/10.1186/1471-­2393-­13-­205 66. Reed R, Sharman R, Inglis C (2017) Women’s descriptions of childbirth trauma relating to care provider actions and interactions. BMC Pregnancy Childbirth 17:21. https://doi.org/10.1186/ s12884-­016-­1197-­0 67. Thomson G, Downe S (2010) Changing the future to change the past: women’s experiences of a positive birth following a traumatic birth experience. J Reprod Infant Psychol 28:102–112. https://doi.org/10.1080/02646830903295000 68. Crossland N, Kingdon C, Balaam M, Betrán AP, Downe S (2020) Women’s, partners’ and healthcare providers’ views and experiences of assisted vaginal birth: a systematic mixed methods review. BMC Reprod Health 17:83. https://doi.org/10.1186/s12978-­020-­00915-­w 69. Shallow H (2013) Deviant mothers and midwives: supporting VBAC with women as real partners in decision making. Essentially MIDIRS 4:17–21

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70. Madeley A, Earle S, Boyle S (2022) What are the views, attitudes, perceptions and experiences of women who make non-normative choices along maternity care pathways? Midwifery 116:103532. https://doi.org/10.1016/j.midw.2022.103532 71. Roberts J, Walsh D (2018) Babies come when they are ready: women’s experiences of resisting the medicalisation of prolonged pregnancy. Fem Psychol 29:40–57. https://doi. org/10.1177/0959353518799386 72. Scamell M (2014) ‘She can’t come here!’ Ethics and the case of birth Centre admission policy in the UK. J Med Ethics 40:813–816 73. Plested M, Kirkham M (2016) Risk and fear in the lived experience of birth without a midwife. Midwifery 38:29–34. https://doi.org/10.1016/j.midw.2016.02.009 74. McMahon M, Ashworth E (2020) Social Care referrals: lifting the lid. https://www.all4maternity.com/social-­care-­referrals-­lifting-­the-­lid/ 75. Keedle H, Schmied V, Burns E, Dahlen HG (2015) Women’s reasons for, and experiences of, choosing a homebirth following a caesarean section. BMC Pregnancy Childbirth 15:206. https://doi.org/10.1186/s12884-­015-­0639-­4 76. Hollander M, de Miranda E, van Dillen J, de Graaf I, Vandenbussche F, Holten L (2017) Women’s motivations for choosing a high risk birth setting against medical advice in the Netherlands: a qualitative analysis. BMC Pregnancy Childbirth 17:423. https://doi. org/10.1186/s12884-­017-­1621-­0 77. Feeley C, Thomson G (2016) Tensions and conflicts in ‘choice’: women’s experiences of freebirthing in the UK. Midwifery 41:16–21. https://doi.org/10.1016/j.midw.2016.07.014 78. Robertson JH, Thomson AM (2016) An exploration of the effects of clinical negligence litigation on the practice of midwives in England: a phenomenological study. Midwifery 33:55–63. https://doi.org/10.1016/j.midw.2015.10.005 79. Feeley C, Thomson G, Downe S (2020) Understanding how midwives employed by the National Health Service facilitate women’s alternative birthing choices: findings from a feminist pragmatist study. PLoS One 15:e0242508. https://doi.org/10.1371/journal.pone.0242508 80. Department of Health (2007) Maternity matters. Choice, access and continuity of care in a safe service. http://familieslink.co.uk/download/july07/Maternity%20matters.pdf 81. Department of Health (2010) Midwifery 2020: delivering expectations. Jill Rogers Associates. https://www.gov.uk/government/publications/midwifery-­2020-­delivering-­expectations 82. Department of Health (1993) Changing childbirth. https://publications.parliament.uk/pa/ cm200203/cmselect/cmhealth/796/79603.htm 83. NHS England (2016) Better births: improving outcomes of maternity services in England: a five year forward view for maternity care. https://www.england.nhs.uk/wp-­content/ uploads/2016/02/national-­maternity-­review-­report.pdf 84. NHS England (2021) Maternity transformation programme 2022. https://www.england.nhs. uk/mat-­transformation/ 85. NHS Digital (2021) NHS maternity statistics, England 2020–21. https://digital.nhs.uk/ data-­and-­information/publications/statistical/nhs-­maternity-­statistics 86. NMPA Project Team (2019) National Maternity and Perinatal Audit: clinical report 2019. Based on births in NHS maternity services between 1 April 2016 and 31 March 2017. RCOG, London. https://maternityaudit.org.uk/FilesUploaded/NMPA%20Clinical%20Report%20 2019.pdf 87. NMPA Project Team (2022) National Maternity and Perinatal Audit Clinical Report 2022 based on births in NHS maternity services in England and Wales between 1 April 2018 and 31 March 2019. RCOG. https://maternityaudit.org.uk/FilesUploaded/Ref%20336%20 NMPA%20Clinical%20Report_2022.pdf 88. Francis R (2013) Report of the mid Staffordshire NHS foundation trust public inquiry executive summary. The Stationery Office Limited. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/279124/0947.pdf 89. Ockenden D (2022) Findings, conclusions and essential actions from the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust. HH Associates Ltd. https://www.gov.uk/government/publications/final-­report-­of-­the-­ockenden-­review

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90. Kirkup B (2015) The report of the Morecambe Bay Investigation. Morecambe Bay Investigation. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/ attachment_data/file/408480/47487_MBI_Accessible_v0.1.pdf 91. Kirkup B (2022) Reading the signals. Maternity and neonatal services in East Kent—the Report of the Independent Investigation. Department of Health and Social Care. https:// assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/ file/1111992/reading-­the-­signals-­maternity-­and-­neonatal-­services-­in-­east-­kent_the-­report-­of- ­ the-­independent-­investigation_print-­ready.pdf 92. Darling (2021) “Normal birth at any cost”—understanding and addressing root causes is important to promoting safety in UK maternity services. https://www.all4maternity. com/normal-­birth-­at-­any-­cost-­understanding-­and-­addressing-­root-­causes-­is-­important-­to-­ promote-­safety-­in-­uk-­maternity-­services/ 93. Feeley C (2021) Normal birth—the scapegoat for poor maternity care. Midwifery Matters 171:16–19 94. Birthrights (2022) Coronavirus. https://www.birthrights.org.uk/campaigns-­research/ coronavirus/ 95. Feeley C, Downe S, Thomson G (2021) ‘Stories of distress versus fulfilment’: a narrative inquiry of midwives’ experiences supporting alternative birth choices in the UK National Health Service. Women Birth 35(5):e446–e455. https://doi.org/10.1016/j.wombi.2021.11.003

2

Recognising Ourselves: The Role of Beliefs, Values, Attitudes and Philosophy on Birthing Choices

2.1 Introduction The previous chapter provided an overview of ‘skilled heartfelt midwifery practice’—the integration of a midwife’s attitudes, beliefs and philosophy in support of women’s autonomy, aligned with values of relational care and expert clinical skills. The benefits of midwifery-led care and physiological birth were presented to provide the context for the concept of ‘alternative physiological births’—those physiological birthing decisions deemed ‘outside of guidelines’. This chapter focuses on the attitudes, values, beliefs and arising philosophies of practice midwives hold which may determine the extent to which midwives are prepared to support alternative birthing choices. First, this chapter will present and explore the evidence regarding different midwifery philosophical beliefs which is important to demonstrate that midwives are not a homogenous group of professionals despite all working under the same protected title [1]. ‘Second, drawing on the’ research participant’s attitudes, values and beliefs that coalesced as their philosophy of care, ‘I will illustrate that the participant philosophy of care was a key factor in their’ willingness to support alternative physiological birth choices. Finally, the chapter will explore the importance of cultivating self-awareness concerning our own attitudes, values, beliefs and philosophy.

2.2 Different Lenses, Different Perspectives Midwives have been determined to be ideally placed to deliver woman-centred care that promotes and optimises women’s normal physiological processes across the childbearing continuum and therefore, are, ideally situated to practice full-scope midwifery [2]. Most midwives in high-income countries are employed rather than working independently. This can lead to a conflicted position (briefly highlighted in

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. Feeley, Skilled Heartfelt Midwifery Practice, https://doi.org/10.1007/978-3-031-43643-7_2

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Chap. 1)1 between providing woman/person-centred care and the expectations of employers desiring conformity to the cultural practices of their workplace [4–7]. As highlighted in Chap. 1, issues of institutionalised birth practices are associated with (over)medicalisation, standardisation, routine and guideline-based care, risk and litigation issues. Therefore, tensions exist between midwives’ professional and employee obligations [7–10]. Midwives can be viewed as the ‘gatekeepers’ of women’s choices [11, 12] who can be facilitative [13–15] or obstructive [16, 17]. However, the gatekeeping role needs to be contextualised by the tensions described; wherein workplace sociocultural-political contexts are challenging for those midwives wanting to deliver woman and person-centred care [8, 18, 19]. Notwithstanding the known tensions for midwifery practice, midwives have been found to have different attitudes, belief systems, values, and subsequent care philosophies. Therefore, midwives are not a homogenous group of professionals. How midwives are aligned can influence their attitude and willingness to facilitate alternative physiological birth choices [19–21]. Despite the unique, specific role and definition of a midwife that is based on the philosophy set out by the International Confederation of Midwives [1, 22], research suggests that not all midwives align themselves with this approach (explained further below). In relation to alternative physiological birth choices, my previous metasynthesis explored midwives’ views, attitudes and experiences of delivering this care [20]. With only five studies2 available at the time, which included 55 midwives, there was a surprisingly polarised spectrum of views: The findings suggested that the midwives in the included studies, which encompassed both employed and independent midwives’ appeared to be situated upon a spectrum of ‘willingly facilitative’ or ‘reluctantly accepting’ of women’s unconventional birth choices. This seemed to be informed by the degree to which they value women’s autonomy over institutional norms and fetal rights. However, their positioning was also influenced by vulnerabilities associated with professional accountability, subsequent litigation, and actual or potential reprisals arising from adverse events. Such vulnerabilities, and the adverse emotional consequences of them were particularly apparent for those working within institutions when compared to those working independently. However, for all midwives, the quality and nature of midwives’ relationships with women were central to their response to, and management of, unconventional birth choices. [20, p. 57]

Whilst these differences highlighted the influence of workplace environments on the ability of employed midwives to provide authentic personalised care; the findings also revealed that to cultivate a skilled heartfelt practice, first, midwives must want to do it. Previous research has also shown differences between midwives’ attitudes, values and beliefs. McFarlane & Downe [23] first identified two kinds of midwives; those who prioritised ‘the clinical event (p. 24)’, who chose to work in hospital settings, and who perceived their work as an occupation. Second were those who prioritised ‘supporting the evolving parent’, preferred to work in  For extensive insights, see my previous book [3].  Despite an extensive search, this metasynthesis (at the time) demonstrated a dearth of literature within this topic area, however, the research base is now rapidly growing. 1 2

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community settings,3 and perceived their work as a vocation. They also found that midwives working outside of the environment they felt comfortable, they experienced a high degree of stress [23]. Similarly, Hunter [24] explored midwives’ accounts of the ‘emotional labour’ when caring for women and established that two coexisting and conflicting ideologies of midwifery existed; ‘with-woman’ and ‘with-­institution’. Those aligned with occupational ideology were mostly associated with hospital-based midwifery driven by the needs of the institution, wherein standardised care, risk reduction, efficiency and effectiveness were valued most [24]. Conversely, those aligned with a woman-centred ideology, associated with community-­based midwifery driven by the needs of birthing women or people, wherein individualised care and physiological birth were valued [24]. Consequently, ‘emotion work’ was most pronounced when there were incompatibilities between the midwives’ personal ethos and workplace environment, i.e. for those aligned ‘with-woman’ but worked across hospital settings, the midwives found it difficult to maintain their approach [24]. Such dissonance and conflicting ideologies created many negative emotions requiring significant emotional work [24]. thus, reflecting McFarlane and Downe’s [23] finding that a key stressor for midwives was working outside of the environment they felt comfortable. This body of work reinforces the idea that to cultivate a skilled heartfelt practice, midwives must want to do it. Expanding this further, Thompson [25] considered the nature of ethics within midwifery practice asserting ‘midwives’ interpretation of their role during childbirth will determine their ethical approach and relationship with others’ (p. 590). Thus, Thompson [25] argued that midwifery practice is informed by midwives’ ethical positioning, in which her study found a ‘values conflict between workplace/ service provider ethics and personal/professional midwifery ethics’ [25, p.  593]. Echoing the studies mentioned earlier, Thompson [25] found salient differences between ‘procedure-oriented’ and ‘with-woman-oriented’ midwives; the former aligned with institutional medicalised practices and characterised by a lack of a meaningful mother–midwife relationship. The ‘with-woman’ midwives valued the mother-midwife relationship and centred the woman’s individual needs—such relational woman-centred care was perceived to minimise power imbalances which were viewed as a key tenet of ethical practice [25]. Williams [26] traced these divergences of approaches to midwives’ a priori frameworks when applying to undergraduate midwifery courses. Williams [26] found most of the 15 first-year student midwives she interviewed were aligned with the biomedical paradigm and reported ‘fears’ of practising midwifery in community contexts. A minority of the student midwives explicitly expressed their ethical positioning as aligned ‘with-woman’ that they reported articulating political views surrounding birth and the importance they placed upon advocacy. Of interest, Williams [26] hypothesised that such divergences reflected the student midwives’ upbringing; those with self-reported

 Community midwives do not usually work in hospitals (although some teams may have offices in hospitals). Community workplaces relate to home visits, running clinics from GP surgeries, children’s centres, birth centres etc. 3

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‘unconventional’ or troubled childhoods had greater alignment with community working and a ‘with-woman’ philosophy. Similarly, Cooper’s 2011 [27] study investigated women’s and midwives’ views on the role of a midwife and identified two types of midwives: ‘doing’ and ‘being’. The former is related to midwives who were comfortable and aligned with technocratic skills of intrapartum care. The latter is related to midwives aligned to a ‘with-­ woman’ philosophy where midwifery skills of watchful waiting were valued [27]. These alignments were found to be contingent on their freedom to practice their preferred way dependent upon their workplace environment. Conflicts arose for those aligned with ‘being’ who appeared to conform to ‘doing’ when working in hospital environments, reflecting the dominance of a technocratic culture [27]. Cooper [27] coined ‘hybrid’ midwives as those who adapted to the obstetric environment and back again when working within a midwifery-led environment. However, Bluff & Holloway [28] found ‘flexible’ midwives were strategic when managing similar tensions in practice—the flexible midwives maintained their subordinate position whilst deceptively practising woman-centred care. Furthermore, Crozier et al. [29] reported three typologies of midwives in relation to competency in birth technology; ‘bureaucratic’, where guidelines and policy govern decisions; ‘classical professional’, where judgements are made based on personal expertise and experience, and ‘new professional’, where women are involved in decision-­ making. These typologies were contextualised by wider cultural changes within nursing and midwifery at the time (e.g. 2007) that promoted better partnership working and individualised care approaches. These were heralded as a ‘new midwifery’ to convey a new professionalism that included partnership working and a shift in decision-making dynamics towards greater woman-centredness [29]. However, their later study [30] found bureaucratic decision-making remained dominant and there was a reluctance by midwives towards this ‘new professionalism’. The authors attributed this to the pervasiveness of managerialism, an overreliance on bureaucrats to guide decision-making within healthcare at the time of the study [30]. All these studies broadly illustrate two extremes. One is based on a ‘woman-­ centred’ philosophy, where the holistic needs of the woman guide the care provided and birthing people’s autonomous decision-making is actively supported [31]. This is opposed to a task-oriented approach, ‘with-institution’ and/or a ‘guideline-­ centred’ philosophy, in which the needs of the organisation are prioritised over the needs of the individual woman [32, 33]. These starkly different philosophies bely moral, ethical and legal issues; for midwives (and obstetricians) not aligned with women’s bodily autonomy, who are fetocentric and aligned to ‘with-institution’ lend their practice to medical paternalism [4]. These differences viewed within an ethical and values-based lens reveal some of the reasons why some women report experiencing tensions or conflicts when seeking particular care packages or pathways (see Chap. 1). Moreover, adherence to the legal frameworks which centre maternal autonomy, and have been a key area of biomedical ethics, are called into question when a paternalistic approach to care is provided [4, 34]. In terms of alternative physiological birth care, midwives can be viewed as part of the problem

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through perpetuating hegemonic birth practices; or as embedded within the problem with structural disadvantages (medicalised, institutionalised etc. work environments) reducing their capacity to practice ‘full-scope’ midwifery; and/or midwives can also be viewed as part of the solution. Midwives who resist hegemonic birth practices, and promote woman-centredness aligned with feminist virtue ethical practices [4], contribute a valuable counter-­ discourse to which we can learn. Accordingly, the rest of this chapter unveils the attitudes, values and beliefs of the research participants who were facilitative of alternative physiological birthing choices. Many of the participants acknowledged their practice was ‘different’ to their peers,4 summed up by Delilah, a research participant: …I think some of it is your own beliefs as a midwife, midwives have different [views] although theoretically we are all there for the women, the reality is, is that some midwives do have different philosophies and different beliefs about births. And that has always been the same, and I think that is why we have such disparity between midwives, and also why you get so much midwife in-fighting as well. Because you do get these different beliefs. I think that is part of it, I think some of it is knowledge, there are some midwives whose underpinning knowledge is sketchy… So, I think, some midwives find it very difficult to support women outside of the norm because they are not confident with the underpinning physiology. I think some midwives come out into the community and still have that medicalised view of childbirth; [but] I think some midwives have that anyway. But I think a lot of this is conflict going on underneath. If you have got somebody that is outside of the guidelines, they don’t have the confidence to approach it and problem solve it.

2.3 Beliefs, Values and Attitudes Underpinning Skilled Heartfelt Midwifery Having identified a spectrum of midwifery philosophies, the study participants’ personal philosophies can be explored through their beliefs, values and attitudes. Understanding these revealed their motivations to support alternative physiological birth choices. Whilst definitions of beliefs, values and attitudes often overlap some distinctions can be made.5 Beliefs generally relate to ideas we hold as true, whether informed by ‘evidence’6 (including direct experience) or without (e.g. faith in a higher power) [36]. Values are generally regarded as deep-seated beliefs about what is right or wrong, important or unimportant, and are guiding principles and standards that motivate our behaviours [37].7 Attitudes broadly arise from an inner framework of beliefs and values where we make judgements (like or dislike) towards

 For some participants, their practice was ‘normalised’ as they had institutional support and buy in for woman/person-centred care—see Feeley [3, 8]. 5  Whilst all three are inter-related, due to the complexity of human beings these can be incongruent or contradictory and may be expressed with inconsistent behaviours [35]. 6  Not necessarily or usually ‘research evidence’ in this particular context, but evidence in a wider context such as direct, personal experience. 7  Examples of values—ambition, authenticity, belonging, compassion, competence, dignity, equality, fairness etc. (https://brenebrown.com/resources/dare-to-lead-list-of-values/) 4

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an ‘object’ (person, thing, task, behaviour etc.) and influence our behaviour towards others and how we approach/handle situations [37].8 The midwives in this study expressed core beliefs that influenced their values and attitudes towards women and alternative physiological birth choices which included a deep valuing of women, their experiences and of birth itself. Valuing physiological birth in itself meant it was largely an easy step to supporting alternative physiological births, particularly with interrelated commitments to supporting maternal autonomy. Whilst it was ­difficult to extrapolate individual beliefs, values and attitudes as they often overlapped, the following depicts the most salient related to ‘alternative physiological births’ which in part, can be summed by Isabel: I guess you know I kind of came to midwifery with the understanding that I was truly coming to be with women and I have always come at it that women are autonomous, independent decision makers in the sense it is their bodies, their babies and their experiences and the kind of McDonald’s menu of care was never something that I subscribed to. I have never worked in the kind of conventions of midwifery, I have always gravitated to kind of the outside, you know what was different, you know I was caseloading when caseloading first started and you know [I was] out there doing homebirths, increasing homebirth rates so it was always outside of normative practice. That was me, that was what I fundamentally believed, where it came from I really really don’t know (laughs) I think it was just how I saw midwifery, how I saw myself as a midwife, I certainly saw the practices as a student and thought ‘there has got to be something better than this’. And I had a fantastic Consultant Midwife who I had the pleasure of working with for about 15 years who was the catalyst really, the support in the background, watching her, emulating her, talking to her, you know I have never had formal training it is just something within myself and then over time it has happened.

 aternal Autonomy as Paramount and the Boundaries M of Responsibility The midwives expressed a fundamental belief in women’s own way of knowing [38] and that they trusted women were making decisions that were right for themselves— ‘I suppose in a way it’s like an active state really isn’t it? I have to trust the women because I really do believe that they will know best (Maria)’. This was related to criticisms of paternalistic attitudes they saw as commonplace within society and in particular, maternity care. The midwives resisted the paternalistic approach that appeared to pit the mother–baby dyad against each other, where the unborn baby needs ‘protecting’ and where pregnant people are treated ‘like children’ [39–41]. Therefore, a recurring firm belief from the study participants centred on birthing women and people’s right to make their own choices, with maternal agency and autonomy highly valued: …we’re not their mothers and fathers are we? They are grown women who have made a decision and you’re not there as a friend, you’re there as a professional who gives advice, does observations and makes recommendations and explains why you are doing those, and  Examples of attitudes—accepting, aggressive, agreeable, cautious, committed, disengaged, disrespectful, flexible, motivated, sincere etc. (https://simplicable.com/en/attitudes). 8

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if the woman says yes or no then that is her choice and responsibility and I think I am quite grounded with that. (Jenny)

These beliefs and values were expressed by the midwives as resisting guidelines as ‘rules’ to follow [42] and preferred to offer individualised care based on women’s preferences by utilising a wide range of evidence sources to support discussions. From this perspective, the midwives were proactively supportive and facilitative of a range of alternative physiological birth choices. For many of the midwives, their beliefs and values were based upon a priori beliefs and experiences related to agency and/or autonomy. Some participants referred to how they might, or have felt, should important decisions be taken out of their hands. For others, they were influenced by family upbringings [26], e.g. growing up within patriarchal, autocratic households heavily influenced their adult feminist beliefs and approaches to women’s decision-making. There were repeated references to ‘her body, her choice’ revealing a consistent interrelated belief and value that favoured maternal autonomy which was coupled with a delineation of responsibilities between the mother and midwife. For example, most of the midwives asserted and strongly believed their role was one of support, guidance and the provision of appropriate information to inform decision-making (and, of course, to provide appropriate clinical care during birth). This was seen as the midwife’s ‘duty’ and responsibility, however, the midwives felt women had responsibilities too which included ‘being informed’. Such responsibilities were viewed positively (not punitively) as a natural consequence of autonomy. Accordingly, the midwives asserted entering into shared but delineated responsibilities with those in their care; the midwife was responsible for appropriate information giving, planning and competent clinical care for the birth women chose, and the woman was responsible for entering into the dialogue, understanding and accepting the risks presented (where necessary).9 Therefore, women were deemed responsible for their decision-making, which was viewed as a natural consequence of asserting maternal agency and autonomy: As a midwife, I believe my role is to support and guide women in decision making and birth planning, not to bully or cajole them into my way of thinking, and to help them to achieve a safe birth which they can feel happy with. I have looked after numerous ‘against guidance’ home births over the last two years, including grand multips [>5 births], GDM [gestational diabetes mellitus] and VBAC’s [vaginal birth after caesareans]. Whilst some of the  Notions of risk depend on many sociocultural-political factors/contexts and individual perceptions will vary widely. However, some birthing women and people do make decisions which may be objectively more physically risky to either mother or baby. However, safety must be viewed within a holistic lens—mental, emotional, spiritual, cultural (explored further in Chap. 3), therefore, decision-making is informed by these other aspects and must be respected [3]. However, midwives do have a professional duty to relay accurate information which may include risks regarding a specific decision; equally, midwives have a duty to present the information factually, in a way that can be understood and to not unduly scaremonger [43] (and women in the UK have the right to decline any aspect of care, including information giving). Furthermore, that evidence is sometimes conflicting, or limited, it creates a complex picture for providing appropriate information to ‘weigh up’. However, the study participants were committed to having nuanced conversations that accounted for these complexities and the majority were prepared to support any decision following an informed discussion. 9

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2  Recognising Ourselves: The Role of Beliefs, Values, Attitudes and Philosophy… women make decisions I would not personally make; I will always support them in their choices. I am clear when discussing birth plans that this is their birth, their baby, their body and they have to be able to live with the choices that they make—and that will be different for every person. What I do aim to do is to give them the resources to make the best decision for their family… (Alice)

A Healthy Baby: The Minimum Expectation The midwives also reported they valued women’s experience of birth and did not perceive a dichotomy between women’s experiences or safety outcomes. They believed both were important and that a healthy baby at the end of childbirth should be a minimum expectation and not the arbitrator of what a ‘good’ birth might be. The midwives perceived safety within an expanded perspective to include mental and emotional wellbeing as equal to physical (explored more in Chap. 3). For example, many of the midwives’ accounts relayed women’s previous traumatic birth experiences that were influential in shaping the women’s subsequent alternative birth decisions which in turn, influenced the midwives’ understanding of ‘safety’: I was more concerned about supporting her birth experience than her epilepsy because for her the experience of her first labour was just horrible, she hated it and she was, and she was more focused on having a good birth experience and worrying about her epilepsy. But I was thinking ‘Oh God, I hope she is going to be ok’, but that was secondary to ‘I hope that this woman has a good birth experience’. (Sam)

It was acknowledged that some labours or births need help (medical support or intervention), and the midwives were careful to balance their interactions with women with this in mind. However, they refuted the idea ‘all that matters is a healthy baby’ which was felt to be the minimum expectation following childbirth and undermined women’s desire for a good experience and a healthy baby. Therefore, the birth experience was valued alongside physical outcomes. This, in turn, influenced the midwives’ motivations and attitudes – they proactively sought to deliver care that optimised birthing people’s chances of having the physiological birth they desired. Such care valued maternal-fetal (holistic) safety and experience which was kept in balance with robust care planning in the event labour or birth required help (see Chap. 4). Extensive care and contingency planning meant the midwives supported maternal agency and autonomy across the continuum of possibilities. By helping women to consider their options and/or creating alternative plans, the midwives facilitated women to maintain/retain a locus of control in any possible event. This was perceived to help maintain a positive birth experience irrespective of the final mode of birth. Stella, below, illustrated these beliefs, values and attitudes that walk the line between these complex issues: … I’ve been pregnant myself. I understand that need to have a healthy baby… a lot of people who end up with a section, you hear midwives say, ‘oh well it doesn’t matter, you

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know you have got a healthy baby out of it’ and that’s great, that’s first and foremost thing you want, but I don’t think women shouldn’t ever apologise for wanting a good experience as well. And it’s definitely a fine line like things at antenatal groups to say ‘this [birth] can be absolutely brilliant, you know you could do all of this and it can be absolutely brilliant’ and I have done all of that at homebirths with a brilliant woman and it has still gone pear shaped, so I am very careful at every antenatal group to say ‘this whole thing is brilliant but it doesn’t matter how your baby comes, what matters is you get the best out of the ­experience you have’ and I totally agree with the hippo birthing,10 the right birth the right day at the right time—because you can’t then load the woman with guilt [i.e.] ‘it was something I did and that’s why I ended up with a section’, you can’t load that guilt onto women, they’re going to feel guilty enough for the rest of the lives for their children (laughs) you just breed guilt as a mother don’t you?

You Have to See It, to Believe It: Women’s Bodies Work The midwives also reported underpinning beliefs in women’s bodies and the processes of birth. The midwives did not consider women’s bodies as inherently faulty and viewed the physiology of birth as something that mostly works only needing help some of the time. These beliefs were formed through their own experiences, either as mothers and/or through their time as student midwives and/or their clinical knowledge and experiences as qualified midwives. For some with pre-existing beliefs (and/or experiences), they actively sought out clinical environments where they could learn the art and science of physiological birth (homebirth teams, birth centres or caseloading models). For Jane, she self-reported ‘being rubbish at birth’ having had caesarean sections, yet she was a pro-homebirth midwife with vast birth centre experience. Her personal birth experiences stimulated a commitment to cultivating the skills that were not available to her when she was pregnant. For Jane, she recognised that some women may not be able to birth without medical intervention but felt women should be given more of a chance: … So I think sometimes people think that’s weird that I am very pro-homebirth that I worked in a birth centre, because I do think women can birth, some people can’t but people should be given a chance. I suppose I wish you know all those years ago I had been given more of a chance and had midwives who were a bit more encouraging…

The midwives’ beliefs in the capabilities of women’s bodies were grounded in experiential experiences of witnessing and attending birthing people in a wide variety of circumstances (within and outside of guidelines). Such experiences led the midwives to frame their faith in women’s bodies as ‘seeing was believing’—this denoted deep, continuous learning from women birthing their babies which afforded new ways of thinking, doing, being and practising as a midwife. Susan, below, reflected on the many years where she typically ‘managed birth’ (medicalised, high levels of intervention and ‘doing’ practices) and how practising this way influenced

10

 ‘Hippo birthing’ refers to a particular company who offers hypnobirthing.

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her beliefs around birth. These prior beliefs were that birth would only happen through midwifery or obstetric ‘doing’, e.g. acting and intervening routinely, with little faith in women’s own abilities. Susan viewed this as a ‘brainwashing’ whereby she wholeheartedly accepted that the medical management of birth was the norm with little critical appraisal or reflection. However, Susan reported a pivotal experience where she witnessed a wholly different way of practising midwifery—a ‘with-­ woman’, hands-off, woman-led approach to birth facilitation. This created a deeply spiritual and fundamental change within her, personally and professionally. In the following extract, we glean insights into her practice before and after this event and see her reframing her beliefs, values and attitudes to birth which served to trust in women’s bodies, their ability to birth and to develop her skills, cultivating a watchful waiting approach (a highly advanced expert skill [44, 45] explored further in Chap. 5): … I think that comes from an increased trust in myself in general and definitely when you see it, if all you have experienced is as I say, managed birth and we feel that if we’re not doing something then it just won’t happen—then you believe that! … But you believe it cos you are in it, it’s almost like a brain washing really that is even necessary, all of the things we do aren’t necessary but it’s a self-serving thing isn’t it? Like the way you sort of, things being interfered with and then ‘oh well it’s a good job, it’s a good job she had that forceps, she really needed that’ and actually if you track back she might not have needed any of that, if you just got out of her fucking way at the start (laughs) let her do what she was doing, but but, it’s messy, it’s messy, it’s messy to watch, it’s chaotic… you’ve got to see it to trust it, you do have to see it to believe…. [my bold]

‘Seeing as believing’ was also something the midwives tried to share with others—colleagues, the multidisciplinary team and their students. Recognising that for many professionals, the lack of exposure to physiological births hindered their knowledge and understanding, therefore, the study participants made attempts to share their knowledge. Where it was possible (and with women’s permission), the midwives took opportunities to help others to witness physiological births to embed this tacit way of learning—something that was equally rewarding as birth facilitation: one of my first clinical shifts back after this break, I had a wonderful primip, you know coming up 4 cm at the end of my shift…and she just suddenly cracked on so I went and grabbed a student midwife and did a first hands on delivery with her and the woman was in a kneeling position that this student hadn’t even seen before so I was buzzing, absolutely buzzing after that, so it’s those things that keep you hooked, certainly not the pay (laughs) (Margot)

 irthplace and Birth Attendants’ Matter: Influencing B Birth Outcomes Whilst the midwives believed in women’s bodies and had an overall trust in the physiological processes of birth, they also believed there were influential factors to consider when supporting physiological birth, particularly those ‘outside of the guidelines’. First, the midwives’ beliefs were integrated with the importance of

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birthplace settings, believing them as either enhancers or inhibitors that influence the chances for physiological birth to occur. For example, homebirth and birth centre environments were felt to be (and backed up by evidence in Chap. 1), the ideal environments to maximise a physiological birth. Therefore, supporting alternative birth choices in midwifery-led settings was par for the course for many study participants, as Kim explains: Well, I went into midwifery as a feminist and believing that the birth system was not serving women as they should be served, you know in my training I always wanted to be a community midwife, I have a strong belief in homebirth so that’s the path I took, it’s not that I don’t enjoy working in the hospital, you know I had some good friends in the hospital, but my plan was get in, get the experience I need and get out (laughs) as quick as I can, so that’s where I’ve always come from that perspective that birth should be interfered with as little as possible in most circumstances so when women don’t want to be [in hospital], or have interventions I completely understand…

Beyond birthplace, the midwives (across all settings) also believed the birth attendant was a critically important factor when considering this type of birth choice. This was based on the belief that willing, skilled, confident and competent midwives attending these births are essential for safe care and to maximise the chances of physiological birth happening. It was felt anxious and fearful midwives who were less willing to support these births would reduce optimal birthing conditions: …[The] consultant midwife is talking about putting together a specialist team for women who want to birth outside of guidelines, regardless of place of birth, it could be anywhere, that team would work with that consultant midwife and we [experienced and willing team of midwives] would be on call for those women—because women’s choices are all well and good being made but if you don’t have confident midwives to carry out those choices uhm then they are unlikely to get the birth they want… it‘s all about having the right environment to have your baby and if you haven’t got confident midwives then you are setting that woman up to fail, she might as well as go into hospital. (Amy)

Loving Women, Loving Birth At the heart of the midwives’ beliefs, values and attitudes was love—the midwives frequently shared how much they loved women, genuinely cared for them and found a strong sense of meaning in connections with those in their care. They also loved birth, valued its importance and viewed birth as a significant transition to motherhood—accordingly, the midwives perceived birth with awe and wonder. Birth for the study participants had inherent meaning and saw their role as ‘safeguarding something precious’. This sense of meaning and sacredness went far beyond a valorisation of physiological birth, their expressed love for women superseded their personal birth preferences to which the midwives were committed to trying to help women have a positive birth experience, irrespective of mode of birth/birth outcomes. This was expressed as the attitude which centred the women—‘it’s not about

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me, it’s about her’. Therefore, love for women and love for birth were not mutually exclusive or in opposition to each other. In this way, the midwives reported a strong sense of service: I was so fortunate I had great mentors that made me understand me catching 40 babies you know it wasn’t about chasing the numbers, it was about being indentured into learning how important to be of service to women…I mean I think for me when I came into midwifery I knew what I wanted out of it, I didn’t come into midwifery on a ticket of I want to do this, do that or the other, I wanted to be with women, I wanted to be able to contribute something, safeguard something that was really precious, I do think that’s the thing about a woman having a baby, it’s magic, its mind blowing, it’s fascinating, it’s clever, you know it’s just the most fabulous thing, and for us to diminish it and erode it and take power away from it well. I couldn’t stand back and do that, I have to contribute something to it because every woman who has a baby, she becomes a mother, she becomes a really powerful person, that’s something that’s good for everybody isn’t it? (Maria)

Moreover, the mother-midwife relationship held great significance and relational care was consistently valued throughout the participant accounts, viewed as having a ‘massively long-lasting effect on the rest of their [women’s] life with that baby’. For some, this belief stemmed from their own experiences of childbearing (which also influenced their decisions to become midwives); the importance of midwifery care and the vividness of their memories were profound. Seana reported applying for her midwifery course based on her ‘wide obstetric experience’. She had four live, healthy children, had experienced a miscarriage and had a stillborn baby. Seana shares the vividness of her experiences and how that has framed her beliefs and values as a practising midwife as well as her attitude towards birth and childbearing women: … when they asked me that question, you know why do you want to be a midwife and everything else. I just said from being a mummy, and my experience, I had a wide obstetric experience, I had four live healthy children thankfully, I had one stillborn and I had a miscarriage, so I ticked a lot of the boxes that way. But despite all of that, I still felt it was such an amazing time in everyone’s life. And for me, on a day-to-day basis, to be a part of that, I feel really privileged. And I don’t think we should abuse that privilege, and that might sound quite hippy or airy fairy or but that’s my, that’s my gloss on what a midwife should be. I can tell you about the midwives that looked after me 23 years ago, right up until the one that looked after me 13 years ago you know, you remember the things they say to ya, the things they don’t say that I think, I think it is an amazing job…

2.4 With-Woman Philosophy and Practice Earlier in this chapter, we explored the variations of midwifery philosophies that co-exist (despite an underpinning philosophy that informs global policy and practice ideals) and examined the midwife research participants’ interrelated beliefs, values and attitudes towards supporting alternative physiological birth. These aspects make up the midwives’ underpinning philosophy of care. A personal philosophy has commonalities with personal values, but a ‘philosophy is oriented to life meaning whereas values form the components of that totality’ [46, p.  71].

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Extrapolating the midwife participants’ beliefs, values and attitudes provided insights into the constituent parts of a ‘with-woman’ philosophy [31, 47–49]. Whilst other research has captured similar insights, this research was unique as it ‘tested the boundaries’ of such a philosophy which included a wide range of complex birth decisions ‘outside of guidelines’ within all the sociocultural-political complexities that contains [8, 10, 20, 50]. Much of the study participants’ philosophy was bound in their identity as a midwife underpinned by firm beliefs as to what a midwife is: e.g., ‘As a midwife, this is what I feel I trained for, to give women informed choice and support them in their decision and be there whatever the outcome (Anna).’ Margot also reflecting the interconnectedness of philosophy and identity, asserts it is this type of ‘with-woman’ midwifery that is first and foremost within her practice: so although my personal ethos does color how I behave, I think professionally those core values, we are midwives and we are there to advocate for women and that is the absolute nugget of our being, no matter what politics or [the] dynamics are going on, you know, that’s who we are, managers second, midwives first…

Within this identity and philosophy was a holistic, salutogenic outlook on childbearing with advocacy central to their role. This can be viewed as a feminist virtue ethical approach11 whereby power differences were acknowledged and attempts to mitigate were apparent throughout the accounts [4]. Within the study, most of the birthing requests were supported, however, in a minority of situations, some birthing decisions were not accommodated. For example, for birthing women or people seeking specific accommodations within a hospital setting or birth centre where guidelines were particularly restrictive, the women were not supported in hospital but supported to birth at home (raising all sorts of safety issues and questions around why hospital birth settings may be less accommodating.) Therefore, whilst women’s views were not part of this study, that most of the births were facilitated indicated a level of congruence within the participant stated values/philosophies and care provision. Stella as an example, reported having a ‘local reputation’, with some women actively seeking her out. As word of mouth is a powerful tool, this suggests Stella had congruence within her values, attitudes and philosophy and sums up a ‘with-woman’ philosophy in action: Partly it is also due my own personal policy of never saying no, and a local reputation for that, so that some women will actively ask me to be their midwife, knowing I will support them. I am not alone—several other midwives are happy to support women in the same way, and I have managers who in turn support me and my colleagues. I feel it is my job to give good, research-based advice to women, but not to tell them what to do. These are grown women capable of making decisions about their own bodies and children, and we should respect that at all times. I may not always agree with it personally, but it is not my role to impress my opinions on them, although I’m well aware that it is possible in a position of relative power.

11

 For more about feminist virtue ethics, see [4, 25, 39].

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2.5 Cultivating Self-Awareness: Exploring Our Beliefs, Values and Attitudes Self-awareness is an essential characteristic of emotional intelligence [51] and crucial to skilled heartfelt midwifery practice. Being self-aware assists in identifying and managing incongruences that may arise within our belief systems [37]. Additionally, intimate self-knowledge and understanding of our belief/value systems can be an anchor when faced with new or unexpected clinical situations. For example, when faced with a birth choice we would not make ourselves, checking in with our beliefs and values will frame and guide our attitude to caregiving in these situations as illustrated by Jess: I’m not such a fan of epidurals and medicalised birth, but it’s not about me, it’s about the woman I am caring for and what makes her feel safe. To me, it’s not about where the woman gives birth, it’s that she was supported to make informed decisions, that she felt in control of her own body and birth and that she had a positive birth experience. For some women, a positive birth will be having an epidural as soon as possible on labour ward. This environment and choice of pain relief will reduce their anxiety and help them feel in control and have a positive birth experience. For other women having a water birth at home with fairy lights and hypnobirthing music will be their idea of a positive birth and will make them feel safe. It is their prerogative. My job as a midwife is to provide them with the evidence, research, guidelines and experience and support them in whatever their decision is. I have to try and be objective. I strongly believe in providing holistic care. This is why I find caseload care so satisfying because you can support the woman and her family fully and see the bigger picture.

Here, Jess demonstrates her beliefs that women will birth best where and in what circumstances they feel safe and in control. Acknowledging the variations in which this may occur, Jess demonstrates she values women’s autonomous decision-­making which superseded her own personal likes or dislikes (here expressing less preference towards medicalised births). Jess’ beliefs and values are expressed through the proactive attitude of support, and she demonstrates self-awareness by decentring her preferences to centre women’s needs, thus remaining in alignment wither her values of maternal autonomy.

2.6 Conclusion Having explored the different perspectives and philosophies of midwives whilst working under the same protected title, an in-depth examination of the most salient beliefs, values and attitudes of the midwife participants was presented. We saw an interrelated set of beliefs around birthing women and people being the primary decision-makers with maternal agency and autonomy as a core value. Additionally, the women’s experience of birth was held in equal regard to issues of physical safety, framing the midwives’ orientation to support alternative physiological birth choices. In contrast to mainstream birth practices, a key message from these midwives was ‘you have to see it, to believe it’—denoting the radical difference between a typically ‘managed’ birth to that of a woman-led, hands-off midwifery practice

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during physiological birth. An open mind and willingness to learn from childbearing women and their birth experiences also offered new ways of knowing; experiencing what is possible during birth has the power to change belief systems and ways of practising, as demonstrated by some of the participants. Thus, highlighting the importance of exposure to a wide range of practice settings with practitioners who have different styles and approaches. Ultimately, this chapter has explored ‘why’ midwives supported alternative physiological births and the next chapter focuses on ‘how’ they cultivated trusting, meaningful relationships to deliver safe, relational care. Personal Reflective Activity

Take some time to consider how you feel about both physiological birth and requests ‘outside of the guidelines’. Without thinking, free write the first feelings, thoughts or emotions that come to mind. Try not to judge or analyse what you write straight away as self-honesty is key. Once you have finished, read what you have written and start gently, with compassion, examine what you have written. Consider questions such as why do I feel like that, where did that come from, what happened to make me feel this way? Does this align with what I thought I believed, if not, why not—again gently asking yourself, where this misalignment may have come from, what happened and how it affected you. From this, and centring on ‘alternative physiological births’ ask yourself these key questions, again free writing without overthinking it: What do I believe (about the birthing woman or person, about the fetus, about birth choices, about midwifery-led care for those with ‘risk’ factors)? What do I think is important (about the care women receive, how I conduct myself as a midwife, about labour and birth)? How do I, or would I, approach requests for ‘out of guidelines’ physiological births? How do I behave when discussing options during the childbearing continuum? How do I want to be, and is this different to how I actually am? The answers to these questions will provide insights to your beliefs, values and attitudes towards alternative physiological births. Perhaps you identify some incongruences, to which, with compassion, you may consider how you may work through these to overcome them. Finally, reading through all that you have written so far, you might wish to write your own midwifery philosophy statement. It can be really helpful to have a copy close to hand when working in practice, a salve when the going gets tough.

Further Resources  1. Case studies—see Chap. 6. 2. Determining our core values—see Brené Brown’s book Dare to Lead and worksheet https://brenebrown.com/resources/dare-­to-­lead-­list-­of-­values/

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3. ‘Living into our values’– see Brené Brown’s podcast and worksheet https://brenebrown.com/resources/living-­into-­our-­values/ 4. How to create a personal philosophy—see Dr. Michael Gervais and Coach Pete Carroll’s blog https://competetocreate.net/create-­personal-­ philosophy/#:~:text=A%20personal%20philosophy%20is%20 a,conceptualize%20philosophies%20in%20many%20ways.

References 1. International Confederation of Midwives (2017) ICM definitions: definition of the midwife. https://internationalmidwives.org/our-­work/policy-­and-­practice/icm-­definitions. html#:~:text=The%20midwife%20is%20recognised%20as,the%20newborn%20and%20 the%20infant 2. Renfrew M, McFadden A, Bastos M et al (2014) Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. Lancet 384(9948):1129–1145. https://doi.org/10.1016/S0140-­6736(14)60789-­3 3. Feeley C (2023) Supporting physiological birth choices in midwifery practice the role of workplace culture, politics and ethics. Taylor & Francis, London 4. Newnham E, Kirkham M (2019) Beyond autonomy: care ethics for midwifery and the humanization of birth. Nursing Ethics 26(7–8):2147–2157. https://doi.org/10.1177/0969733018819119 5. Goldkuhl L, Dellenborg L, Berg M, Wijk H, Nilsson C (2022) The influence and meaning of the birth environment for nulliparous women at a hospital-based labour ward in Sweden: an ethnographic study. Women Birth 35(4):e337–e347. https://doi.org/10.1016/j.wombi.2021.07.005 6. Berg M (2000) Guidelines, professionals and the production of objectivity: standardisation and the professionalism of insurance medicine. Soc Health Illn 22(6):765–791 7. Gabriel L, Reed R, Broadbent M, Hastie C (2023) “I didn’t feel like I could trust her and that felt really risky”: a phenomenographic exploration of how Australian midwives describe intrapartum risk. Midwifery 118:103582. https://doi.org/10.1016/j.midw.2022.103582 8. Feeley C, Downe S, Thomson G (2021) ‘Stories of distress versus fulfilment’: a narrative inquiry of midwives’ experiences supporting alternative birth choices in the UK National Health Service. Women Birth 35(5):e446–e455. https://doi.org/10.1016/j.wombi.2021.11.003 9. Kruske S, Young K, Jenkinson B, Catchlove A (2013) Maternity care providers’ perceptions of women’s autonomy and the law. BMC Pregnancy Childbirth 13:184. https://doi.org/10.118 6/1471-­2393-­13-­84 10. Jenkinson B, Kruske S, Kildea S (2017) The experiences of women, midwives and obstetricians when women decline recommended maternity care: a feminist thematic analysis. Midwifery 52:1–10. https://doi.org/10.1016/j.midw.2017.05.006 11. Chilvers A, Hosie P (2015) Midwives should not act as gatekeepers to the maternity services. J Fam Health 25(3):13–15 12. Thomson G, Feeley C, Hall Moran V, Downe S, Oladapo O (2019) Women’s experiences of pharmacological and non-pharmacological pain relief methods for labour and childbirth: a qualitative systematic review. Reprod Health 16(7):11–20. https://doi.org/10.1186/ s12978-­019-­0735-­4 13. Reed R (2013) Midwifery practice during birth: rites of passage and rites of protection. PhD thesis, University of Sunshine Coast. https://research.usc.edu.au/esploro/outputs/doctoral/ Midwifery-­practice-­during-­birth-­rites-­of/99448729602621 14. Nicholls S, Hauck YL, Bayes S, Butt J (2016) Exploring midwives’ perception of confidence around facilitating water birth in Western Australia: a qualitative descriptive study. Midwifery 33:73–81. https://doi.org/10.1016/j.midw.2015.10.010 15. Feeley C, Thomson G, Downe S (2020) Understanding how midwives employed by the National Health Service facilitate women’s alternative birthing choices: findings from a feminist pragmatist study. PLoS One 15(11):e0242508. https://doi.org/10.1371/journal.pone.0242508

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16. Plested M, Kirkham M (2016) Risk and fear in the lived experience of birth without a midwife. Midwifery 38:29–34. https://doi.org/10.1016/j.midw.2016.02.009 17. Feeley C, Thomson G (2016) Tensions and conflicts in ‘choice’: women’s experiences of freebirthing in the UK. Midwifery 41:16–21. https://doi.org/10.1016/j.midw.2016.07.014 18. Cobell (2015) What are midwives’ experiences of looking after women in labour outside of trust guidelines? MSc thesis, Private copy 19. O’Connell R, Downe S (2009) A metasynthesis of midwives’ experience of hospital practice in publicly funded settings: compliance, resistance and authenticity. Health 13(6):589–609 20. Feeley C, Thomson G, Downe S (2019) Caring for women making unconventional birth choices: a meta-ethnography exploring the views, attitudes, and experiences of midwives. Midwifery 72:50–59. https://doi.org/10.1016/j.midw.2019.02.009 21. Westbury B, Einion A (2021) Matricentric or medically responsible: an exploration of midwives’ attitudes towards caring for women and birthing people who choose to birth outside of guidelines. Practising Midwife 24:10. https://doi.org/10.55975/EJOZ4427 22. ICM (2014) Core document philosophy and model of midwifery care ICM. https://www. internationalmidwives.org/assets/files/definitions-­files/2018/06/eng-­philosophy-­and-­model-­ of-­midwifery-­care.pdf 23. McFarlane S, Downe S (2000) An interpretation of midwives’ views about the nature of midwifery. Pract Midwife 2(11):23–26 24. Hunter B (2004) Conflicting ideologies as a source of emotion work in midwifery. Midwifery 20(3):261–272 25. Thompson FE (2003) The practice setting: site of ethical conflict for some mothers and midwives. Nurs Ethics 10(6):588–601. https://doi.org/10.1191/0969733003ne649oa 26. Williams J (2006) Why women choose midwifery: a narrative analysis of motivations and understandings in a group of first-year student midwives. Evid Based Midwifery 4(2):46 27. Cooper (2011) Perceptions of the midwife’s role: a feminist technoscience perspective. PhD thesis, University of Central Lancashire https://clok.uclan.ac.uk/2404/2/CooperTthesis-­ hardbound_final_collated.pdf 28. Bluff R, Holloway I (2008) The efficacy of midwifery role models. Midwifery 24(3):301–309. https://doi.org/10.1016/j.midw.2005.02.008 29. Crozier K, Sinclair M, Kernohan G, Porter S (2007) The development of a theoretical model of midwifery competence in birth technology. Evid Based Midwifery 5(4):119–121 30. Porter S, Crozier K, Sinclair M, Kernohan WG (2007) New midwifery? A qualitative analysis of midwives’ decision-making strategies. J Adv Nurs 60(5):525–534. https://doi. org/10.1111/j.1365-­2648.2007.04449.x 31. Carolan M, Hodnett E (2007) A ‘with woman’ philosophy: examining the evidence, answering the questions. Nurs Inq 14(2):140–152. https://doi. org/10.1111/j.1440-­1800.2007.00360.x 32. Griffiths R (2009) Maternity care pathways and the law. Br J Midwifery 17(5):324–325 33. Kotaska A (2011) Guideline-centered care: a two-edged sword. Birth 38(2):97–98 34. Buchanan K, Newnham E, Ireson D, Davison C, Geraghty S (2022) Care ethics framework for midwifery practice: a scoping review. Nurs Ethics 29(5):1107–1133. https://doi. org/10.1177/09697330221073996 35. Chrystal M, Karl JA, Fischer R (2019) The complexities of “minding the gap”: perceived discrepancies between values and behavior affect Well-being. Front Psychol 10:736. https://doi. org/10.3389/fpsyg.2019.00736 36. The Communication Department at Indiana State University (2016) Introduction to public communication. Press Books, Indiana 37. Hanel CF, Maio GR (2021) Attitudes and values. Oxford University Press, Oxford 38. Clinchy B, Tarule J, Belenkey MF, Goldberger N (1997) Women’s ways of knowing: the development of self, voice, and mind 10th, Anniversary edn. Basic Books, New York 39. Cahill H (2000) Male appropriation and medicalization of childbirth: an historical analysis. J Adv Nurs 33(3):334–342 40. Newnham E (2014) Birth control: power/knowledge in the politics of birth. Health Sociol Rev 23(3):254–268. https://doi.org/10.1080/14461242.2014.11081978

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41. Blaylock R, Trickey H, Sanders J, Murphy C (2022) WRISK voices: a mixed-methods study of women’s experiences of pregnancy-related public health advice and risk messages in the UK. Midwifery 113:103433. https://doi.org/10.1016/j.midw.2022.103433 42. Downe S (2010) Toward salutogenic birth in the 21st century. In: Walsh D, Downe S (eds) Essential midwifery practice: intrapartum care. Wiley-Black, Oxford 43. Begley K, Daly D, Panda S, Begley C (2019) Shared decision-making in maternity care: acknowledging and overcoming epistemic defeaters. J Eval Clin Pract 25(6):1113–1120. https://doi.org/10.1111/jep.13243 44. Downe S, Simpson L, Trafford K (2007) Expert intrapartum maternity care: a meta-synthesis. J Adv Nurs 57(2):127–140. https://doi.org/10.1111/j.1365-­2648.2006.04079.x 45. de Jonge A, Dahlen H, Downe S (2021) ‘Watchful attendance’ during labour and birth. Sex Reprod Healthc 28:100617. https://doi.org/10.1016/j.srhc.2021.100617 46. Krone B (2014) A personal philosophy. J Space Philos 3(2):71–89 47. Bradfield Z, Duggan R, Hauck Y, Kelly M (2018) Midwives being ‘with woman’: an integrative review. Women Birth 31(2):143–152. https://doi.org/10.1016/j.wombi.2017.07.011 48. Berg M, Dahlberg K (2001) Swedish midwives’ care of women who are at high obstetric risk or who have obstetric complications. Midwifery 17(4):259–266. https://doi.org/10.1054/ midw.2001.0284 49. Newnham E (2011) With woman: a genealogy of Australian midwifery practice. Women Birth 24:S10–S11. https://doi.org/10.1016/j.wombi.2011.07.048 50. Hollander M, Miranda E, Vandenbussche F, Dillen J, Holten L (2019) Addressing a need. Holistic midwifery in the Netherlands: a qualitative analysis. 14(7):e0220489. https://doi. org/10.1371/journal.pone.0220489 51. Goleman D (2004) Emotional intelligence. Bloomsbury Publishing, London

3

Cultivating Emotional Safety, the Cornerstone of Safe, Relational Care

3.1 Introduction The previous chapter explored different philosophies and approaches to maternity care, highlighting that midwives are not a homogenous group of professionals. Despite an underpinning philosophy attributed to midwifery practice [1], some midwives are more aligned ‘with-­procedure, guidelines and/or institution’ [2–4]. Whilst there is a place for intra-­professional differences such as avoiding ‘group think’, the previous chapter argued that stark philosophical differences directly impact the degree to which birthing women and people will have their individualised needs met. Therefore, for this research study, the midwives were proactively recruited for their beliefs, values and attitudes towards supporting alternative physiological births [5].1 The purpose of this chapter is to explore how the midwife participants enacted their philosophy when providing care. However, given the wider socioculturalpolitical concerns surrounding birth ‘outside of the guidelines’ [6, 7], first, the chapter explores notions of safety within maternity care. The discussion will highlight inconsistencies and incongruences in the current approach before drawing on the participant’s accounts which demonstrate the importance of widening conceptions of safety in maternity care. Here, I show what the midwives did to cultivate a holistic safety approach which included an interconnected proactive stance of understanding, support, trust and trustworthiness. These were the building blocks of safe care, through which, the midwives centred emotional safety that I argue to be the precursor to other safety constructs. Finally, this chapter will examine the  While there were some differences between the research participants, these were mostly contingent on levels of experience (i.e. those with less experience found delivering the care slightly more challenging) and/or the levels of support within their workplaces (i.e. delivering care they wanted to, was not always achievable due to workplace constraints). 1

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. Feeley, Skilled Heartfelt Midwifery Practice, https://doi.org/10.1007/978-3-031-43643-7_3

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importance of exploring our own feelings and relationship to the notion of safety and trust within our midwifery practice.

3.2 ‘Safety’ in Maternity Care Safety in maternity care is typically associated with the avoidance of physical harm caused by healthcare systems and through the identification of ‘risks’, steps are made to mitigate against them [8]. For example, risk management approaches within hospitals are often related to managing ‘iatrogenic’ harms that occur by virtue of being in a hospital such as slips, trips, falls, medication errors and hospital-­ acquired infections such as methicillin-resistant staphylococcus aureus (MSRA) or clostridium difficile. These situations, known as ‘human generated risks’ [9], are typically managed through risk reduction hospital policies and protocols which guide risk assessments, interventions and staff behaviours. In other situations, such as screening for and managing ‘first order risks’which are those potential physiological hazards that may occur during the childbearing continuum [10] are key tenets of good quality maternity care [10]. For example, one purpose of antenatal care is to screen, identify and manage or treat modifiable diseases or disorders such as HIV, pregnancy-­induced hypertension, pre-eclampsia, gestational diabetes etc. In these situations, research evidence and national guidelines2 inform the maternity care provision that should be offered3 to ensure birthing women and people have equitable access to timely appointments screening and treatment measures [11, 12].4 However, issues arise if, and when, risk management strategies conflate ‘human generated’ risks with potential but not yet occurring physiological ‘first order’ risks [7, 10, 15]; are reductionist in their approach such as hyperfocusing on physical risks [16, 17] and only seek to manage isolated factors devoid of context such as dismissing patient/client preferences [7, 10, 15, 18, 19]. In these situations, an overzealous approach to risk management occurs, risking overdiagnosis and treatment—all of which may cause iatrogenic harm [20, 21]. As Wiener [22]

 To note, that there is not always consensus around the diagnostic threshold, management or treatment of some of these pathological disorders during childbearing; with evidence contradictory and differences found within and between countries—but that is beyond the scope of this book. 3  ‘Offered’ is the crucial word here, as women have the right to decline any or all aspects of maternity care in many countries. 4  Most of the health benefits (‘safety’) in maternity care stem from antenatal care [13], particularly a public health approach that acknowledges the ‘social determinants’ of health [14]. Public health strategies are a cornerstone of midwifery care and embedded within national drivers/targets and can be seen as risk management for modifiable ‘risks’ within childbearing including supporting smoking cessation, identifying and supporting victims of domestic violence (among many others). However, good public health is contingent on top-level governmental responsibilities such as adequate housing, jobs, financial safety nets, access to good sources of food and clean drinking water, therefore, maternity public health measures may be limited by the wider socio-political context [14]. 2

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asserted ‘risk management both helps and hurts p.  41’. For example,5 assessing contractions (frequency, length etc.) and measuring cervical dilation during labour via vaginal examinations is a routine approach to assess whether labour is progressing ‘normally’. These measurements are typically plotted on a partogram and should a labouring woman or person not meet expected progress accordingly, interventions such as artificially breaking the waters (ARM) and/or augmentation with artificial syntocinon are typically carried out [23]. These interventions, with low-quality evidence demonstrating some benefit [23] have risks attached6 and women have reported more painful and distressing labour when augmented [32]. Whilst a slowly progressing labour is potentially risky to the mother–baby and may indicate emerging pathology warranting interventions [23],7 in the absence of clinical or psychological concerns, a routine approach to augmentation is problematic, risking overtreating otherwise healthy mother–baby dyads [26, 32, 33]. Evidence demonstrates that cervical dilation (a subjective assessment) and subsequent safe progress in labour differs more widely than previously acknowledged and is ‘an extremely variable phenomenon and the assessment of cervical dilatation over time is a poor predictor of severe adverse birth outcomes p. 991 [34].’ Therefore, clinical judgements regarding interventions require a judicious approach, individualised to the mother–baby dyad’s clinical and psychological needs, rather than based on arbitrary timelines or due to risk management strategies better suited to managing ‘human generated’ risks. Within this context, risk and risk management need to be viewed as a socially embedded process, not an impartial probability of harm, whereby through social processes, some harms are amplified, and others ignored [10, 35]. I have previously argued [7],8 current maternity risk management strategies favour a medicalised and technocratic approach even where evidence demonstrates otherwise. For example, in the case of midwifery-led birthplace settings (home/birth centres), with strong evidence of safety and beneficial outcomes, they remain under-resourced and underutilised [40–44]. Even birthing pool use, with significant maternal benefits and no evidence of long-term harm for the neonate during labour or birth,9 evidence demonstrates access to use is limited in obstetric units [40, 48]. Numerous obstacles related to birthing pool use have been reported with an overarching influence of  This is one example, there are many others within maternity care.  Although, this evidence is conflicting and contradictory, within two Cochrane reviews from 2013 there appeared to be no adverse maternal-neonatal outcomes [24, 25], however, studies since then report poorer perinatal outcomes [26] and an increased risk of OASI [27, 28] and post-partum haemorrhage [29, 30]. In addition, an injudicious use of augmentation was frequently observed in the Ockenden review (a public inquiry into the failings of a NHS Trust) as contributing factors to serious morbidities [31]. 7  And of course, only if the mother consents [32]. 8  And many others before me, see [10, 18, 36–39]. 9  There is a small but increased risk of cord avulsion when the baby is brought to the surface during a waterbirth, but typically not associated with long-term adverse outcomes [45–47]. To reduce the risk, midwives must not use undue traction and gently guide the baby to the surface and if cord avulsion occurs, simply clamp the cord to stop the bleeding [47]. 5 6

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overzealous policies and guidelines restricting access based on unfounded grounds of ‘safety’ [49–51]. Further issues of medicalised approaches to ‘risk’ were highlighted recently in the UK, where the National Institute for Health and Care Excellent (NICE) recommended induction of labour at 39 weeks for Black, Asian and minoritized women in response to continuing inequitable health outcomes [52]. The reviewers acknowledged this recommendation was not based on evidence, therefore, arguably, was a non-evidence-based medicalised technocratic solution to address structural racism. A groundswell of service user responses and campaigns voiced dissent during the consultation period [52, 53] challenged the idea of Black and Brown ‘faulty bodies’ need ‘fixing’ and resisted this option as a solution. With due credit, NICE responded and excluded this recommendation from the final guideline [54], but concerns have been raised about how a recommendation without any evidence was included in the first place. Moreover, such a medicalised approach to addressing racial disparities sits in direct contrast to the discontinued ‘Albany Midwifery Practice’ that ran from 1997 to 2009 [55]. A unique service consisting of a small group of independent midwives contracted by the NHS offering full caseloading to a community in Peckham, which at the time, was in the 14th most deprived district across England. This diverse community included approximately 50% Black women (African, British, Caribbean or other), with a further 14% of women from ethnic groups other than white. The midwives offered an ‘all risk’ caseload model of care and demonstrated outstanding outcomes, exemplifying how the social and public health model of midwifery care mitigates some of the ‘social risks’ to health [55]. For example, their higher-than-­ average rates of initiation of breastfeeding (99%), spontaneous vaginal birth (81.4%), and home birth (44.8%) and low caesarean section rate (15.2%) all contributed to significant improvements to the community’s health and wellbeing. Yet, the disbanding of the service under spurious ‘safety’ grounds (since quashed)10 [56] reiterates that ‘safety’ and ‘risk’ approaches across maternity care remain incongruent to underpinning principles of safety. The examples shared so far demonstrate ‘risk’ management approaches in maternity care bely numerous contradictions and inconsistencies. If ‘safety’ relates to the absence or avoidance of harm, then questions remain as to why technocratic approaches with strong evidence of harm remain commonplace and beneficial midwifery-led interventions (those discussed here, and those highlighted in the Lancet Midwifery Series [57]) are not consistently supported across maternity organisations. Largely, the sociocultural-political landscape, unchecked medicalisation, institutionalisation and technocratic birth practices, along with a litigious society, unduly influence maternity risk management approaches [7]. Within this context, current risk management approaches risk denying other components of safety such as mental, emotional, cultural or spiritual. Across all of healthcare there is growing recognition that ‘absence of harm’ or ‘safety’ must account for all these components [16, 17, 58–61]; for a lack of dignity or respect for  The Albany Practice had huge support from the community they served, the closure was a devastating situation for the women and midwives alike, see [56]. 10

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a person’s individual context can negatively influence their engagement with care or treatment, subsequent outcomes and can foster healthcare avoidance [16, 17, 59–61]. It must be recognised that healthcare decision-making does not solely rest upon the information of risk/benefit clinicians may provide11—patients/clients/service users, within their unique set of circumstances, will make decisions that account for their personal values, beliefs, situation and broader cultural contexts. For example, a woman declining induction of labour may do so because as a lone parent, there is no one to care for her other children (thus a different safety issue); or for someone else, they may decline because of a philosophical belief that ‘babies come when they’re ready’ and do not believe inductions for post-term pregnancy ‘alone’ is necessary [68]. In another situation, a birthing person may decline blood products as they have safety concerns regarding the products [69]; or for someone else, to accept blood products would be a deep violation of their religious beliefs [70]. Within just two examples, we see a variation of individual circumstances that influence perceptions of safety and subsequent decision-making. Therefore, notions of safety must be viewed with a holistic lens, and with recognition that individual’s conceptions of safety differ [7]. Therefore, the onus is on healthcare systems and individual practitioners to ascertain what is deemed safe by individuals, and therefore, understand what care package, treatment or pathway may be acceptable to each maternity service user [7]. An individualised, holistic approach is fundamental to good highquality maternity care, is a ‘humanised’ approach [71] and was epitomised by this study’s participants through caring for women making alternative physiological birth decisions.

3.3 Widening Conceptions of Safety in Maternity Care Having explored typical concepts of safety within maternity care and calling for parameters of safety to be widened, it is important to consider new thinking within healthcare safety. For example, notions of safety have recently expanded beyond merely ‘the absence of harm’ to consider safety as the ‘presence of something’ [8]. This has been expressed as the presence of capacity and capability or the presence of learning, responding, monitoring and anticipating possible outcomes [72]. Whilst largely these definitions relate to system-level approaches, we can view the specifics of the midwives’ care as a safety device—for they were the ‘presence of something’ for those seeking alternative physiological birth care (but the principles can be applied to all maternity care interactions). This section focuses on the actions and

 Also noting that information provided may not be the most up to date, and/or rest upon conflicting evidence, not account for someone’s particular needs particularly in light of the complexities for those living with co-morbidities [62–65] or may be provided in a manner that steers service users towards a particular decision [66, 67]—therefore, information may not be impartial (although it should be) and is also subject to sociocultural-political influences. 11

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qualities of the midwives’ which prioritised the cultivation of emotional safety.12 Feeling safe is a neurobiological and psychological event [73]13 and by signalling ‘safeness’ to birthing women and people making these decisions, the midwives reported creating the space for openness, honesty and of critical importance—trust. Conversely, feeling emotionally unsafe within a therapeutic (healthcare) environment is negatively associated with a lack of information, poor communication, disengaged/disinterested caregivers, lack of autonomy, helplessness and diminished respect for personhood through not being heard, understood or taken seriously [16, 17, 61, 75]. Within maternity care, the consequences may include disengagement with care, negative or traumatic experiences and/or poor outcomes [76–80]. I posit that emotional safety encompasses mental, spiritual and cultural safety; for respect, compassion and dignified emotional care centre the valuing of individuals within their lifeworld and unique circumstances [58, 61]. Therefore, I suggest emotional safety is the precursor to physical safety and the following sections reveal the different facets of support that give rise to emotionally safe, relational care as exemplified by Trish: [caring for a woman with twins wanting a home waterbirth with previous obstetric health concerns] Far from the reckless woman I had been led to expect her points seemed entirely reasonable to me [having experienced extreme maternity care trauma]. Safety for her and the babies was her priority, but she was aware that her own mental health would be a significant factor in the health and wellbeing of her babies. It was in order to protect her mental health that she wanted to avoid a birth like her previous one. She felt this would allow her to be the mother she wanted to be and was particularly important as she would have the additional work and sleep deprivation that comes with twins…We talked about how the guidelines are generic and can’t take into account risk factors such as mental health that may be unrelated to the subject of the guideline. Many women I work with will have competing risk factors like this, particularly with mental health. In her unique situation, she didn’t believe that the advice of the guidelines was the safest and best option for her. [Therefore] asking the woman to make a list of her non-negotiable points, important points and icing on the cake wishes… The things that were non-negotiable though were not to do with clinical care. She wanted everyone who came in her room to introduce themselves, no one to touch her without asking permission and all changes to the plan to be explained to her first…

Understanding as Safety A primary component of cultivating emotional safety was enacted by the midwives through seeking to understand the women’s ‘viewpoint, history and ethos around birth’. Listening and ‘really listening’ was crucial to building a sense of shared understanding between the mother and midwife, which cultivated emotional bonds.  But was combined with clinical safety measures as further explored in Chap. 4 will demonstrate the which included a learning, responding, monitoring and anticipating possible outcomes approach [72]. 13  Feeling safe has been described as an existential feeling of security that, if absent, leads to anxiety [74]. 12

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Edna emphasised the importance of the women actually feeling ‘heard’—a crucial aspect of emotional safety [75]—‘…it really boils down to women feeling listened to, I really believe that you know, listen to them, listen but don’t just listen, hear what they’re saying you know?’ Deep within this comment is a subtle but important nuance—with the emphasis of not just listening but ‘really’ hearing what women are saying is indicative of empathetic concern and seeking empathetic connection [81]. Listening, therefore, was to understand birthing women or people, and demonstrated a willingness to ‘walk with’ those in their care: …I think is important is being able to get alongside the woman essentially and to be able to start to understand where she is coming from. And I think there are so many cases where women want to make choices it is really important to understand why they want to make those choices, and why it is they feel that is the best choice for them… (Becky)

Empathy is the ability to understand the experiences and feelings of others outside of our own perspectives, it is an emotional skill that discerns between the emotions of ourselves and others and broadly is understanding, sharing and caring about the emotions of other people [82, 83]. With fundamental importance for individuals, relationships, communities and society—hardwired within our neurobiology [84] ‘really listening’ was crucial to demonstrating empathy and fostering emotional safety within the mother–midwife relationship. Moreover, mirroring wider research, Becky observed women noticed and responded positively when they are being authentically listened to and with attentive presence [85, 86]. Becky observed a tangible connection could be quickly forged (that could also occur within a fragmented model); thus, a demonstrable effect of emotional safety could be observed within the clinical encounter: I think it is about the skill set you use and really listening to what they are saying to you and hearing what they are saying to you and people pick that up really really quickly in my experience… actually as human beings when they do have somebody hears their story and hears their voice, they align to it very very quickly.

Along with tacit emotional connectivity, the midwives’ willingness to listen, understand and empathise elicited more personal insights from the birthing women and people in their care. For example, women revealed stories of previous birth traumas that guided their current decision-making and attempted to avoid repeated traumas by opting for ‘alternative’ decisions. Therefore, understanding was a safety mechanism to ensure women received the care they needed. Claire, a study participant, was supporting Carly14 in declining an induction for postdates and it was through listening to Carly recount her trauma from her first birth experience that facilitated an empathetic understanding which guided the care planning; care that accounted for Carly‘s mental and emotional safety needs. This included two pathways, first, support for expectant management should she experience postdates in the current pregnancy. Second, in the event of foetal wellbeing concerns, an elective caesarean was preferred to circumvent an induction. Rather than steer Carly to a 14

 Pseudonym.

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certain decision, the midwife was able to provide two pathways that centred Carly as the decision maker and accounted for Carly’s emotional (and mental/physical) needs. In this example, we see the importance of taking the time to understand women’s emotional landscape: I was caring for a lady, Carly, who had had a previous double instrumental birth following a long induction with her first baby and in this, her second pregnancy, she wanted to have a homebirth. I had seen her throughout the pregnancy, both in clinic and during the birth hypnosis classes and aqua natal classes I run so we had a good relationship and a high level of trust, which is so important. Over the course of her pregnancy, it became clear that she had many emotional issues left over from her last birth and I offered to go through her old notes with her and help to debrief her. During this it became clear that she had felt that she had no choice previously, had been railroaded into the induction process without knowing that she could make decisions. She started crying during it and afterwards she did say she had a big release about realising what had happened was not her fault—the key line in the notes for her was where the midwife had written ‘Carly is pushing well’—she didn’t feel she had had that encouragement at the time and felt she was ‘doing it wrong’. This really gave me insight into where she was coming from. As the pregnancy progresses Carly mentioned the fact that she would not be induced this time, that if there was something wrong with the baby and they needed to be born imminently she would rather have a caesarean. (Claire)

Support as Safety Building on empathetic listening and understanding as safety mechanisms, the midwives followed this up with proactive support for women in their care. Support is defined ‘a quality that indicates you want to help and encourage somebody’ (Dictionary); which was explicitly demonstrated by the midwives in different ways. For example, aligned with their attitudes discussed in Chap. 2, the midwives referred to a ‘personal policy of never saying no’. This was grounded in their belief that saying no and being unsupportive was less safe for women ‘citing’ concerns that should women make decisions made in response to unsupportive caregivers, this was problematic: …Being told ‘you can’t’, ‘I won’t allow’ ‘no’ can often create a communication problem that may encourage decisions based on fear of not being supported rather than a true assessment of risks and benefits. [Jenny]

Recognising the potential harm of not listening to or supporting women’s decision-­making, the midwives raised concerns of women disengaging with the services and/or freebirthing should their needs not be met [77, 87, 88]: …as a group of supervisors we have always been supportive of that [women’s alternative birthing decisions] because we are mindful that you know if we don’t give these women options and don’t put a support plan in place then either they won’t choose to have a midwife with them or they’ll just completely disengage with the care we provide, then it causes more problems than if we just listen to them… [James]

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Therefore, the midwives viewed being supportive of alternative physiological birthing choices as a safety mechanism. Conveying attitudes of support were typically carried out in the early stages of meeting the women to break down potential barriers and foster early stages of relationship building. Through which, the midwives broadly approached women’s decisions with a ‘how can we help you to achieve that’ attitude. The emphasis being ‘how’, which served as demonstrable emotional and practical support of the woman’s decision that guided future discussions and robust care planning. A ‘how-to’ attitude offers a starting point to reassure women that the midwives were walking alongside them on their journey. Furthermore, communicating their support in this way, with a ‘never say no’ policy, was also a way of approaching women on a psychological level and a means to disarm women who presented as defensive—‘prepared to fight to get the birth they want’. The caveat here is that this approach must be authentic and not a manipulative tactic; but when carried out with empathetic connectivity, the benefit is the cultivation of emotional safeness and safety [61, 89]: You have to go with what people want, you’ve got to pick your battles and fights and you will get more out of people if you say ‘yes I’ll support you in that but here you are, here are the risks’, rather than saying ‘no you can’t? that doesn’t really help anybody does it? [Jane]

Within this context, the midwives felt strongly they wanted to convey their investment in the woman’s experience through their words and their actions— ‘empathic concern’ which is an action-driven empathic response [82, 83], meaning the midwives were ‘compelled to act’ in alignment with the woman’s needs and wishes. This was viewed as a genuine indication of their emotional support for the woman’s birthing decisions and was anticipated to support the cultivation of emotional safety: …I just think that makes a big difference to them, that feeling that you want them to have the experience that they want and trying to see how much you can put in place to make it happen. [Trish]

It is important to consider that for those supporting birthing women or people during intrapartum situations and within a fragmented model, the midwives had less time to convey their support and it was considered ‘trickier’. However, midwives did manage to express support by creating time at the start of the care episode to discuss a birth or care plan, creating the space to (really) listen and offer reassurance they would honour their decisions—therefore, verbal support, reading and respecting birth plans, conveying agreement and understanding in a non-judgemental way were all supportive emotional safety mechanisms within fragmented care models. These ways of support can be seen as compassionate care to which other studies have highlighted its value to women, particularly in fragmented models of care [90, 91]. Susan described the importance of building relationships quickly within intrapartum fragmented models. In her earlier interview, Susan strongly emphasised the role of a midwife is to create the space in which birthing women and people can ‘let go’ and surrender to labour. Whilst more challenging within fragmented models,

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Susan described a mixture of verbal and non-verbal communication to convey a supportive presence and how women will attune with, and trust in, a midwife’s authenticity when they feel seen and respected: I think because if you have got a woman that comes in labouring then she is accessing that sensory space much more so there is like an instant, there is an instant knowing. There is a knowing that you are, that you are being seen and being respected and I think you can only bring that by authentically seeing and hearing and respecting if you try and fake it doesn’t work, they know…

 rust and Trustworthiness as Safety T A cause for, and an effect of, the midwives’ approach to listening, understanding and conveying support, was to foster trust with the women. The participants perceived trust to reflect the ‘bond’ between mother and midwife and was viewed as the ‘glue’ that holds the mother–midwife relationship together. This can be seen as the expression and as an outcome of cultivating emotional safety [92–94]. Two important aspects of trust were present in the study. First, trust was perceived as essential to safe care, where midwives perceived gaining a woman’s trust meant they would be more likely to accept recommendations to act, intervene and/or transfer in an emergency. As such, trust functioned as a method of safe practice essential to the midwives’ caregiving: …I just think it’s about for those women who have the more unconventional birth plans it’s about making clear we’re working with them, but that also means working with us so they do listen, as I say if we say actually we do need to go in, cos I think they’re more likely to if they feel listened to and respected… [Alice]

However, it is important to note that the desire to be trusted by the birthing women or people was taken seriously and seen as a profound responsibility. For the midwives recognised and asserted they had to be deemed trustworthy by those in their care. Therefore, gaining trust was not a manipulative tactic to get women ‘onside’ but an authentic approach viewed through a holistic safety lens. For example, Stella acknowledged that women may feel distrustful of their midwives and/or local services with concerns that support for alternative physiological birth choices may not be authentic. Drawing on knowledge that some midwives would be reluctant to support such homebirths Stella also recognised that some women would need extra reassurance that her commitment (and her colleagues’) was genuine: I think they really need to trust in the person that is there, that’s not going to you know, because you and I know, that you could be at any [home] birth and make something up that that, you can find a reason for them to be transferred. [Stella]

Issues of trust and the consequences of distrust were demonstrated by Katie who was supporting a woman who wanted a homebirth but had a raised BMI therefore, ‘outside of guidelines’. Katie was willing to support this decision but working within a fragmented model of care, other midwife caregivers were involved, and not all were as supportive. Attempts to convey support and build trust were also

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undermined by her manager who had deemed the decision unsafe and Katie incompetent for not changing the woman’s mind resulting in Katie being accompanied by another midwife on her next antenatal visit. Two midwives in attendance were viewed as coercion and as ‘the final nail in the coffin’ for the mother–midwife relationship, for the woman then opted out of care to freebirth due to these coercive tactics. With broken relationships and mistrust in the service, this situation reveals the real importance of trust/mistrust as a safety issue [7]: …so I went to my manager who was already up in arms that this woman was going to have this homebirth with a BMI of 40 and also that she wouldn’t speak to anybody else apart from me uhm, my manager was really unsupportive because she made out, because I was a junior member of the team, I hadn’t managed to change this woman’s mind, you know that I wasn’t doing my job correctly, that I wasn’t counselling her enough, you know I wasn’t telling her about the risks enough, which I don’t think was the case I think you know at the end of the day the woman had reached the end of her pregnancy, she knew what the risks were, you can’t really bully anyone into doing, you can’t frighten someone with all these things uhm, my manager insisted I took another member of the community team to one of our appointments, which I did, but that really was the nail in the coffin for the woman’s relationship with community midwives, and uhm she then after that she text me saying that she didn’t trust me, that she wanted to freebirth and it was really stressful because all I wanted to do is support her, that really upset me because she obviously felt really cornered by everyone, uhm… (Katie)

The second component of trust, and unique to this study, was that cultivating meaningful relationships, garnering trust by the women also fostered trust in the women. Therefore, trust was ‘mutual’ and reciprocated. This was seen as significant and beneficial, as the cultivation of mutual and reciprocal trust increased the confidence of the midwives to support women’s decisions, particularly in the more complex cases. As Kelly stated, ‘a relationship of trust enables me to feel safe when supporting women who make choices outside the normal’. Equally, other research found women need to feel trusted by their midwives and it was a critical factor influencing the trust they placed in the midwives—revealing just how important this is [95]. Therefore, feelings of safety work both ways within the mother–midwife relationship and trust or the lack of, is a safety issue.

3.4 Relational Care Is Safe Care Earlier in this chapter, we explored the common notions of safety within maternity care highlighting the inconsistencies and incongruences, before using new ways of thinking and evidence to expand the conception of safety to include emotional, mental, cultural and spiritual components. The midwives’ approach to centring emotional safety was directly informed by their beliefs, values and attitudes discussed in Chap. 2. For example, the midwives’ commitment to supporting births ‘outside of the guidelines’ was also based on a belief that a meaningful, trusting

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mother–midwife relationship is important and central to safe care. Irrespective of specific birthing choices and in the context of a holistic lens of safety, emotional needs were taken as seriously as physical needs, to which a positive relationship was felt to be crucial. Therefore, the midwives highly valued ‘relational care’ and sought to cultivate meaningful relationships as highlighted throughout this chapter. This was exemplified by Kelly—working with a woman with multiple complex needs including a phobia of any medical intervention and hospitals, Kelly was firmly committed to supporting her throughout. Believing that following the woman’s lead was safer than not, Kelly felt pressurising the woman to conform would simply push her away from maternity care to freebirth. Freebirth (birth without a qualified midwife or doctor) was viewed as riskier than supporting her choices. International research has commonly captured that freebirthing decisions are associated with a lack of support for birthing choices, obstructive care and practice [77, 87], therefore, is not a theoretical concern.15 Kelly, valuing and believing in the benefits of supporting the woman’s choices meant she proactively sought to garner trust and to facilitate the woman’s decisions. Moreover, Kelly described the two-­ way benefit of trusting mother-midwife relationships, affording her more confidence to support women’s choices: … What makes birth safer, is appropriate antenatal care and a trusting relationship with a midwife. Where continuity of care can be achieved through the antenatal, intrapartum and postnatal periods, I believe this increases safety and satisfaction for women. I believe that continuity of carer is of vital importance for high-risk pregnancies and that women who have trust in their midwives will accept help, transfer and intervention when necessary. This relationship of trust enables me to feel safe when supporting women who make choices outside the normal. For this particular birth with the history of previous births, I did not feel the risk factors of grand-multiparity, no screening or scans and home birth were such that a hospital birth would be significantly safer and I felt that the distress it would cause to E to be pressurised into going to hospital would cause more psychological harm and would be more likely to lead to an unassisted birth [freebirth] which would be far more risky.

Therefore, the study participants revealed a centring of emotional safety as the precursor to providing holistically safe care, providing a range of insights as to how this may be achieved within the mother–midwife relationship:

( really ) listening + understanding + active support = mutual trust = safe care

This expanded notion of safety and the ways the midwives’ articulated their approach to cultivating meaningful and authentic relationships provides the ‘colour’ to understand the term ‘relational care’ (explained in Chap. 1). Such relational care was based on a range of emotional approaches reflecting the three different types of empathy; cognitive, emotional and empathic concern [83]—with  While many birthing women and people make a proactive and positive decision to freebirth (that is their right within the UK), I have argued previously that it is those who feel ‘forced’ into freebirthing after being let down by the system that raises significant concerns [79, 96], including the ethical issues of maternity professionals not supporting maternal autonomous decision-making which as this study shows, can be achieved. 15

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the latter a crucial component that compelled the midwives to act [5] by proactively helping the women to access their desired care. These qualities and approaches align with Menage et al.’s [97] concept analysis of compassionate midwifery care; ‘as the interrelations of authentic presence, noticing suffering, empathy, connectedness/relationship, emotion work, motivation to help/support, empowering women and alleviating suffering through negotiation, knowledge and skills p. 568.’ Furthermore, it was the midwives ‘emotional openness’ where they sought to understand the women—who they were as individuals and how their experiences shaped their decision-making—which created the foundation for compassionate care. Emotional openness also reveals emotional vulnerability as meaningful relationships occur within a space of intimacy where both parties risk their emotional selves [98]. A guarded professional disposition is unlikely to generate feelings of emotional safety that are required for women to ‘open up’ but can guard against perceived professional vulnerabilities [99]. However, these midwives actively retained an emotional openness by creating the space to listen and hear the women’s stories and potentially be moved by them. Flemmer, Dekker, and Doutrich [100] argue for Brown’s [99] Acompañar (accompany) theory where mutual vulnerability between professional/client is essential to the development of an empathetic partnership. Additionally, they argue where mutual vulnerability occurs, it creates a shift in power in favour of the client (woman) [100] and provides the space to forge meaningful connections [99]. Additionally, emotional openness and vulnerability can be likened to Crowther and Hall’s [58] notions of relationship building as a spiritual act. Such emotional connection expressed via empathic concern [81] was a key facilitatory factor that enhanced the midwives’ willingness and ability to deliver womancentred care in a wide range of clinical situations. Empathic concern was expressed by the midwives who were moved by the women’s accounts, usually distressing, which ‘compelled them to act’. Such compulsion seemed to create a mother–midwife allegiance that mitigated against potential obstacles such as workplace cultures or constraints [7, 101]. Moreover, the midwives were motivated to provide this care, partly based on their values and philosophy (seen in Chap. 2), and partly because of emotional attunement to the women in their care. An emotional attunement gave the midwives a personal connection to the women’s lifeworld’s and stories which induced empathy (emotional response) and a compulsion to act (behavioural response), even when that meant an increased workload and challenging constraints. For example, Lucy demonstrated this attunement and connection as she relayed the woman’s previously traumatic experience using powerful language (and later demonstrated how she acted to help this woman have a homebirth): She was haunted by the words spoken by the obstetric team, the alarm bells that echoed through the hospital corridors and couldn’t think of anywhere more frightening to birth her second child. Joanna told me she that was wishing to have a homebirth, as she felt most in control, comfortable and safe in her own home, which would therefore mean that she would have the best chance possible to labour naturally.

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3.5 Cultivating Self-Awareness: Exploring and Managing our Fears Self-awareness is an essential characteristic of emotional intelligence [102] and crucial to skilled heartfelt midwifery practice. Such self-awareness, in relation to this chapter, is an opportunity to reflect on any potential fears that we may hold. This is important because our feelings of fear (or safety) will influence our capabilities to hold the space and/or provide emotional safety for those in our care. Whilst for some fears may be related to unsupportive workplaces16 and in other situations, in may be related to specific (or all) decisions ‘outside of the guidelines’.17 When fear goes unchecked, it may influence the degree of support we are willing to provide, and be detrimental to the safe relational care that women desire. Such fears need to be identified and processed so as not to unduly influence the care we can provide. For example, Lucy openly discussed her fears supporting women opting for vaginal birth after caesarean (VBAC) in community settings. Through self-inquiry and awareness, Lucy proactively sought to overcome her fears. Lucy’s fears were based on caring for two women who had uterine ruptures in 1 year.18 Whilst Lucy recognised the statistically small risk of uterine rupture, for her, it was a ‘very real risk’. These fears were heightened as one resulted in foetal death. Lucy reflected on the clinical case and viewed the poor outcome as emblematic of poor mistrusting relationships between the woman and herself, and between the woman and the wider maternity services: …On reflection, I felt that if there had been better support antenatally and more of a relationship between the maternity professionals and the patient, she may have been more trusting and, in turn, listened to the advice given to her at the time of the incident. There was no trust, and I felt unable to build a relationship with the woman, which I feel is key during labour care.

 To explore the workplace issues in depth is beyond the scope of this book, but it is important to acknowledge that a lack of psychological safety within the workplace will detrimentally affect how well (if at all) midwives can provide alternative physiological birth care [7, 101, 103]. Therefore, in the event of feeling uncomfortable or alarmed about a birthing person’s decision, it could be helpful to explore whether the discomfort comes from a fear of not being supported within your organisation. If you work within a ‘blame’ culture with little regard for women’s autonomy or midwives’ professional competence, then it is likely to foster distrust within the employer/ employee relationships and/or affect how you feel about supporting these choices [7, 101, 103, 104]. Such distrust can create fearful environments which ultimately reflects poor psychological safety within the workplace [105] and is counter to the strong evidence in favour of psychological safety improving patient outcomes [106, 107]. 17  Some fear may be ‘healthy’ so to avoid complacency during our caregiving (overconfidence is not safe); and/or if we have not had exposure to a particular birth choice, it is likely to provoke some level of fear of the unknown. Both can be managed through supportive collegial relationships, where working alongside more experienced colleagues will help develop the skillsets to overcome such fears. 18  Unusual occurrence for an individual midwife as uterine ruptures are so rare. 16

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There were numerous issues reported throughout the woman’s pregnancy care fostering distrust within the maternity service. Lucy did not know the woman prior to intrapartum care and in making sense of the sad situation, Lucy empathetically aligned with the woman and felt the situation arose due to a lack of trust or any semblance of relationship between them. For many of us, such a situation would compel an avoidance of providing alternative physiological birth care and indeed Lucy reported feeling frightened when facing someone else requesting a home VBAC.  However, through self-awareness and reflection, Lucy was motivated to cultivate a meaningful, trusting relationship to ‘ensure that it [adverse outcome] didn’t happen again’. Constructing relational care as safe care, a key tenet of her philosophy, Lucy committed her support to this next woman seeking a home VBAC. Methods to manage her fears appeared to be a process of Lucy returning to and reiterating her personal values (as per Chap. 2), a form of inner ethical guidance in how to proceed in her midwifery practice, thus exemplifying the power and importance of recognising ourselves and what we bring to our practice: …It would not be fair of me to let my past experiences taint her birth plan, as it’s not about me, or my fears: it’s about the woman at the centre of my care…

3.6 Conclusion Having explored and challenged the limitations of typical notions of safety within maternity care, this chapter has demonstrated that safety must encompass holism—physical, mental, emotional, cultural and spiritual components. I have argued that emotional safety is the fundamental building block, and when achieved, is the precursor to other aspects of safety (including physical safety outcomes). Creating emotional safeness requires a humanised perspective, seeing the person as whole, and within their lifeworld contexts—therefore, when this is achieved through emotional connection, the rest follows. Within the context of alternative physiological birth choices, the midwives in the study showed how they cultivated emotional safety. Through (really) listening, seeking to understand and demonstrating proactive support the midwives fostered mutually trusting relationships—and with various examples, it was demonstrated that it is within the space of mutual trust where the true notion of safety exists. This chapter has captured what the midwives did to cultivate safe care, putting their beliefs, values and attitudes into action; the next chapter turns to the clinical skills the midwives possessed, highlighting the constituent components of ‘expert’ midwifery practice which also characterises safe care.

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Personal Reflective Activity

First, have you personally experienced a healthcare interaction where you did not feel emotionally safe? If so, consider taking some time to reflect upon the situation, i.e. what happened and what were the cues from the health professional who felt unsafe? What were the implications or knock-on effects of this interaction? Furthermore, what did you need in that situation to feel safe? Doing this reflective exercise can remind us as healthcare professionals what it is like to be the client, and how the power differentials within clinical encounters can cause adverse or positive effects. This can help us cultivate empathy for those in our care. Second, can you think of a time when you cared for someone when their emotional needs were not met? Consider writing about the situation and exploring what happened, how it happened, who was involved in the situation and what the implications for the birthing woman or person might be where their emotional safety needs were not met? Did this influence their decision-­ making? How might it have influenced their experience of care? How were you feeling within the care episode? And crucially, what could have been done differently to cultivate emotional safety?

Further Resources 1. Case studies—see Chap. 6. 2. Understanding emotional intelligence and its importance—see Daniel Goleman’s seminal book https://www.danielgoleman.info/purchase/ 3. Understanding emotions and the power of giving language to each as a way of cultivating self-understanding and awareness—see Brené Brown’s book Atlas of the Heart https://brenebrown.com/book/atlas-­of-­the-­heart/ 4. Central to providing emotional safety and relational care is self-compassion— see Kirsten Neff https://self-­compassion.org/

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27. Tunestveit JW, Baghestan E, Natvig GK, Eide GE, Nilsen ABV (2018) Factors associated with obstetric anal sphincter injuries in midwife-led birth: a cross sectional study. Midwifery 62:264–272. https://doi.org/10.1016/j.midw.2018.04.012 28. Rygh AB, Skjeldestad FE, Körner H, Eggebø TM (2014) Assessing the association of oxytocin augmentation with obstetric anal sphincter injury in nulliparous women: a population-based, case-control study. BMJ Open 4(7):e004592. https://doi.org/10.1136/ bmjopen-­2013-­004592 29. Graugaard HL, Maimburg RD (2021) Is the increase in postpartum hemorrhage after vaginal birth because of altered clinical practice? A register-based cohort study. Birth 48(3):338–346. https://doi.org/10.1111/birt.12543 30. Ende HB, Lozada MJ, Chestnut DH et al (2021) Risk factors for atonic postpartum hemorrhage: a systematic review and meta-analysis. Obstet Gynecol 137(2):305–323. https://doi. org/10.1097/AOG.0000000000004228 31. Ockenden D (2022) Findings, conclusions and essential actions from the independent review of maternity services at the Shrewsbury and Telford hospital NHS trust. HH Associates Ltd. https://www.gov.UK/government/publications/final-­report-­of-­the-­ockenden-­review 32. Alòs-Pereñíguez S, O’Malley D, Daly D (2023) Women’s views and experiences of augmentation of labour with synthetic oxytocin infusion: a qualitative evidence synthesis. Midwifery 116:103512. https://doi.org/10.1016/j.midw.2022.103512 33. Girault A, Blondel B, Goffinet F, Le Ray C (2021) Frequency and determinants of misuse of augmentation of labor in France: a population-based study. PLoS One 16(2):e0246729 34. Souza J, Oladapo O, Fawole B et al (2018) Cervical dilatation over time is a poor predictor of severe adverse birth outcomes: a diagnostic accuracy study. BJOG 125(8):991–1000. https:// doi.org/10.1111/1471-­0528.15205 35. Douglas M (1992) Risk and blame: essays in cultural theory. Routledge, London 36. Newnham E (2014) Birth control: power/knowledge in the politics of birth. Health Sociol Rev 23(3):254–268. https://doi.org/10.1080/14461242.2014.11081978 37. Edwards N, Murphy-Lawless J, Kirkham M, Davies S (2011) Attacks on midwives, attacks on women’s choices. AIMS J 23:31–39 38. Newnham E, Kirkham M (2019) Beyond autonomy: care ethics for midwifery and the humanization of birth. Nursing Ethics 26(7–8):2147–2157. https://doi. org/10.1177/0969733018819119 39. Shallow H (2013) Deviant mothers and midwives: supporting VBAC with women as real partners in decision making. Essentially MIDIRS 4(1):17–21 40. Brocklehurst P (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. BMJ 343:d7400. https://doi.org/10.1136/bmj.d7400 41. Walsh D, Spiby H, Grigg C et al (2018) Mapping midwifery and obstetric units in England. Midwifery 56:9–16. https://doi.org/10.1016/j.midw.2017.09.009 42. Reitsma A, Simioni J, Brunton G, Kaufman K, Hutton EK (2020) Maternal outcomes and birth interventions among women who begin labour intending to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: a systematic review and meta-analyses. Lancet 21:100319 43. Hutton E, Reitsma A, Simioni J, Brunton G, Kaufman K (2019) Perinatal or neonatal mortality among women who intend at the onset of labour to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: a systematic review and meta-­ analyses. E Clin Med 14:59–70. https://doi.org/10.1016/j.eclinm.2019.07.005 44. Birthrights (2022) Coronavirus. https://www.birthrights.org.uk/campaigns-­research/ coronavirus/ 45. Taylor H, Kleine I, Bewley S, Loucaides E, Sutcliffe A (2016) Neonatal outcomes of waterbirth: a systematic review and meta-analysis. Midirs Midwifery Digest 26:3 46. Vanderlaan J, Hall PJ, Lewitt M (2018) Neonatal outcomes with water birth: a systematic review and meta-analysis. Midwifery 59:27–38. https://doi.org/10.1016/j. midw.2017.12.023

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47. Burns E, Feeley C, Hall PJ, Vanderlaan J (2022) Systematic review and meta-analysis to examine intrapartum interventions, and maternal and neonatal outcomes following immersion in water during labour and waterbirth. BMJ Open 12(7):e056517. https://doi.org/10.1136/ bmjopen-­2021-­056517 48. Hollowell J, Rowe R, Townend J, et  al (2011) The Birthplace in England national prospective cohort study: further analyses to enhance policy and service delivery decision-making for planned place of birth. https://www.npeu.ox.ac.uk/birthplace/birthplace-­ follow-­on-­study#:~:text=The%20Birthplace%20in%20England%20national,(FMUs)%20 and%20at%20home 49. Russell K (2011) Struggling to get into the Pool room? A critical discourse analysis of labor ward midwives’ experiences of water birth. Int J Childbirth 1:52–60. https://doi. org/10.1891/2156-­5287.1.1.52 50. Nicholls S, Hauck YL, Bayes S, Butt J (2016) Exploring midwives’ perception of confidence around facilitating water birth in Western Australia: a qualitative descriptive study. Midwifery 33:73–81. https://doi.org/10.1016/j.midw.2015.10.010 51. Newnham EC, McKellar LV, Pincombe JI (2015) Documenting risk: a comparison of policy and information pamphlets for using epidural or water in labour. Women Birth 28(3):221–227. https://doi.org/10.1016/j.wombi.2015.01.012 52. NICE (2021) Inducing labour (update) consultation on draft guideline—stakeholder comments table. https://www.nice.org.uk/guidance/ng207/documents/html-­content 53. Birthrights (2021) Induction proposals ignore black and brown women’s experience of maternity services. https://www.birthrights.org.uk/2021/07/05/induction-­proposals-­ignore-­ black-­and-­brown-­womens-­experience-­of-­maternity-­services-­says-­birthrights/#:~:text=% E2%80%9CInduction%20proposals%20ignore%20black%20and,of%20maternity%20 services%E2%80%9D%20says%20Birthrights&text=Birthrights%20has%20published%20 its%20response,offered%20induction%20at%2041%20weeks 54. NICE (2021) Inducing labour NICE guideline [NG207]. https://www.nice.org.UK/ guidance/ng207 55. Homer CS, Leap N, Edwards N, Sandall J (2017) Midwifery continuity of carer in an area of high socio-economic disadvantage in London: a retrospective analysis of Albany ­midwifery practice outcomes using routine data (1997–2009). Midwifery 48:1–10. https:// doi.org/10.1016/j.midw.2017.02.009 56. Davies S, Edwards N (2010) Termination of the Albany practice contract: unanswered questions. Br J Midwifery 18(4):260–261. https://doi.org/10.12968/bjom.2010.18.4.47380 57. Renfrew M, McFadden A, Bastos M et  al (2014) Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. Lancet 384(9948):1129–1145. https://doi.org/10.1016/S0140-­6736(14)60789-­3 58. Crowther S, Hall J (2015) Spirituality and spiritual care in and around childbirth. Women Birth 28(2):173–178. https://doi.org/10.1016/j.wombi.2015.01.001 59. O’Brien AP, Bloomer MJ, McGrath P et  al (2013) Considering aboriginal palliative care models: the challenges for mainstream services. Rural Remote Health 13:2339 60. Esegbona-Adeigbe S (2020) Cultural safety in midwifery practice—protecting the cultural identity of the woman. Pract Midwife 23(1):110–112 61. Veale D, Robins E, Thomson AB, Gilbert P (2023) No safety without emotional safety. Lancet Psychiatry 10(1):65–70. https://doi.org/10.1016/S2215-­0366(22)00373-­X 62. Greenhalgh T (2014) Evidence based medicine: a movement in crisis? BMJ 348:g3725 63. Wieringa S, Greenhalgh T (2015) 10 years of mindlines: a systematic review and commentary. Implement Sci 10(45):1–11 64. Greenhalgh T (2015) Six biases against patients and carers in evidence-based medicine. BMC Med 12:200. https://doi.org/10.1186/s12916-­015-­0437-­x 65. Greenhalgh T (2018) Of lamp posts, keys, and fabled drunkards: a perspectival tale of 4 guidelines. J Eval Clin Pract 24(5):1132–1138. https://doi.org/10.1111/jep.12925 66. Levy V (1999) Protective steering: a grounded theory study of the processes by which midwives facilitate informed choices during pregnancy. J Adv Nurs 29(1):104–112

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67. Blaylock R, Trickey H, Sanders J, Murphy C (2022) WRISK voices: a mixed-methods study of women’s experiences of pregnancy-related public health advice and risk messages in the UK. Midwifery 113:103433. https://doi.org/10.1016/j.midw.2022.103433 68. Roberts J, Walsh D (2018) Babies come when they are ready: women’s experiences of resisting the medicalisation of prolonged pregnancy. Fem Psychol 29(1):40–57. https://doi. org/10.1177/0959353518799386 69. Graw JA, Eymann K, Kork F, Zoremba M, Burchard R (2018) Risk perception of blood transfusions—a comparison of patients and allied healthcare professionals. BMC Health Serv Res 18:1122. https://doi.org/10.1186/s12913-­018-­2928-­x 70. Zeybek B, Childress AM, Kilic GS et  al (2016) Management of the Jehovah’s witness in obstetrics and gynecology: a comprehensive medical, ethical, and legal approach. Obstet Gynecol Surv 71(8):488–500. https://doi.org/10.1097/OGX.0000000000000343 71. Newnham L (2019) Midwifery technology: midwifery practice for the humanisation of birth Dr Elizabeth Newnham. Pract Midwife 23:2 72. Verhagen MJ, de Vos MS, Sujan M, Hamming JF (2022) The problem with making safety-II work in healthcare. BMJ Qual Saf 31(5):402–408. https://doi.org/10.1136/ bmjqs-­2021-­014396 73. Porges S (2022) Polyvagal theory: a science of safety. Front Integr Neurosci 16:871227. https://doi.org/10.3389/fnint.2022.871227 74. Sandler J, Sandler AM (1998) Internal objects revisited. Karnac Books, London 75. Kenward L, Whiffin C, Spalek B (2017) Feeling unsafe in the healthcare setting: patients’ perspectives. Br J Nursing 26(3):143–149. https://doi.org/10.12968/bjon.2017.26.3.143 76. Reed R, Sharman R, Inglis C (2017) Women’s descriptions of childbirth trauma relating to care provider actions and interactions. BMC Pregnancy Childbirth 17:21. https://doi. org/10.1186/s12884-­016-­1197-­0 77. Greenfield M, Payne-Gifford S, McKenzie G (2021) Between a rock and a hard place: considering “freebirth” during Covid-19. Front Glob Womens Health 2:603744. https://doi. org/10.3389/fgwh.2021.603744 78. Plested M, Kirkham M (2016) Risk and fear in the lived experience of birth without a midwife. Midwifery 38:29–34. https://doi.org/10.1016/j.midw.2016.02.009 79. Feeley C, Thomson G (2016) Tensions and conflicts in ‘choice’: women’s experiences of freebirthing in the UK. Midwifery 41:16–21. https://doi.org/10.1016/j.midw.2016.07.014 80. Heys S, Downe S, Thomson G (2021) ‘I know my place’; a meta-ethnographic synthesis of disadvantaged and vulnerable women’s negative experiences of maternity care in high-­ income countries. Midwifery 103:103123. https://doi.org/10.1016/j.midw.2021.103123 81. Ménage D, Bailey E, Lees S, Coad J (2017) A concept analysis of compassionate midwifery. J Adv Nursing 73(3):558–573. https://doi.org/10.1111/jan.13214 82. Guidi C, Traversa C (2021) Empathy in patient care: from ‘clinical empathy’ to ‘empathic concern’. Med Health Care Philos 24(4):573–585. https://doi.org/10.1007/s11019-­021-­10033-­4 83. Zaki J (2019) The war for kindness: building empathy in a fractured world. Little Brown Book Group, London 84. Riess H (2017) The science of empathy. J Patient Exp 4(2):74–77. https://doi. org/10.1177/2374373517699267 85. Carroll K (2021) Attentive presence: considerations for focusing on another. Nurs Sci Q 34(1):28–29. https://doi.org/10.1177/0894318420965227 86. Klaver K, Baart A (2016) How can attending physicians be more attentive? On being attentive versus producing attentiveness. Med Health Care Philos 19(3):351–359. https://doi. org/10.1007/s11019-­015-­9669-­y 87. Hollander M, de Miranda E, van Dillen J, de Graaf I, Vandenbussche F, Holten L (2017) Women’s motivations for choosing a high risk birth setting against medical advice in The Netherlands: a qualitative analysis. BMC Pregnancy Childbirth 17:1423. https://doi. org/10.1186/s12884-­017-­1621-­0

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88. Holten L, de Miranda E (2016) Women′s motivations for having unassisted childbirth or high-­ risk homebirth: an exploration of the literature on ‘birthing outside the system’. Midwifery 38:55–62. https://doi.org/10.1016/j.midw.2016.03.010 89. Lyndon A, Davis D, Sharma AE, Scott KA (2023) Emotional safety is patient safety. BMJ Qual Saf 32(7):369–372. https://doi.org/10.1136/bmjqs-­2022-­015573 90. Menage D, Bailey E, Lees S, Coad J (2020) Women’s lived experience of compassionate midwifery: human and professional. Midwifery 85:102662. https://doi.org/10.1016/j. midw.2020.102662 91. Nicholls L, Webb C (2006) What makes a good midwife? An integrative review of methodologically-diverse research. J Adv Nurs 56(4):414–429. https://doi. org/10.1111/j.1365-­2648.2006.04026.x 92. Wilkins CH (2018) Effective engagement requires trust and being trustworthy. Med Care 56(10 Suppl 1):S6–S8. https://doi.org/10.1097/MLR.0000000000000953 93. Misztal B (1996) Trust in modern societies: the search for the bases of social order. Polity Press, Cambridge 94. Garfinkel H (1963) Motivation and social interaction cognitive determinants. In: Harvey O (ed) Motivation and social interaction. Ronald, New York, pp 187–238 95. Lewis M, Jones A, Hunter B (2017) Women’s experience of trust within the midwife–mother relationship. Int J Childbirth 7(1):40–52. https://doi.org/10.1891/2156-­5287.7.1.40 96. Feeley C, Thomson G (2016) Why do some women choose to freebirth in the UK? An interpretative phenomenological study. BMC Pregnancy Childbirth 16:59. https://doi.org/10.1186/ s12884-­016-­0847-­6 97. Menage D, Bailey E, Lees S, Coad J (2017) A concept analysis of compassionate midwifery. Midwifery 73(3):558–573. https://doi.org/10.1111/jan.13214 98. Brown B (2002) Acompañar:a grounded theory of developing, maintaining and assessing relevance in professional helping. University of Houston, Houston 99. Patterson D, Begley A (2011) An exploration of the importance of emotional intelligence in midwifery. Evid Based Midwifery 9(2):53–60 100. Flemmer N, DEkker L, Doutrich D (2014) Empathetic partnership: an interdisciplinary framework for primary care practice. J Nurse Pract 10(8):545–551 101. Feeley C, Downe S, Thomson G (2021) ‘Stories of distress versus fulfilment’: a narrative inquiry of midwives’ experiences supporting alternative birth choices in the UK National Health Service. Women Birth 35(5):e446–e455. https://doi.org/10.1016/j.wombi.2021.11.003 102. Goleman D (2004) Emotional Intelligence. Bloomsbury Publishing, London 103. Cobell (2015) What are midwives’ experiences of looking after women in labour outside of trust guidelines? MSc thesis, Private correspondence 104. Gabriel L, Reed R, Broadbent M, Hastie C (2023) “I didn’t feel like I could trust her and that felt really risky”: a phenomenographic exploration of how Australian midwives describe intrapartum risk. Midwifery 118:103582. https://doi.org/10.1016/j.midw.2022.103582 105. Edmondson A (1999) Psychological safety and learning behavior in work teams. Adm Sci Q 44(2):350–383. https://doi.org/10.2307/2666999 106. West M, Collins B, Eckhert R, Chowla R (2017) Caring to change: how compassionate leadership can stimulate innovation in health care. King’s Fund. www.kingsfund.org.uk/ publications/caringchange 107. West M, Eckert R, Steward K, Pamore B (2014) Developing collective leadership for health care. King’s Fund. https://www.kingsfund.org.uk/sites/default/files/field/field_publication_ file/developing-­collective-­leadership-­kingsfund-­may14.pdf

4

Moving from a Rule-Based Practice to Expert Clinical Midwifery Practice

4.1 Introduction The previous chapter explored the common conception of ‘safety’ within maternity care and demonstrated the need for safety to encompass a holistic approach where mental, emotional, cultural and spiritual aspects are held equally to that of physical safety. Furthermore, using examples from the midwife participants, emotional safety was argued as the precursor to the other components of safety including physical. This chapter focuses on the cultivation of expert clinical midwifery practice, exploring first the tensions between professional, autonomous practice and a ‘rule-based’ approach that is increasingly restricting the autonomy of midwives. This juxtaposition limits the effectiveness and efficacy of midwives to deliver the positive outcomes the evidence shows they can provide [1, 2]. Through, drawing on the study participant accounts, an exploration of expert midwifery practice will be presented, with a focus on their clinical skills when providing alternative physiological birth care. Using insights from the data, expert midwifery practice is understood as knowledgeable, technical, proactive, responsive/adaptable and intuitive. These components are individually explored to foster a deeper understanding of what constitutes ‘expert’ clinical practice but with acknowledgement that they are inextricably intertwined. Moreover, this chapter will demonstrate that it is these components that are the hallmarks of safe care, rather than routinised care. Finally, this chapter will examine the importance of exploring our exposure to, and experiences of physiological birth.

4.2 Rule-Based Versus Autonomous, Professional Practice As identified in Chap. 1, whilst the personal qualities, attributes and behaviours (such as emotional intelligence, respect and dignity) of midwives are essential to providing good quality care, it is also paramount their clinical skills are robust. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. Feeley, Skilled Heartfelt Midwifery Practice, https://doi.org/10.1007/978-3-031-43643-7_4

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Therefore, both a mindset and skillset are required to safely support all births. Skill is defined as ‘the ability to use one’s knowledge effectively and readily in execution or performance’ [3]; and for midwives the required clinical skills are complex and wide ranging in the provision of safe care across the childbearing continuum. These of course include the understanding of the ‘normal’ or typical parameters of childbearing physiology to effectively recognise deviations that require timely management/intervention and/or escalation for medical assistance [4–6]. Midwifery practice also encompasses preventative measures, seeks to optimise biopsychosocial outcomes within a public health model of care1 whilst seeking to strengthen women’s own capabilities [1, 2, 6]. Therefore, effective midwifery practice should be viewed both as a preventative mechanism for a host of potential morbidity/mortality concerns and should also be viewed within a salutogenic lens that focuses on the creation, enhancement and maintenance of wellbeing [1, 2, 6]. Moreover, a salutogenic approach recognises the potential for childbirth to be a positive transformative experience for both mother and baby; neuro-hormonally, psychologically, physically and emotionally, rather than just a means of getting the baby out of the mother’s body [7]. Herein lies the core skills of midwives, the ability to support wellbeing-enhancing mechanisms grounded within women’s unique personal circumstances, whilst remaining alert to, and attending to potential life-threatening deviations should they occur [1]. This approach requires robust knowledge and competence to practice and apply sound clinical judgement; and requires holding two perspectives at once—both/and—childbirth as a normal life event and one that can endanger life. It is within this space that the benefits of skilled midwifery facilitate over 56 maternal/neonatal outcomes, previously highlighted in Chap. 1 [1]. Crucially, to achieve these beneficial outcomes, midwives need to be educated,2 trained, licensed and regulated to international standards [1, 9]3; embedded and integrated properly within healthcare systems and structures [11, 12]; supported by interdisciplinary teams [1, 11] and situated within ‘enabling environments’ [13] in order to maximise their effectiveness [1, 2]. For direct entry midwives in high-­income countries they are deemed competent, autonomous practitioners4 at the

 See Chap. 3 footnotes for further discussion about the public health role of the midwife.  This is important as evidence indicates that over half of the global newborn deaths and half of maternal diseases now result from poor quality care [8].Therefore, the educational standards of both incoming student midwives and those currently practising is of vital importance—a particular concern in low-middle income countries [8]. 3  International standards have been set by the International Confederation of Midwives (ICM) and the title ‘midwife’ is protected, only to be used by those in receipt of the appropriate education/ training/education, regulation and accreditation etc. [9]. The role of the ICM is vitally important as many countries do not yet recognise midwifery as an autonomous profession, one where it is midwives who determine and control the standards for midwifery education, regulation and practice [10]. 4  Several researchers have provided a historical critique around the notion of ‘professionalism’, the rise (and dominance) of professional medicine and how midwifery has mirrored itself on problematic beginnings including capitalist and colonial premises see [14–16]. However, for the purposes of this chapter, I situate professional midwifery practice within a positive sense that means autonomous and accountable. 1 2

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point of qualification [10, 17]. Autonomous practitioners5 are deemed as professionals, with specific expertise, who are responsible and accountable (through regulation6) for their actions (or non-actions) [10, 17]. Therefore, to work autonomously, and with its associated accountability, is the ability to work within one’s scope of practice, to make sound clinical judgements (based on professional knowledge and expertise and in partnership with service users) and with the authority and/or power to do so [10, 17]. However, midwives professional autonomy is frequently curtailed either through other professional groups and/or institutions influencing their standards of practice [14].7 For example, midwifery practice has not only been determined by obstetric practice/preferences [14–16]8 and heavily influenced by nursing [14]; but increasingly by institutional demands for those working as employed midwives [19].9 Institutional demands encompass excessive bureaucracy, rules and regulations, routine and procedure-based care [19–21]—compounded by short staffing, busyness and heavy workloads, employed midwives frequently report they are required to prioritise the needs of the institution over those in their care [19, 22–24]. Furthermore, the inappropriate reliance on clinical guidelines as ‘rules to follow’ in many countries10 has further marginalised the professional ability of midwives to act autonomously and to use their professional judgement to provide personalised care. ‘Guideline-centred’ care [25], where the guidelines wield excessive power over individualised care, is heavily influenced by the issues surrounding risk/ safety cultures in maternity care explored in Chap. 3. Furthermore, guideline-centred care is contextualised by an increasingly fear based, litigation-centric culture that stimulates increased defensive practice [14, 29, 30],11 as well as the issues surrounding risk/safety cultures in maternity care explored in Chap. 3. Collectively,  Hence, the importance of the ICM’s [12] work of ensuring midwifery is an autonomous profession which must include a unique body of knowledge; a code of ethics; self-governance; processes for decision-making by its members; recognition from society through regulation. 6  Such occupational accountability has generated the need for certain standards to be met to acquire professional status, combined with the function of regulatory bodies to ensure the standards are being met for public protection [14]. 7  This section will focus on contemporary issues, but it is important to recognise the longstanding and historical issues that have challenged midwifery autonomy—for more insights see [14–16]. 8  This can also be seen in terms of research investments, e.g. Evidence demonstrates most maternity-­related research (and money invested) has focused on the pathologies of birth [1, 18];revealing underlying values in favour of biomedicine and technologies. This has been at the expense of very little (comparatively) on the prevention of complications/pathologies and/or the support of women—as Kennedy et al. [18] argue, are where the most gains are to be made. 9  It’s important to note that most midwives globally report different degrees of restricted autonomy. However, the most significant influential factor may be context specific and differ; for example in some US states midwifery is still illegal, in countries such as Spain obstetric practice and preferences dominate etc. The issues I raise here, particularly around institutionalisation may not resonate in all settings but is certainly problematic in the UK, Australia and many European countries. 10  There is absolutely a place for clinical guidelines, clinicians cannot remember everything about everything! But issues arise when guidelines supersede service user decision-making and professionals’ clinical judgment see [25–28]. 11  I have explored this extensively elsewhere, see [19]. 5

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these issues all risk deducing professional midwifery practice to one that is ‘rulebased’—thus, contradicting the notion of autonomous professional working and reducing the efficacy of midwifery care [1, 2, 10, 13]. The increasing institutionalisation of midwifery practice marks another shift away from professional practice12. A bureaucratic-based approach to care is problematic taking time away from direct patient/client care, and is in direct conflict with individualised caregiving [31].13 Moreover, a bureaucratic-based approach is not what preserves comfort, safety or dignity or what necessarily saves lives [32, 33]. Whilst efforts to standardise healthcare to decrease unwarranted variations in practice are important, the unintended consequence, particularly in institutionalised settings, is that ‘care’ is often deduced to ‘tick-boxes’ and rules (and often duplications/triplications that cost more time) which may meet the needs of the institutions (governance structures etc.) but not meet the needs of those receiving the care [32]. For example, the nature of schedules and routine-based care in hospitals shape women’s experiences of labour and birth—hospital schedules prioritise ‘clock time’ running counter to the natural rhythms of unpredictable labour [34, 35] which has been attributed to an increase in routine-based approaches (medical management and interventions) so to manage the unpredictability of labour, and is related to the ‘smooth’ running of hospital processes and procedures [15, 36, 37]. This accounts for the evidence that demonstrates fewer physiological births occur within hospitals for healthy women [38, 39].14 The emphasis on processes, procedures and rules within hospitals has been said to mirror industrial production lines where efficiency is super-valued over individualised care delivery [40, 41]. Furthermore, I argue that institutional rule-based expectations, keep qualified midwives stuck as ‘advanced beginner practitioners’ [42]. So, for midwives who have developed competency, proficiency or expertise as per Benner’s [42] taxonomy of clinical competence, institutional constraints limit their ability to apply their skills, knowledge and clinical judgement, and/or respond to individual needs. Or for those yet to cultivate advanced skills, their exposure to such development can be curtailed. These issues frequently arise in relation to supporting and optimising the physiological processes of labour and birth (irrespective of in or outside of ‘guidelines’). For example, a recent ethnographic study explored midwives’ use of and competence in physiological care practices15 in an obstetric unit to identify barriers and facilitators of implementing a physiological approach during intrapartum care [43]. The research found that despite good leadership from the consultant

 Arguably, there has been a push-pull on midwifery professional autonomy since the 1800s, see previous footnotes for further reading on this. 13  Excessive bureaucracy and a ‘tick-box’ approach is a significant source so service user complaints [31]. 14  As just one example, there are many others with similar issues—see discussion in Chap. 1. 15  Physiological practices within this study [43] included emotional support, physical support (comfort, dignity measures, food/drink, supporting freedom of movement, offer and support non-­ pharmacological pain relief measures), ‘watchful waiting’ with interventions only if clinically indicated, midwifery-led solutions to non-emergency deviations during labour. 12

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midwives16 to promote physiological care practices, they met resistance from both midwives on the ground and obstetricians [43]. Moreover, the research found most midwives (on the ground) within the obstetric setting ‘did not regard themselves as autonomous decision-makers and sought permission to implement a physiological approach’; nor were the midwives found to challenge routine clinical intervention use [43]. These findings reveal the negative influence of a rule-based, technocratic approach to midwifery care within hierarchal settings and raises concerns that the full-scope of midwifery practice (and its benefits) are not enabled. Furthermore, this study reflects others that have identified midwives report a lack of skills and confidence working within midwifery-led nontechnical settings, with an emphasis on non-invasive, physiologically oriented care [45–48]—despite it being a core role and function of a qualified midwife [6, 9]. Arguably, a rule-based practice is limiting midwives’ ability to meet professional standards of autonomy which has a negative impact on knowledge and skill acquisition, competence and confidence; and importantly, a negative impact upon access to appropriately skilled care for those seeking physiological birth care (alternative or otherwise). However, for midwives who had opportunities to work in other birthplace settings, Darling’s [43] research found they were observed to use a higher number of physiological care practices and were rated as more competent in using these practices. This positive finding also reflects other research that has found exposure to and experience in, midwifery-led settings is critical for the cultivation advancing midwifery intrapartum skill, competence and confidence [49–52]. It is within a firm theoretical and practical grounding of the physiological process of labour and birth, which includes the recognition, identification and management of deviations, alongside the willingness and skill to be woman-led in which the optimal benefits of full-­scope midwifery can be realised. Accordingly, the rest of this chapter explores the study participants’ accounts of ‘expert midwifery practice’ exemplified by their ability to facilitate alternative physiological births. Acknowledging the challenges that exist, Margot, below, shares a flexible perspective, one that is woman-led and resists midwifery care as rule based to one that is of a professional, accepting appropriate responsibility and accountability: I have a very clear view about accountability and I think people get very confused and upset and worried by if women are making different choices, [as if] it’s the professionals fault if something goes wrong … the NHS system forgets that the NHS is not law and that things change all the time so just because the policy[/guidelines] says this now, in three years’ time they might get around to working out that what women said was right all along and change the policy and everyone will be ‘oh god I can’t believe we used to do that’ like early cord clamping, you know women asking to not have the cord clamped, to have it left pulsating until separation from them and the baby, used to be looked on as being completely batty and now delayed cord clamping is recommended by the World Health Organisation. So, you know I think people lose sight of that, that actually knowledge is very fluid and people making choices that don’t appear to be in line of what is the accepted norm doesn’t necessarily mean they’re wrong. There are a range of colours that we manage in the world, it’s not black and white, as long as we all understand that we’re responsible for our own actions, then that’s how I proceed, and I try and instil that in others and empower them to understand that.

 In the UK, consultant midwives are senior expert midwives in leadership roles within NHS Trusts (organisations) [44]. 16

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4.3 Expert Midwifery Practice We have explored the challenges to midwifery autonomous practice and how such limitations may reduce the efficacy of midwives as a powerful intervention to improve maternal–neonatal biopsychosocial outcomes, particularly in the intrapartum period. However, for other midwives, those in this research study, they did practice as autonomous professionals to cultivate an ‘expert practice’ [19, 53]. In contrast to a rule-based approach (novice/advanced beginner [42]), expert practice is adaptable and responsive whilst grounded in evidence-­based and experiential knowledge [54]. Such skill meets the demands of supporting women with a wide(r) range of birth choices, thus offering genuine personalised care; and importantly, during intrapartum care should the clinical picture suddenly change (either new or unexpected situations or clinical deviations) expert midwives can apply their knowledge to these situations with agility and adaptability [54]. Essential to expert practice is the understanding why something might be happening by knowing the underpinning mechanisms (psychologically or physiologically speaking) which when applied to the individual, fosters adaptability and responsiveness. A simple ‘rule-based’ approach without a solid knowledge base can miss subtle but crucial markers of deviation or deterioration or miss the holistic context which may reveal overall wellbeing with no concerns.17 It is within this space of uncertainty that expert practice holds, and is attentive to a range of possibilities, with a readiness to change course, if necessary, all the whilst resisting the urge to overly manage a situation [54]. Crucially, the midwives’ expert practice was not about ‘normal birth at any cost’ [55] but about creating the conditions to maximise the chances of a (wanted) physiological birth and to centre women as the primary decision maker (irrespective of the final mode of birth). For example, the midwives demonstrated careful planning either prior to the birth with antenatal care planning or during birth, whereby ongoing clinical assessments based on a firm grounding of the normal parameters were held in conjunction with what birthing women or people needed (emotional safety being prioritised, see Chap. 3). This included occasions where care plans required a pivot, such as recommendations to transfer from a homebirth for medical support. The midwives demonstrated expert practice across a wide range of ‘out of guidelines’ birth choices. As seen in Chap. 1, the birthing decisions included those just a ‘nudge’ outside of guidelines such as healthy women declining an aspect of routine care (induction for prolonged pregnancy,18 augmentation to speed labour, antibiotics for ruptured membranes); and those with complex pregnancies (medical or obstetric

 Isolated readings or assessments may be misleading on their own, therefore, the skill is to retain contextual information throughout and use all the information to guide clinical care. For example, raised maternal heart rate may signify emerging infection or may just reveal the work of hard labour. 18  Although, given the current climate around inductions, this may now be perceived as a ‘radical jump’ outside of guidelines. 17

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conditions)19 seeking midwifery-led care and/or midwifery-led birthplaces (such VBAC at home or someone with gestational diabetes using a birthing pool). Central to the cultivation of expert midwifery practice was extensive exposure to physiological birth in all birthplace settings along with supportive teachers or mentors— which cannot be underestimated. Downe, Simpson & Trafford [54] carried out a metasynthesis to define expert intrapartum maternity care, drawing on seven papers they identified three core concepts; wisdom, skilled practice and enacted vocation which were fundamental to this expertise. Wisdom was based on a combination of education, ongoing intellectual curiosity, embodied and theoretical knowledge that accumulated with an acceptance of uncertainty. Skilled practice was a combination of reflexive competence (anticipatory, preventative and responsive), confidence (including when not to act), judgement and clinical skills (to retain ‘normality’ and manage emergencies and also included emotional intelligence and technical skills). Enacted vocation consisted of the values belief, trust, courage, intuition (supported by clinical skills) and connected companionship—‘being with’ the woman.20 The study participants reflect this definition of expert intrapartum care and extend it across the childbearing continuum. The remaining section breaks down expert midwifery practice into five core components, knowledgeable, technical, proactive, responsive/adaptable and intuitive. These are explored individually below; however, it must be acknowledged at the expert level these components become so closely intertwined it is challenging to separate and that a gestalt practice emerges [54].

Knowledgeable The study participants all demonstrated a firm grounding in theoretical knowledge—understanding the anatomy, physiology and mechanics of pregnancy, labour and birth; knowing the parameters of ‘normality’; and the deviations which require management and/or escalation. This underpinning knowledge base of what constitutes ‘normal’ and through understanding the mechanisms of healthy labour and birth, meant they were able to apply their knowledge to a wide range of different  Of course, in conjunction with the multi-disciplinary team (MDT)—the midwives in this study shared many stories of working constructively within MDTs, where there was mutual respect for each other’s knowledge and expertise—see [53, 56–58]. 20  Furthermore, the authors synthesised these three concepts explaining expert intrapartum maternity care [54]: ‘As the practitioners in our review became more expert, they appeared to (re)value and to express qualities such as trust, belief and courage, to be more willing to act on intuitive gestalt insights, and to prioritize connected relationships over displays of technical brilliance. This did not, however, result in denial of responsibility. On the contrary, in some of the accounts, the enactment of vocation led these experts to move outside of and beyond normative childbirth practices, and so to become more exposed to critique. Equally, while stepping back and doing less may seem to be less skilled than stepping in and doing more, Kennedy succinctly describes the expertise of enacted vocation in this way: ‘working to create an environment of calm, trusting in the normal birth process, and being present during labour may appear to be nothing, or inconsequential, but, in reality, it is likely to be very significant’’. 19

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clinical situations including those with medical or obstetric complexities. For most participants, their theoretical knowledge was informed by their university education, however, in addition they all reported a commitment to ongoing self-directed learning (accessing the latest research, being on top of changes in guidelines or policy, attending study days etc.) This proactive approach was characterised by a love of learning, acknowledgement that evidence or knowledge changes and a humility that learning never stops. Their theoretical knowledge base was coupled with embodied and tacit knowledge gained through practical experience of intrapartum care (in all birth settings).21 The midwives’ knowledgebase also included self-­ awareness of the gaps in their knowledge or limitations to their scope of practice which they actively addressed either by self-directed learning or through seeking support from medical specialists. Knowing one’s boundaries and limits in terms of scope of practice was also viewed as an essential component of safe, expert care: When I am with a woman I am looking after her, I am trying to give her the best experience that she can have… When I am in a room with a woman that is my role, you know. It is also knowing the boundaries, I would never (emphasised) put a woman or a baby in danger, and I if I think there is something is off, I would be the first one to call the medics in. That’s not a problem. You have to know your limitations as well… (Seana)

Implicit to the midwives’ approach was a recognition of the ‘unique normalness’ [59] of each labour/birth which meant they were able to suspend their ideas of how pregnancy/labour ‘should’ go (according to the textbooks or guidelines) and be present to what was unfolding in front of them. This approach was informed by a willingness to learn from each woman they cared that continually challenged any preconceived ideas of what labour and birth should look like: I am not sure how many of those midwives would have actually seen what an undisturbed labour looks like, cos it doesn’t look labour in the books, and it doesn’t follow the same, it’s got its own kind of rhythm… It’s only something in the past few years that I have really got to grips with and observed cos the way I learnt was you know ‘a contraction should be coming this often and this should happen and then this should happen’ and actually when you sit back and watch and just hold that space and have that buffer between you and your actions you’re like ‘ok, ok this doesn’t look like it does in the book but is it all ok? Mum’s alright, baby is alright okay, well let’s just sit back for a while’ and then you see something different and you’re like ‘oh god wow she’s had a baby and she didn’t, but she missed this bit, she didn’t do that bit!’ [correspond to textbooks] (laughs) that she’s supposed to do! this is my book!’ (laughs) but if you have only worked in a way that follows this kind of strict set of rules that labour should happen and if it doesn’t then well something is wrong so we must have to start syntocinon, we must have to break her waters we must have to, we must have to do something. When you stop that need to be doing something, if you have only ever worked in a way that you just do things if it doesn’t look like it is happening properly, then I don’t suppose they have ever seen—that it [birth] does just happen. (Susan)

 Several of the participants had midwifery experience in extremely rural areas such as the Australian Outback, others had worked in caseloading models in their earliest introduction in the 1990s, others had been community midwives for many years which consolidated and advanced their expert practice due to these working contexts. 21

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These midwives leaned on their theoretical knowledge as a heuristic model for care (not as rules) and embodied knowledge to both stay alert to the wide variations of ‘normal’ that did not require intervention or action or in other cases respond to a seemingly unexplainable need for action (explored in ‘intuitive’). Thus, expert midwifery practice was holding the space of uncertainty and the ability to apply different rationales (knowledgebases or evidence) to different contexts; i.e., the application of knowns to ‘unknowns’ which is also called ‘interpretative practice’ [33]. This involved looking at the ‘whole picture’ which emphasised the importance of understanding context when making clinical assessments. This included not assuming that ‘low risk’ healthy women would be free from complications—‘actually I am more worried about a primip having a long long labour at a birth centre, than I am about uhm a multip who is having her fifth baby with a BMI of 35 by far’ (Anna). It also meant that midwives used their knowledge and clinical judgement/discernment when assessing potential ‘risk’. For example, Alice, demonstrated a systematic approach when assessing potential concerns, drawing on a wide range of knowledge, whilst remaining supportive of the woman’s decision to have a homebirth: [attending an unexpected homebirth with a woman who was 43 weeks pregnant] but yea it was fine cos I looked at the scans everything was normal, she measured normally, she was labouring as a normal would, there was no mec [meconium] so there was nothing, she didn’t palpate big so no immediate concerns that there was something wrong, it was just that she was quite far postdates. So if you took that out of the situation, she was low risk, there was no other risk factors going on, there was nothing else in her care. It was just that [the postdates], I did ask her if they’d changed her dates on the scan, cos I know that happens but actually no they hadn’t so this was just, but she said her own mum had gone to 43  weeks as well and you think well probably that’s her normal gestational period isn’t it?… (Alice)

Proactive The midwives demonstrated proactive knowledge seeking behaviour and it was fundamental to their practice. This included the willingness to access a wide range of evidence sources, the ability to assess the quality of that evidence and the ability to apply the (wider sources of) evidence to the individual in their care. Whilst evidence-­ informed/evidence-based practice is a key tenet of professional practice [60, 61], the midwives observed their practice stood out in comparison to their peers who largely relied on their local guidelines to inform birth conversations and clinical care recommendations: … I think you have to be a particular type of person to be able to firstly, be able to do it [read and understand research papers] and secondly have the will to do, the number of people that have said to me they don’t know how I can sit there and read a paper and then apply it… (Edna)

The midwives used their knowledge gained from a wide range of sources to inform their antenatal discussions and care planning with those seeking alternative

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physiological birth care. Being proactive in the antenatal period was viewed as the ideal time to have meaningful woman-centred discussions, where together, they could discuss a wide range of options, the risks and benefits of each option. Additionally, this created the time and space for follow-up discussions where needed. Moreover, the antental period was opportunity to discuss contingency plans should labour or birth not unfold as desired. This meant the midwives helped birthing people to retain control by considering all possible scenarios (transfers, induction, augmentation, instrumental or caesarean births etc.), and was an opportunity to discuss genuine clinical indications to action and what the women would prefer, should those occur. Factoring all of this information the midwives would co-create care plans based on ‘non-negotiable’ aspects of care and what would be acceptable in these different potentialities. In this way, the midwives enacted genuine supported decision-­making [62], which was viewed as a central role of the midwife (see Chap. 2) and was a way to demonstrate commitment to maternal autonomy and a trust seeking activity (highlighted in Chap. 3): [caring for a woman who had pregnancy induced hypertension and a traumatic induction with her first baby] She was advised by the consultant to have an induction at 39 weeks due to her age and was put on an anti-hypertensive for her high blood pressure… Following her previous traumatic birth experience… she was keen to avoid birthing on labour ward and wanted as natural a birth as possible. However, when I met her, she was very anxious and felt pressured in to doing what the consultant advised. We talked in depth about her birth choices. We discussed that it was her informed decision, and that as health professionals we can advise based on research, experience, guidelines and policies, but at the end of the day she had the final say. Our job is to support her in whatever informed decisions she makes, as it’s her body and her birth. She is an autonomous individual. We went through the research and guidelines regarding her age and risks. We talked about her previous birth, and she was tearful and emotional when discussing it…. She talked about feeling abused during her previous birth and that she was scared that it would happen again. I then booked her to see the Supervisor of Midwives and Consultant Midwife. They were very kind and supportive. Together we made and individualised care plan for her to give birth at home or on the Midwife-led Birth Centre. We took in to account her risk factors, personal preferences and that a medicalised environment could potentially affect her BP, asthma and anxiety. We discussed transfers to labour ward and contingency planning if observations became abnormal in labour and made a plan for induction at 41/40. She felt so much more relaxed and in control, because she had made the plan for her own care with supportive, experienced care providers. She went into labour at 40+3 and had a long but calm labour and birth at home. Her blood pressure stayed nice and low and she felt in control and supported. Baby came out in excellent condition and… she was delighted and so happy that she had had the birth that she wanted. (Jess)

Proactivity was also related to pre-empting possible risks and/or in considering the skillsets either of themselves or the attending midwives. Birth planning in the antenatal period gave the opportunity to instil safety measures where needed, these included educational activities regarding potential obstetric emergencies, ‘skills n drills’ or refresher days and/or setting up specific on-call teams with midwives with the appropriate level of experience or expertise. Collectively, the proactivity demonstrated was a tool for preparedness and anticipation which are core components of new thinking in safety [63, 64]. This was not viewed through the lens of anxiety or expectations for

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birth to go ‘wrong’, rather, this was the ‘work’ involved in creating safety at all levels, and included considerations for the psychological safety of midwife caregivers that may not have been involved in the care planning.22 Moreover, preparedness and anticipating possible events were a core component of ­intrapartum caregiving with the midwives staying alert to any clinical situation and where needed, subtly preparing the birth space just in case support was needed, e.g. having drugs and equipment ready for someone who had a previous haemorrhage23 or having the resuscitaire outside the room where there was more likelihood of a baby needing help following birth etc.

Technical Hands-on technical midwifery skills are essential to expert midwifery practice and the study participants demonstrated high levels of advanced competence in these practical skills. These skills ranged from everyday measurements and monitoring technicalities to core midwifery technical skills such as abdominal palpation, vaginal examinations, neonatal resus and suturing etc: I am pretty good at that [neonatal resus] I like suturing, I am weird like that. So, I am quite confident to being able to do the complete care at home and am quite often called in to do the suturing if somebody is finding it tricky. Or sitting, if a woman doesn’t want to get on the suturing bed [e.g., at birth centre or hospital], I am so used to doing it at home, I can do it on the floor and things like that. (Stella)

The midwives also shared their skills for optimising the physiological processes of labour and birth which they applied to all birthing women or people, irrespective of their health or risk status. For example, ‘normalising the abnormal’ referred to providing midwifery-led skilled care and optimisation techniques to women with so-called high-risk pregnancies such as women labour in hospital with syntocinon running, a CTG attached and an epidural in situ: I’ve also always been a birth midwife. It became clear early into our training that some students are attracted to birth, and others not so. I thrived on birth, loved working a labour to achieve normality from higher risk or abnormal scenarios on delivery suite—getting

 In many situations, the study participants were not caseloading midwives so their care plans needed to be used to support other midwifery caregivers to understand the conversations, the informed decision-making by the women and to provide structured support/advice to those caregivers should labour/birth does not go as planned—for more information on ‘care plans as tools’, see [56]. 23  Many of the midwives reported being routinely ‘organised’ when attending to women during labour/birth. For example, arriving at a homebirth and preparing all equipment for the birth, a baby resus area and drugs/equipment in case of a postpartum haemorrhage etc. was seen as both a signal to the homebirthing woman that the midwife was really ‘there’ and present to support the homebirth and a way of being prepared for any eventuality—thus was a safety mechanism. Being organised and preparedness also helped the midwives to be fully present during intrapartum care, knowing they were equipped (literally and metaphorically) to deal with the clinical situation as it arises. 22

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4  Moving from a Rule-Based Practice to Expert Clinical Midwifery Practice women off beds (on occasions with epidurals), using mats on the floor, use of birthing stools etc… (Stella)

The midwives actively sought out opportunities to learn and hone their skills in a variety of circumstances. This proactive approach to honing their skills was deemed a central component of authentic midwifery care and of course, crucial for safe care. However, advanced technical skills included the discernment of knowing when to use a skill and when not to: I don’t do admission VE’s [vaginal examinations] routinely… so I don’t routinely do that, but if a woman asks specifically for an examination then I will do one, if there are things [warranting a concern], maybe, it just depends on the situation, but I don’t personally think a VE says much about a labour, it tells you about a snapshot in time but it does have an awful lot of connotations for the care of the woman… when you need these clinical tools and they are beneficial in lots of situations, but it’s about using them judiciously really… (Katie)

The ability to stand back, hold the space, with readiness and the skill to act if needed, is known as ‘watchful waiting’ [65] and is an advanced technical skill [54, 66]. In this way, the midwives held a ‘never say never, never say always’ attitude to their care which signified their understanding that some midwifery or obstetric-led interventions, when timely and appropriate, can avert or manage a complication but when used routinely, are either unnecessary or problematic. Therefore, expert midwifery practice honoured a judicious approach to care and most importantly the capability to deal with unexpected clinical situations: But I think skills as a midwife, watching and waiting, yea I think I have confidence in that and I am fairly confident about reading a labour, of course there are always ones where women are getting on and you don’t think they are or vice versa. And… if you have got mec at a birth, or a low heart rate we deal with it at the time, that’s what we’re good at as midwives dealing with things at the time, that’s what we’re paid for and certainly that’s what we’re there for at a standalone unit, to deal with things there at the time… You do the best you can at the time and you prepare for the best and then if it doesn’t, you do something about it… … (Stella)

Responsive and Adaptable Closely intertwined with the midwives’ technical skills was their ability to be responsive and adaptable to individual women’s needs and changing clinical situations—they were ‘agile practitioners’. As the participants have highlighted it is a midwife’s job to have the skills that are adaptable so to provide safe, appropriate clinical care. As identified earlier, this is embedded within the role and definition of the midwife, is the basis of international educational and regulatory frameworks, but clearly in these accounts the midwives are demonstrating expertise within their practice. Being responsive and adaptable was evidenced across a range of scenarios. In some situations, this is related to supporting women to make (and change) their antenatal care plans. For example, Kerry was supporting someone with a

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blood-borne virus to access midwifery-led care at hospital, but through further conversations with the consultant midwife, the woman decided to birth at home. The team adapted to the decision to support the woman: yea I think, we have, we are really lucky here as we have a specialist midwife for women who birth outside of the guidelines and I think she [the woman] was just feeling quite ­overwhelmed by the whole process because she just wanted to have her baby but there was so much surrounding her bio status and everything, which was very well controlled. She came along wanting a pool birth in our home from home room and it ended up with her having a homebirth. I think that was just speaking to X [consultant midwife] that she realised ‘actually I don’t even want to be here, I want to be at home’ so then she contacted us, our team were quite well known for homebirths, so yes she contacted us and then we discussed it at our team meeting and out of us six, five of us were ‘yep we’re take this, of course we’re having her’ and just one midwife was hesitant and a bit anxious about her being at home and everything and then myself and my other colleague were assigned to her and we went and met her and clicked right away. So it was just like a total blessing that day she went into labour, we were both on call… she was just so strong, it was so calm in there, her partner was there… it was just really really lovely, and yea a beautiful birth in the living room, and then the placenta… it was just wonderful. Yea, yea it was really emotional cos she kept saying that since her diagnosis her life has been really medicalised and sterile… yea she was pleased to feel like a normal woman.

In some situations, clinical judgements were made to not carry out ‘routine’ interventions such as vaginal examinations based on the way the individual woman’s labour was unfolding such as observing external signs of progress. Such discernment was responsive to the individual situation but with the readiness (and skill)24 to use an intervention should it be wanted/needed. Similarly, some of the midwives significantly adapted their practice based on explicit instructions from women. For example, Maria cared for someone at home who did not consent to any direct clinical midwifery care and who laboured and birthed in the dark. Once the baby was born Maria, respecting the woman’s wishes to remain in the dark, relied on her other senses to consider maternal/neonatal wellbeing such as listening for normal maternal breathing (increased respiration could indicate heavy bleeding) and was reassured by the baby ‘snuffling at the breast’ as a sign of neonatal wellbeing. Drawing on her knowledge base and advanced technical skills, Maria could adapt her care to support this woman in this unusual circumstance. Similarly, other midwives had the ability to perform technical tasks in different ways in response to women’s needs such as performing vaginal examinations in different positions so to minimise retriggering trauma: … if it is something like you mention, the no vaginal examinations if it is something to do with trauma in the past that has happened to her, [then] it’s making her aware that if she says to stop that you will stop immediately, and sometimes it can be different positions or something like that, we’ve had a lady before who didn’t want an examination because she didn’t

 The midwives ‘could’ do all the necessary technical tasks, but here they demonstrate the skill and discernment of knowing when to or when not to carry out a task. This is different to unskilled professionals avoiding technical care because they are not competent. 24

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4  Moving from a Rule-Based Practice to Expert Clinical Midwifery Practice want to lie down but she was quite happy for the examination to be done on all fours so it’s trying to reach that compromise where you’re at a level that you’re both happy with. (Claire)

Furthermore, the midwives demonstrated responsiveness to emerging clinical concerns during labour and birth, but crucially retained woman and person-­ centredness when recommending and/or actioning necessary medical care. In some situations, the midwives honoured women’s decision to decline emergency care, and whilst in extremely challenging situations, the midwives maintained their respect for maternal autonomy. In other situations, the midwives shared insights into how they maintained dignified care when some recommendations were accepted, and some were not, and provided supportive adaptable care. This also included supporting women’s decision-making for interventions such as caesareans births and not cajoling them to continue with labour: [caring for a first-time mum declining postdates induction of labour at home] She laboured at home and the birth was attended by a SoM [senior midwife], myself and another midwife, her progress had slowed, and the leading midwife offered an ARM [artificial rupture of membranes], again we discussed the possible risks. She consented, upon ARM she remained at 8 cm and there was thick meconium. As we had previously discussed this as a potential outcome, we prepared for transfer. During transfer she requested to use the pool, I said I would discuss this with the coordinator. Upon arrival the coordinator was not keen for this to take place, even though we had discussed the risks, both she and the consultant came and discussed the risks, but she was still keen to use the pool with our wireless monitoring. I ran the pool and she got in and kneeled down, she experienced two contractions and decided she didn’t want to be in the pool. So she stood knee-deep going forward, upon the next VE, she was 8 cm, we discussed syntocinon use and she was adamant she did not want this course of action, throughout all of this the fetal heart was normal. After a lot of discussion both she and her husband made their decision, they would not consent to synt, they would rather a caesarean section. (Ginny)

Intuitive Expert practice across disciplines has consistently demonstrated that at an advanced level of clinical practice—observations, decisions and actions often occur at an intuitive level [42, 54, 67]. Intuitive practice is borne out of extensive experience, tacit knowledge combined with theoretical knowledge and is typically reflected in speedy decisions that on the surface appear to lack explicit rationale but are underpinned by ‘mindlines’ [68, 69]. Whilst intuition alone does not make expert practice due to the potential of unconscious biases/fallacies, when combined with extensive experience, knowledgeable practice and the appropriate technical skills, intuition was a powerful allay for the midwives in this study: I think it’s about knowledge actually isn’t it? It’s about understanding what the warning signs are, the subtle signs, being intuitive, listening to the women, because I have looked after a couple of women who had uterine ruptures and a lot of the time it is the woman who is telling you that something is not quite right… I think it is really about homing in your midwifery skill. (Jenny)

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The midwives often reported listening to their ‘gut’, an inner knowingness that all was well or crucially, that something might be ‘off’: the only example I can possibly give [of being uncomfortable with a birth choice], it was a homebirth, someone I hadn’t looked after her antenatally so I wasn’t facilitating her choice [antenatally], but she was out of guidelines, but she had a raised BMI choosing to have her baby at home, her situation was almost identical to mine so there was absolutely no reason that I should feel uncomfortable with that situation, but I did. I felt uncomfortable throughout the entire labour, something didn’t sit right, something didn’t feel right and then the next morning when it was time to handover, rather than handing over to the relatively newly qualified midwife I actually rang two other midwives who were team leaders, and asked them to come and take over from me, because I just felt that something wasn’t quite right and after that baby was born it went straight to cooling after really crap cord gases, no indication in the labour of anything being wrong at all and baby had quite a significant hypotonia but without any HIE, they think there was some fundamental underlying issue with the baby that happened antenatally or chromosomal, but certainly something that happened before. And yea she was the only one I didn’t feel comfortable and bizarrely really felt that there needed to be senior people at the birth… (Amy)

Central to intuitive practice were two important factors; first, watchful waiting (or known as watchful attendance) described earlier, whilst seemingly a non-active state, is in fact a highly alert state of attunement to the labouring woman [65]. With the midwives are not ‘busying’ themselves through ‘doing’ they are attentive to the subtle cues of wellbeing or pathology, using all their senses to account for ongoing holistic (risk) assessments: I had another woman who had an abruption once and it was a girl who was labouring during the day and she’d had a previous section and I don’t know where her husband was, I think he’d gone to the shop to buy some biscuits, he’d been around but had popped out and she was labouring in her front room leaning over a birth ball and all of a sudden she said to me, ‘oh I can feel some pain’ and she bled, she bled about 30 ml and I thought ‘that’s not normal’. She wasn’t, she wasn’t obviously in that stage of labour where I’d think ‘oh great it’s a show’ it was fresh red blood, so I thought right I am calling an ambulance now, and it was just one of those fortunate days you know, an ambulance came, we got her into hospital and then she popped out 1500  ml of blood, so we got her into theatre. But she had told me immediately, she told me that what she was feeling, she didn’t describe as anything other than pain and it wasn’t right, you know? I just think, I do love listening to women, because they tell you everything… Ah yea you know, it is simple but you don’t often get the opportunity, maybe if her husband had been around and they’d been chatting or you know doing something else maybe I wouldn’t have heard that, but it was just me and her, she could tell and I could hear it, I just think it’s so clever, really clever [women’s bodies] (Maria)

Second, an integral part of intuitive practice is genuinely listening and trusting women. This was viewed as vital to the provision of safe care, where the midwives frequently asserted how much women themselves will reveal consciously or subconsciously throughout their labour and birth. The skill was to be alert to either subtle signs, e.g. women reporting something ‘just being a bit off’ or overt statements of concerns but where there were no clinical indications of emerging

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pathology. Both situations could be viewed as problematic for the novice,25 as without firm ‘evidence’ that there is something wrong, women’s concerns may be dismissed or ignored. However, for these midwives, expert practitioners, they were not only alert to these cues but were ready to act on them despite a lack of specific clinical evidence: you know that’s the interesting thing is women know, and I know when I had, for example, VBAC’s or women with other things going on, if there is something going on in the labour they know sooner than I do and they’ll tell me if I listen to them. I had a woman once who phoned me up in the middle of the night, it was her third or fourth baby and she phoned me up to say she was niggling, but she said ‘something’s not quite right’ and I said ‘look I’ll come out’ so I went out, but on the way interestingly enough when I went out to her I came by the hospital and picked up some ergometrine and we don’t normally carry it, we just carry syntometrine, but I thought ‘I’m going to get the ergometrine’. I went out to her …I got to her, it was light but not bright and I set everything out to be prepared so I put my bag out, drew up my drugs and her husband had gone down to make a cup of tea and she was leaning over a chest of drawers and she said ‘oh Maria’ and then she SROM’d [waters ruptured] and I looked over at thought ‘bloody hell that’s a lot of mec [meconium]’, it was dark dark brown and it was blood, she’d had an abruption and I thought ‘oh my god’ and she knew something wasn’t right and that’s what she told me earlier, so I laid her down and luckily she popped the baby out there and then, at the same time pretty much, it was really really lucky. And I thought, the thing that made me think she knew something wasn’t quite right, what was interesting was that I’d gone to pick up the ergometrine, because I hadn’t really processed that at the time, I hadn’t thought ‘oh my god I’m going out to something that’s not quite right’ all I thought was I’m going to go out and see what’s going on but I’ll just go via the hospital, how strange is that? (Maria)

The midwives also acknowledged the importance of self-awareness and reflection above relying on intuition alone which was to safeguard against possibly projecting their own fears or anxieties onto a situation, particularly for those birthing choices they had less experience with. This provided emotionally intelligent ‘checks and balances’, seeking to avoid an overreliance on intuition alone, and meant they continued to draw upon their other expert clinical skills. Additionally, the midwives demonstrated cognitive skills when weighing up different circumstances that might be of concern (or not), combined with listening to women, really listening, demonstrates an expert approach: Uhm I am not sure about how to put that into words… our bodies tell us more than we necessarily hear I don’t know I think if you know or feel something is right, it probably is, my mum went to 43 weeks with me and my brother because she didn’t want to be induced, and my family history suggests that that’s a normal gestation for us, so postdates don’t tend to worry me so much, but if I had a woman who was 38 weeks who was already getting anxious the baby being born, and it may be innately that her body is telling her something is not quite right… I just think we need to hear what a woman is saying to us. (Alice)

25

 And/or for those overly reliant on a ‘rule-based’ practice.

4.4  Safe Care Is Not Routinised Care

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4.4 Safe Care Is Not Routinised Care Earlier in this chapter, we explored the problem of a routine or rule-based approach to midwifery care. A rule-based approach not only undermines the concept of professionality but does not provide the opportunity for midwives to work to the fullest scope of their practice and/or provide personalised care for birthing women and people. Viewing rule-based practice in light of the expertise the participants displayed, critical insights into the benefits of expert practice are illuminated. However, the cultivation of expertise is both an individual responsibility and a systems responsibility (explored further in Chap. 5) which will need radical reconsideration to redirect this increasing cultural shift towards more ‘rules’. This is important because the five core components of expert practice that the midwives demonstrated (knowledgeable, proactive, technical, responsive/adaptable and intuitive), when viewed within a holistic safety lens, offer a robust safety net around birthing women and people. As discussed in Chap. 3, new thinking in safety is moving away from merely ‘the absence of harm’ to consider safety as the ‘presence of something’ [63, 64]26 which includes capacity and capability, the presence of learning, responding, monitoring and anticipating possible outcomes. The midwives with expert practice are the ‘presence of something’ who embody a learning, responsive, monitoring and anticipatory approach. This does not mean there is no place for standardised approaches (useful to consider equity to access to care and reduce unwarranted variations) or guidelines (useful aide memoirs for busy clinicians) but as seen in this study, should safety be a goal, then it requires much more than checklists, tick boxes and rules—it needs expert practitioners who centre the individuals in their care and who work within enabling environments [1, 2, 13, 54]. Central to the midwives’ expertise was their desire and commitment to gain experience in physiological birth care. Whilst other studies (previously mentioned) have found many midwives are fearful of intrapartum care even for healthy ‘low risk’ women, these midwives were not. They demonstrated high levels of experience, skill, competence and confidence in their physiological birth skills which they were able to apply to out of guideline birth choices. This was partly explained by their personal motivations or philosophy (Chap. 2), actively seeking to develop their skills and competence, and extensive exposure to non-obstetric environments. Repeated exposure within supportive environments has been found as a key facilitator for midwives to develop confidence and competence [49–52]. Extending this further, the study participants could apply their knowledge of healthy women to those with complications to support their birth choices. Crucially, this involved working in liaison with multidisciplinary teams, seeking medical input as required. Therefore, another component of their expertise was recognising their limitations, either from a knowledge perspective or boundaries to their scope of practice. However, again, repeated exposure to women with complicated pregnancies appeared to broaden their experience and enhanced their skill sets [49–52]. In this  Dr. Gabor Mate, physician, trauma and addiction expert advocates ‘safety as the presence of connection’. 26

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context, the midwives acknowledged that their experience gave them a different perspective to others, therefore they advocated the importance of working with women to gain the necessary exposure and experience to constructively challenge fears around alternative physiological birthing choices: ‘[supporting a junior midwife supporting a woman having a VBAC at home] I think it’s different when you are in the room with the woman, I think when you just see the woman’s statistics like when you see someone who is VBAC homebirth, it is very easy to look at that and think what a terrifying and a dangerous thing, but I think when you’re actually with the person, when you’ve read all the notes and when you’ve spoken to them and realise that they’re not, they’re not mavericks who are just going to homebirth at any cost. But she said ‘if the baby is happy and I’m progressing well then I want to stay at home’, I think it does change your perspective on it. I think if I’d been one of those managers just looking and going ‘oh god’ and seeing that the second midwife was quite a junior midwife I do get where their angst came from over that.’ (Alice)

4.5 Cultivating Self-Awareness: Exploring Our Experiences of, and Exposure to Physiological Birth Self-awareness is an essential characteristic of emotional intelligence [70] and crucial to skilled heartfelt midwifery practice. Such self-awareness, in relation to this chapter, provides an opportunity to pause and reflect upon our experiences of birth so far. This may include our personal experiences of birthing babies, or our family and friendship circles, and of course our experiences as students and professionals. Reflecting on our experiences, taking the time to consider the views and beliefs we hold is vital as this will influence how one approaches supporting alternative physiological births (and indeed physiological birth more generally). As this book has shown so far, the level of support birthing women or people receive in relation to these birth choices is dependent on their caregivers—women’s ability to assert their agency and get their needs met can be influenced positively or negatively [71]. Such influence may be related to the midwives’ personal philosophy of childbirth [72], personal experiences of birth [73], or professional experiences of birth [67], skill sets [74, 75], perceptions of risk [71, 76] or how they value women’s autonomy [77]. However, as explored throughout the study participants’ accounts, midwives’ views, attitudes and philosophies are not necessarily fixed. These can change or evolve when exposed to authentic midwifery practice, observing true physiological birth, and when we are willing to walk alongside those in our care. For James, as a nurse before becoming a midwife he explored the ‘unlearning’ and ‘relearning’ he needed to work through which marked a shift from a disease model to a social model of care. However, his extensive experience as a nurse meant he had advanced skills when caring for those with medical complexities and through an active process of learning from women, and walking alongside them, he found a new niche of supporting so-called ‘high-risk’ women to have midwifery-led care:

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I think, I was an 18 month conversion to midwifery, I came from a really high-risk background, I’d never done any gynae or obstetrics and my nursing was cardiac surgery, I was a sister at that level so I was very high risk, when I decided to go into midwifery I really struggled with the normality, it took me a long time to break down that I’m not a nurse now, I’m a midwife and you know I’ve got to change the way I am thinking and I think it probably comes from that, it took me a long time to get my head around being confident to go out, to you know be the midwife who would go and support these women at home, I think partly the reason why my position changed on it was when I was, I ended up going into the high risk team like the diabetics, epileptics, we’d provide intrapartum care to those women in the hospital but then a lot of those women started to choose homebirths when they were type 1 diabetics so it would us to go out to them, once I got past that fear and started going out and providing that support to them and understanding their thoughts and vision as to why they didn’t want to be in hospital and why they felt even though they had a medical condition, they still felt their pregnancy was normal and therefore they should birth in the way they wanted to. I think that’s where it [supportive of women’s choices] comes from…I really listened and took on board what they were saying, I think it’s a challenge for a lot of midwives to think yea epileptic woman at home, but providing the intrapartum care to those women is where you get your skills up.

4.6 Conclusion Having explored and challenged the limitations of a ‘rule-based’ practice that has become increasingly common in many countries, this chapter has demonstrated the importance of expert midwifery practice in the provision of safe care. Expert midwifery practice is based on intertwined components of knowledge, proactivity, technical skills, responsivity and adaptability as well as intuition. Here, the sum is certainly greater than its parts. When midwives are encouraged to move beyond the novice/advanced beginner stage they can cultivate expertise that lends itself to the science and art of midwifery practice. Not conforming to a rule-based approach meant that the midwives took a proactive approach to their learning, acknowledged the limitations of their knowledge or scope of practice, as well as demonstrating advanced competence in their technical skills which included the critical skill of knowing when to intervene and when not to. Expert practice was demonstrated to be thoughtful, flexible and agile with strong threads of holistic safety measures throughout, therefore expert practice is safe care. This chapter has captured the midwives’ embodiment of professional practice which means to take ownership, responsibility and accountability for their clinical care and decision-making. The next chapter reintegrates all components of skilled heartfelt midwifery practice to explore what midwives need to practice this way.

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Personal Reflective Activity

Having reflected on your feelings around alternative physiological births in Chap. 2 and the importance of emotional safety in Chap. 3, here is an opportunity to take a self-inventory of your clinical skills. Using the five components of expert practice (knowledge, proactivity, technical skills, responsivity and adaptability, intuition) take one at a time and free write some thoughts about where your strengths are and where need some further development. Try not to judge or analyse what you write as self-honesty is key. Once you finish that for all five components, reassess what you have written, are these accurate, would your colleagues suggest the same strengths and weaknesses? This is to avoid the tendency of being our own worst critics! Once you feel you have an accurate appraisal of your strengths and weaknesses can you devise a plan to: (a) Share your strengths with others? For example, can you proactively seek students to work with so to help them learn from you? Can you find a way to share your strengths with other colleagues, perhaps you have advanced expert skills in waterbirth, could you put on a teaching session or find a way to share your expertise? (b) Overcome those weaknesses? Can you brainstorm what you need to do, action or gain experience in to help strengthen these weaknesses? Could you identify a colleague who has these skills who could help you improve? Can you volunteer to work in a different setting to gain extra skills?

Further Resources 1. Case studies—see Chap. 6. 2. For all things related to physiological birth—see Dr. Rachel Reeds website which includes courses and ongoing blog all around the physiology (and cultural contexts of practice)—https://www.rachelreed.website/ 3. For midwifery-led interventions to correct deviations of labour, see Molly O’Brien’s website and courses which centres biomechanics—https://www. optimalbirth.co.uk/index.php/about 4. To enhance learning around the value and importance of birth centres, particularly in relation to optimising physiological birth, explore the Midwifery Unit Network website—https://www.midwiferyunitnetwork.org/

References 1. Renfrew M, McFadden A, Bastos M et al (2014) Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care. Lancet 384(9948):1129–1145. https://doi.org/10.1016/S0140-­6736(14)60789-­3 2. Renfrew M, Malata A (2021) Scaling up care by midwives must now be a global priority. Lancet Glob Health 9(1):e2–e3. https://doi.org/10.1016/S2214-­109X(20)30478-­2

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62. Begley K, Daly D, Panda S, Begley C (2019) Shared decision-making in maternity care: acknowledging and overcoming epistemic defeaters. J Eval Clin Pract 25(6):1113–1120. https://doi.org/10.1111/jep.13243 63. Hollnagel E, Wears RL, Braithwaite J (2015) From safety-I to safety-II: a white paper. The Resilient Health Care Net. https://www.england.nhs.uk/signuptosafety/wp-­content/uploads/ sites/16/2015/10/safety-­1-­safety-­2-­whte-­papr.pdf 64. Verhagen MJ, de Vos MS, Sujan M, Hamming JF (2022) The problem with making safety-II work in healthcare. BMJ Qual Saf 31(5):402–408. https://doi.org/10.1136/bmjqs-­2021-­014396 65. de Jonge A, Dahlen H, Downe S (2021) ‘Watchful attendance’ during labour and birth. Sex Reprod Healthcare 28:100617. https://doi.org/10.1016/j.srhc.2021.100617 66. Feeley C, Crossland N, Betran AP, Weeks A, Downe S, Kingdon C (2021) Training and expertise in undertaking assisted vaginal delivery (AVD): a mixed methods systematic review of practitioners views and experiences. Reprod Health 18(1):92. https://doi.org/10.1186/ s12978-­021-­01146-­3 67. Daemers D, van Limbeek E, Wijnen H, Nieuwenhuijze M, de Vries R (2017) Factors influencing the clinical decision-making of midwives: a qualitative study. BMC Pregnancy Childbirth 17:345. https://doi.org/10.1186/s12884-­017-­1511-­5 68. Gabbay J (2016) Mindlines: making sense of evidence in practice. Br J Gen Pract 66(649):402–403. https://doi.org/10.3399/bjgp16X686221 69. Wieringa S, Greenhalgh T (2015) 10 years of mindlines: a systematic review and commentary. Implement Sci 10:451–411 70. Goleman D (2004) Emotional Intelligence. Bloomsbury Publishing, London 71. Coxon K, Chisholm A, Malouf R, Rowe R, Hollowell J (2017) What influences birth place preferences, choices and decision-making amongst healthy women with straightforward pregnancies in the UK? A qualitative evidence synthesis using a ‘best fit’ framework approach. BMC Pregnancy Childbirth 17:103. https://doi.org/10.1186/s12884-­017-­1279-­7 72. Thompson FE (2003) The practice setting: site of ethical conflict for some mothers and midwives. Nurs Ethics 10(6):588–601. https://doi.org/10.1191/0969733003ne649oa 73. Church S (2014) Midwives’ personal experiences of pregnancy and childbirth: exploring issues of autonomy and agency in relation to the use of professional knowledge. Hum Fertil 17(3):231–235. https://doi.org/10.3109/14647273.2014.949879 74. McCourt C, Rayment J, Rance S, Sandall J (2012) Organisational strategies and midwives’ readiness to provide care for out of hospital births: an analysis from the birthplace organisational case studies. Midwifery 28(5):636–645. https://doi.org/10.1016/j.midw.2012.07.004 75. Walker S, Batinelli L, Rocca-Ihenacho L, McCourt C (2018) ‘Keeping birth normal’: exploratory evaluation of a training package for midwives in an inner-city, alongside midwifery unit. Midwifery 60:1–8. https://doi.org/10.1016/j.midw.2018.01.011 76. Houghton G, Bedwell C, Forsey M, Baker L, Lavender T (2008) Factors influencing choice in birth place: an exploration of the views of women, their partners and professionals. Evid Based Midwifery 6(2):59–63 77. Kruske S, Young K, Jenkinson B, Catchlove A (2013) Maternity care providers’ perceptions of women’s autonomy and the law. BMC Pregnancy Childbirth 13(1):84. https://doi.org/10.118 6/1471-­2393-­13-­84

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What Midwives Need to Provide Skilled Heartfelt Practice

5.1 Introduction The previous chapter explored the third component of skilled heartfelt midwifery practice—expert clinical skills. Such practice was demonstrated to consist of five elements, knowledgeable, technical, proactive, responsive/adaptable and intuitive, with the recognition at the expert level these elements are closely interconnected and the sum is greater than their parts. This chapter focuses on what midwives need to provide skilled heartfelt practice. First, this chapter will shift the lens from the skills, attributes and qualities of the midwives, to examining the wider workplace context to situate their wellbeing needs. As workplace is highly influential factor of whether midwives are enabled to provide such care, this is important to consider, especially given the work (mental, emotional, physical) involved when providing meaningful, personalised care. Then, the ‘ASSET’ model [1] will be presented; a model generated from the research findings features what midwives need to provide personalised care. The model attends to personal and system-level responsibilities offering further insights from the research and wider literature to help embed these principles into practice. In this context, this chapter closes the book with a call to system-level professionals to help make personalised care a meaningful reality for all. Safe, relational care cannot be contingent on an individual midwife, which risks a significant burden, but must be seen as a collective service level responsibility that must support midwives to support birthing women and people. When midwives are enabled to work to the fullest extent of their scope of practice, they are able to achieve the international policy drivers of safe, relational, and equitable personalised care.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. Feeley, Skilled Heartfelt Midwifery Practice, https://doi.org/10.1007/978-3-031-43643-7_5

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5.2 Midwives’ Wellbeing: A Crucial Component of Safe, Relational Care Globally, there is a shortage of 900,000 midwives with the greatest burden felt in low-income countries and Africa, with serious negative consequences for maternal– neonatal morbidity and mortality [2]. Midwifery shortages are also occurring in high-income countries and whilst recruitment is somewhat problematic more profoundly, are issues of retaining midwives once in the profession [2–5]. Issues of organisational and professional adversity are frequently raised as retention issues, i.e. shift working, heavy workload, bullying, staff shortages and poor-quality support are all associated with high levels of stress, poorer physical and mental health, increased sickness and staff turnover [2–5]. Within this growing body of evidence, midwives also cite emotional distress due to a conflict between their desire to prioritise woman-centred care and institutional demands pulling them away from the good quality, personalised care they wish to provide [3, 5, 6]. Such emotional distress was found in my study, where 19/45 participants, cited moral compromise, distress and even injury through practice-based stories of ‘feeling torn’, ‘battles’ and ‘reproach, recrimination and vilification’ [7, 8].1 Their experiences were bound by institutional constraints, unsupportive workplaces, and low valuing of their or women’s autonomy which created significant challenges and tensions when supporting alternative physiological births [7, 8]. Fundamentally, the 19 midwives’ philosophical approach to care was radically misaligned to that of their employing institutions and they reported significant stress, ostracization, and in some cases bullying [7, 8]. Whilst most of the participants stated the work they did and the meaningful relationships with women were protective factors that kept them in the profession,2 their skilled heartfelt practice came at a cost—mentally, emotionally, physically and even financially3 [7, 8]. Therefore, working in psychologically unsafe environments is not a sustainable practice and mirrors the retention issues already discussed. Given the UK’s policy drivers for equitable, personalised care for all [9], human rights legislation in favour of women’s bodily autonomy [10] and all national guidelines in support of autonomy [11–14]—it is vital to listen to the voices of midwives and the challenges they face when providing care aligned with policy, legislation and national guidelines. My previous analysis of why midwives face these challenges can be found in Feeley [8], but largely I, and others argue, it is caused by a complex interplay of sociocultural-­political discourses of medicalisation, technocratic, risk-adversity,  Important to note, that these issues were found in 19/45 of the participants, where 20 participants reported positive working environments and were enabled to provide good quality care. For the remaining six participants, they worked in roles as ‘change-agents’ mostly senior midwives tasked with changing the culture to one that was more woman-centred, therefore, they reported different challenges and positives. 2  With one exception who was planning on leaving midwifery at their earliest opportunity. For more on Leanne’s story, and the distressing punitive investigation that led to this decision see Feeley [7]. 3  Some of the participants managed the workplace stressors by working part time etc. 1

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guideline-centric approaches to care and institutionalisation that has shaped childbirth practices in the UK (and beyond). Moreover, these issues are also reflected in other high-income countries whereby midwives also face battles to uphold birthing women and people’s autonomy [15–20]. Ultimately, to turn these rhetorical ideals of upholding women’s human rights during childbirth into reality, the onus must be on the systems and the midwives’ workplace environments. Conversely, 20 participants in this study shared positive accounts of workplace environments where they were enabled to consistently practice skilled heartfelt midwifery [7, 8]. Their radically different experiences illuminate the recommendations from a recent King’s Fund4 [21] report that identified three core needs of nurses and midwives to ensure staff engagement, wellbeing and flourishing. These core needs are known as the ABC model [21];—autonomy—the need to have control over one’s work life, and to be able to act consistently with one’s values; belonging—the need to be connected to, cared for by, and be caring of colleagues, to feel valued, respected and supported; contribution—the need to experience effectiveness in work and deliver valued outcomes. Within this model, psychological safety is critical5 and these 20 midwives highlighted that their physchologically safe workplace environments met their fundamental needs to provide skilled heartfelt midwifery practice [7, 8, 21]. For these midwives there was an alignment between their values and their institutions; characterised by trust and respect with embedded support across the hierarchal structures, these positive workplaces created the conditions for midwives to find fulfilment in their roles [7, 8]. Such a positive impact was harnessed by consistently working within their values (A), a sense of belonging (B) and crucially, meaningful contribution (C)—all fundamental components of workforce sustainability [21, 23, 24]. In stark contrast to the other 19 midwives, these 20 midwives were unburdened by conflict and had a lessened mental and emotional load which allowed the midwives to not only get on with the job but to flourish [7, 8]. Therefore, within the same study, there were stark differences between the midwives’ accounts, with the workplace environment as the core mediating factor of these differences. This highlights the necessity of tackling improvements to maternity care through a systems approach. Organisations led by compassionate, collective leadership upholding the values of women’s autonomy, who trust their staff, perpetuate positive virtuous cycles of wellbeing and beneficial outcomes for staff and families alike [21, 25–29]. For example, staff wellbeing is directly correlated with patient/client outcomes and supportive, psychologically safe environments protect workforce sustainability [21, 25–29]. Whilst it was reassuring that this study found many organisations working

 The report centred on the longstanding issues of consistent and persistent healthcare workplace stressors, poor organisational cultures, working contexts and (good/poor) leadership as having a detrimental impact on staffing recruitment, retention and wellbeing [21]. Therefore, this report was based on the recognition that healthcare and its culture needed to be transformed, so they sought to identify what midwives (and nurses) need to deliver high-quality care. 5  Psychological safety was first defined by Edmondson [22] as ‘a shared belief held by team members that the team is safe for interpersonal risk-taking p.350’. 4

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in this positive way,6 all organisations must meet the King’s Fund ABC [21]7 criteria to ensure the needs of their staff are met. In maternity services, the wellbeing of midwives is a crucial component of safe, relational care and urgent action needs to address their concerns, to create enabling environments and to support midwives to work to the fullest extent of their practice.

5.3 The ASSET Model The mnemonic ‘ASSET’ was developed from across the research findings to highlight a) that midwives are the ‘asset’ for both birthing women or people and employers to provide safe, relational care; and b) situates what midwives need from an individual level across to the organisational level to provide skilled heartfelt practice [1]. The ASSET model (Fig. 5.1) mirrors the recent King’s Fund ABC model [21], previously mentioned, which identified for nurses and midwives to flourish they

Fig. 5.1  The ASSET model first printed 2019, published 2022, permissions gained  A reminder, the study participants were from different organisations from across the UK.  There was a similar report carried out by the GMC which generated similar findings to the King’s Fund. 6 7

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need autonomy, belonging and to provide a meaningful contribution within their work [1]. The ASSET model complements and extends this by centring the needs of midwives concerning the core tenets of midwifery practice. Whilst physiological birth is one component, the model can be applied more broadly to all birth choices because it is rooted in supporting the needs of midwives to practice autonomously. The ASSET model has since been used in clinical practice as a systems self-­ assessment tool, demonstrating research impact within clinical settings.

A: Autonomy and Access, Assess and Apply EBM Autonomy Autonomy is a core human and professional need. Van den Broeck et al.’s. definition [30] draws on Self Determination Theory to define autonomy as the need for volition, choice and psychological freedom when carrying out an activity. Moreover, autonomy is associated with self-integrity which is the ability to integrate our behaviour and experiences with our sense of self (values, beliefs, attitudes and philosophies as explored in Chap. 2) [30]. From my study, the midwives had variable workplace experiences; for those who had control and power over their working lives whilst supported to work in line with their midwifery philosophy and values, they flourished [7, 8]. Conversely, those who were not supported or trusted to work autonomously reported negative experiences with huge impacts on their wellbeing [7, 8]. Workplace cultures and politics were key negative influential factors in my study and given a lack of autonomy is a core reason for midwives leaving the profession [3–5], this needs urgently addressing for those who work in sub-optimal environments. For example, Alex reflected on her journey from student midwife (a former experienced nurse) to working as a qualified midwife who found that the reality of ‘autonomous’ practice did not mirror her education (or previous experience as a nurse) which led to frustration and disappointment. Her account below reveals an ongoing battle within hospital settings to practice skilled heartfelt and full-scope midwifery; mirroring the findings from the King’s Fund [21, 31] that identified layers of hierarchy, its associated bureaucracy and control over staff reduce the potential for innovation and staff wellbeing and satisfaction: … when you train to be a midwife you go along this journey as an undergraduate where they kind of say you’re this, this facilitator, for this woman, you’re an autonomous practitioner and I think as you go along as an undergrad you kind of think, this is something I am really passionate about, yes I am autonomous and I am going to do the best for the ladies I care for. And I think, from an undergrad knowing best practice to an institution where there is hierarchy and there are people above you that are actually, although you feel like an autonomous practitioner there are people there who’s word goes above yours, …you have to kind of fight against the system really, which is a shame really because you are supposedly an autonomous practitioner…

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 ccess, Assess and Apply Evidence-Based Medicine A Midwives in this study (who worked across Bands 5–8 and across settings community/hospital) were skilled and confident in their research and evidence-based skills [32]. Rather than relying on the local guidelines to be the sole source of information for their practice, the midwives reported extensive wider knowledge bases and sources of information including research databases, NICE, RCOG, RCM, professional networks and actively connecting to midwives working at other organisations. Thus, the midwives resisted ‘guidelines as rules’ [33] to instead, utilise their skills to access, assess (critique) and apply the evidence to the person in their care. It also entailed accessing wider sources of guidelines including NICE, RCOG, RCM and connecting to midwives working at other organisations. This was important as the midwives understood that local guidelines vary greatly and were not always based on the latest evidence,8 which guided deeper learning to understand the underpinning research, anatomy or physiological evidence to support effective care planning. Collectively, the midwives emphasised the research skills required to be an effective practitioner—whilst a core competency in undergraduate education and professional practice [34, 35], the reality for many midwives is that local guidelines (often used interchangeably with policy [13]) dominate practice [36–38]. However, for these study participants understanding research and providing evidence-­based or informed care was integral to their beliefs, attitudes, philosophy and practice. Therefore, to practice skilled heartfelt midwifery, these skills are vital, as Edna, illuminates: we all have an obligation, these are the midwives that are training students, students are going to come out not knowing not knowing how to appraise evidence and apply to it to their practice, [for me] I had a particularly inspirational lecturer who was so frothy about research (laughs) and she just lit a fire in my belly, … and she inspired me in reading research, doing research and it’s just inherent in what I do really, some people don’t want to sit down and read a paper. I am doing my Master’s so I am going to be frothy about it (laughs) all I do is read research it’s really sad (laughs) and I want to be able to share that

S: Skills, Skill Development  kills in Physiological Birth and Across All Settings S Underpinning the study participants’ approach to care (and indeed is central to the role of the midwife) was their vast experience in supporting physiological labour and birth. Having expertise in physiological birth generated the competence to apply those skills to the more complex alternative birthing decisions or situations, which was especially pertinent for choices where little evidence exists (e.g. someone pregnant with twins wanting to birth in water) or in unexpected situations (e.g. unanticipated breech). The midwives used a combination of scientific knowledge (e.g. basic sciences, anatomy and physiology etc), research evidence and their tacit  As explored in my previous book, guidelines are fraught with epistemological concerns and the authority guidelines wield are of significant concern—see [8]. 8

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and experiential expertise to apply these sources of knowledge to different situations. Moreover, where women’s decisions were voiced antenatally, this offered the time and opportunity to carefully consider ways of support. Working through a range of possible scenarios, and sometimes practical simulations, the midwives demonstrated careful planning and contingency planning based on enhancing the physiology. Their physiological birth expertise was gained in different ways but central to which, most had experience in out-of-hospital birth settings. For some, they directed their own learning by actively seeking opportunities either as a student or once qualified. For example, they may have asked for specific mentoring, or requested to work at a birth centre or joined a homebirth or caseloading team. For some, it was by chance they worked with a particular mentor who had these skills and supported the midwife participants to gain knowledge, skills, confidence and passion for supporting physiological labour and birth. However, for others, incidental exposure to physiological birth care within enabling environments changed the course of their professional trajectory to that described in this book. For example, by virtue of circumstance, some of the midwives were rotated to community settings with high homebirth rates, or to busy birth centres and for others, they happened to work in hospital settings which proactively and skilfully supported physiological birth. For example, Sam, an experienced midwife, reflected that it was only during an opportune elective placement that she witnessed both skilled midwifery and authentic woman-centred care. Sam reported this had not been the case at her training hospital and the elective was ‘like a smack in the face’ conveying the significant contrast of practice: When I did my training…I just knew that I wasn’t comfortable on labour ward, I didn’t like it. I thought ‘these women are just not having any choice in their care’. I went to a different Trust on my elective, I went on their birth centre and it was the first time I had ever seen what I’d read in books about supporting women with the water, I’d never seen a waterbirth before, never seen a physiological third stage, and I just thought that this is supporting women’s choice and I think if I hadn’t have gone to that Trust maybe I would practice different… Honestly, it was like a smack in the face, I remember thinking that that ‘yea it was a smack in the face’. I couldn’t believe it, you know like all the really lovely texts you read about supporting women’s choice and letting them birth their baby’s stood up and I thought ‘oh wow, people aren’t strapped to a bed’. Yea, and that was the Trust then and I applied for the community post and got it and that was the first couple of years that influenced my career really, working in that area…

This suggests that approaches (including beliefs, values and philosophies) in midwifery are, and can be, influenced by workplace environments and experiences. This is encouraging when considering systemic change and how to support more to practice skilled heartfelt midwifery; where systems can ensure midwives (and more importantly childbearing people) have access to different birthplace settings and strong midwifery-led care in obstetric units, they can cultivate the skills in this book, aligned with the Lancet Midwifery Series ‘full-scope’ midwifery [39]. It is also essential that student midwives have equitable opportunities and exposure to a

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wider range of placement experiences to facilitate these core skills.9 The importance of undergraduate education and opportunities cannot be underplayed; Sam above highlighted this as she had the opportunity for an elective placement within her education. Whilst her original placement area was less woman-centred, she was exposed to other ways of practising through her elective placement. In contrast, was Delilah, who had a very different primary placement experience as a student. As a long-standing midwife with extensive community and skilled heartfelt midwifery experience, who has supported a wide range of alternative physiological births; Delilah is extremely competent and confident. When discussing how she came to practice this way, Delilah referred to her education, specifically the hospital she was placed in as being highly influential and which was aligned with skilled heartfelt practice (midwives and obstetricians). Furthermore, her education equipped her with the skills, confidence and competence on qualifying to provide robust clinical care: Dare I say, it was right from my training? I have always said this, but when I did my training, it feels like it was 1902 but it wasn’t! (laughs) It was in 1988… But the training I had, was very much rooted in normality. The midwives I trained with, some of whom have become very well known, sort of nationally and locally were all very much rooted in normality. So, it was there right from the start, we were very much, you have to know this, in order to understand that. And that was right from day one. Uhm, so it was drummed in, you know our midwives’ rules were drummed into us, we had to know them inside out, so that made scope of practice and rules clear right from day 1. You had to get how labour worked, and although some knowledge has changed since then, some of the words have changed, we had to know the basics… So I have always that clarity about what is normal and what is not and if it’s not what to do next. And it was always focused on, the woman might want to have her baby at home, and she has had a previous PPH therefore, how are you going to support that woman? It was never you cannot have a baby at home, it was never there. I cannot ever ever recall anybody saying well she can’t do this, because of that. Uhm, and that was right from then. Also, the section rate was quite low, about 15% then and induction rate was low, so we were used to normal birth. You know breech birth was normal. It was unusual, but it was normal so unless you know there was a clear indication for a section, it was pre-Hannah trial and all of that. And so, we were used sort of unusual situations as well the normal, so we knew what to do if something, something happened. And it was also really good relationships between, in this unit, between obstetricians and midwives… once I qualified, I was happy to go anywhere. In fact, I wanted to go to uhm, to community because that is where my head is, where my soul is but as it was, I did 6 months of nights on labour ward. And it was fantastic, I had a great time, I learned so much.

 kill Development/Continuing Professional Development S The previous point highlighted that midwives need exposure to physiological birth care in all settings but especially need opportunities to cultivate their skills in midwifery-led settings and be taught or mentored by those who possess these skills. Midwives must gain experience in midwifery-led environments as it is within this space that core midwifery skillsets advance beyond the novice  In the UK, this is becoming an increasing concern for students (high induction rate, growing caesarean rate, increasing medicalisation and restricted practice) and some are finding it difficult to fulfil the NMC criteria of 40 facilitated births. 9

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practitioner (highlighted in Chap. 4).10 To which, expert midwifery skills can and should be applied to caring for those in obstetric units,11. From a systems perspective, all birthplace settings must be available, primarily for women’s benefit, and to ensure midwives gain proficiency and expertise in these core skillsets that are fundamental to the role [35, 39, 40]. This is important, so to ensure midwives’ professional development is not generated from ‘incidental’ or ‘opportune’ moments but is consistently supported so safe, high-quality midwifery care is available to all. Studies have found some midwives report a lack of skills and confidence during midwifery-led intrapartum care [41–44], therefore, systems must bear some responsibility to address this skill deficit, for skills cannot be gained without experience, which requires access to all birthplace settings. Furthermore, systems need to cultivate enabling, psychologically safe environments for midwives to learn and professionally grow, which will directly benefit birthing women and people’s access to safe maternity care. For example, Alice a community midwife and team leader shares how her homebirth team supports those new to community working; both in terms of skill development and through nurturing their psychological safety [22]: Yes we do a lot of work outside [the clinical area], so when the preceptor midwives come out we do our own home emergency skills and drills training with them uhm so just to try and give them that boost before they get out there and do it, so we do try to do a lot of homebirth based assessments, like we do assessments together with them and we do a lot of additional support training outside of the actual labour environment. And then it all comes down to making sure no one is ever on their own, but no one is ever on their own because you could have been qualified 10 years and not feel confident to be there. So yea I think it’s as much supporting the midwives as it is the women, because the last thing we want is a midwife to end up that they’re not happy with and it ruins their career for them. It doesn’t take much to push midwives out of midwifery because the nature of the work we do uhm so I think it’s really important that we try and look after the newer people and make sure they’re being supported and that they don’t have a horrible time and not want to be a midwife or be on call again.

This is also important for student midwives—the next important generation coming through the system who have voiced concerns they are not witnessing or participating in enough physiological birth care.12 Coupled with concerns over experienced midwives leaving either through retirement or burnout [45] the system must work to provide the appropriate skill mix to offer families authentic choice and to ensure their staff can provide skilled care. For example, Kerry, who worked in a team with a 30% homebirth rate shared her experiences of taking up a particular caseloading opportunity as a newly qualified midwife. This early experience was integral to both

 While this can be achieved in obstetric units as Delilah above identified, arguably that is more challenging today. 11  Arguably, it is even more important that birthing people with medically complex pregnancies receive highly skilled, expert midwifery care. 12  Now working as a lecturer I am seeing this firsthand, new research to explore this issue is currently in progress. 10

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her physiological birth skill development across all birth settings and the power of relational care, but importantly her experience was enabled by the o­ rganisation/ system. Given it is at the organisational/system level which has the power to commission services, and that this organisation was forward thinking to employ a newly qualified midwife, and who enabled a continuity team to operationalise, we can see the powerful benefits for Kerry which in turn has enhanced both her skillset and job satisfaction: I had the best introduction to midwifery post-qualifying. I moved from a small cottage hospital to a large London Trust [employing organisation] to get experience but also to take up the opportunity to work as a caseload midwife. I joined a team of 5 amazing midwives who all took me under their wing. I also learnt so much from the women I had the privilege of getting to know throughout their varied pregnancy journeys. I got to witness the power of trust and respect gained from caseloading and I feel this is what made me a better midwife—being WITH woman. Whilst caseloading we as a team had numerous birth journeys which stepped outside the comfort zones of consultants and guidelines. Some even did Olympic-sized long jumps. But the most important aspect of all these journeys was the open discussion which enabled plans to be put in place to make the woman and her family feel confident we were listening, and we were there to support them safely and honestly. These ranged from VBAC waterbirths at home to PROM >72 hrs at home to vaginal breech birth on our low-risk birth unit to declined IOL’s. All were facilitated with ongoing communication and ongoing trust.

S: Systems Approach, Support  Systems Approach that Supports Full-Scope Midwifery A Aligned with the above point regarding system-level responsibility to ensure midwives are enabled to cultivate expert midwifery skills, here, the focus is on organisational and systems culture. Workplace cultures determine the working conditions for their staff, and influences staff wellbeing [46–48] and patient/client outcomes [28, 29, 48, 49]. Central to this, is how psychologically safe the workplace environment is [22, 28, 29]. Where some of the study participants worked in hostile environments, unsupportive of midwifery and women’s autonomy, this created poor working relationships with negative impacts on the midwives’ mental, emotional, physical and financial wellbeing [7, 8]. Working as a ‘lone ranger’ when delivering authentic woman-centred care is unsustainable, and leads to distress and burnout [7, 8]. Conversely, some participants worked in supportive environments whereby the organisational values and culture created the optimal environment for midwives to deliver woman-centred care where women’s (alternative) choices were ‘normalised’ [7, 8]. These positive cultures went beyond individual midwives, teams, or areas of midwifery practice but were organisation-wide, top-down and bottom-up. As such, the burden of delivering woman-centred care was not placed upon one individual or team, rather, it was a shared vision and a collective responsibility across the organisation. Central to this was the valuing of women’s autonomy over organisational needs, and trust in the midwives to deliver such care.

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Compare and contrast the following two extracts from study participants who were both working in the community at the time of data collection and were frequently supporting alternative physiological birthing decisions. First, Edna who worked in a punitive and restrictive environment reported extreme stress with direct repercussions on her mental health. Second, Amy, worked in a supportive environment characterised by top-down support and the engaged staff she managed (bottom-­ up); and demonstrated a culture of psychological safety throughout the organisation. Here, the midwives were supported to support birthing women and people’s alternative physiological births. These two accounts show the necessity of organisations tackling their cultures—and given the international and national policy drivers towards personalised care, it can only be achieved if midwives are supported.

Edna Edna was working in a traditional community model at the time of data collection and largely her narratives were one of ‘battles’ [7, 8]. Battling to work within her values, battling to support women’s choices. The battles were due to working within an unsupportive environment where she was largely isolated and had little support from management/seniors. In this context, Edna felt deeply responsible for women going through their journey in an unsupportive system and was morally distressed when their choices were not facilitated: …[you] walk in the woman’s journey and you do and you take a little bit of every woman’s journey and you feel so responsible when it doesn’t go right, uhm and if they don’t get the choices facilitated that they want, you take that on the chin and you shoulder that and you blame yourself …

Such a burden to carry in isolation was magnified by the professional vulnerability of working in a hostile system. She voiced fears of ‘finger pointing’ and the NHS ‘blame culture’ as the root cause of her stress, rather than providing alternative physiological birth care: …uhm if I’m honest I don’t think it’s the fear that anything is going to go wrong, because actually I am not going to put a woman in that position, I am not going to put myself in that position, it’s the fear of finger pointing, it’s the fear of being hauled up in front of the Trust (employing organisation) and saying and them saying that you didn’t do all that you could, you didn’t talk her out of it, I hate that, you get that a lot, ‘why can’t you talk her out of it’ …

Collectively, this placed a significant mental and emotional toll on Edna. When I asked how she managed, she reported: …but I don’t think I do manage it if I’m honest, my mental health suffers because of it, my family life suffers because of it uhm and everyone is the same, I’m not in isolation from that point of view, but I do, I lose sleep at night we all suffer with anxiety, I’d say 50% of the midwives that practice in the same way as I do suffer because of the effort and the strain it puts on everything…

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 my A In direct contrast, Amy was a homebirth team leader, managed staff and had a caseload of women. Amy led and was led by supportive staff, demonstrating a positive, psychologically safe working culture that honoured woman/person-centred care. When referring to her homebirth team of midwives she reported the privilege of working with ‘really incredible midwives’. They had a cohesive team based on open, respectful communication where they were all aligned with ongoing learning and support. This meant that supporting alternative physiological births was easeful and well-facilitated. As an example, Amy reported being ‘inundated with volunteers’ when seeking midwives to set up a rota for a woman wanting a homebirth with multiple risk factors. This was indicative of the team’s similarities in terms of skill sets and values (and the psychologically safe culture in which they worked). Moreover, this sense of togetherness and comradery was echoed by upper management. Amy reported many positive stories of ‘top-down’ support her team received from senior members of staff. For example, she described the consultant midwife as the ‘most amazing one going’, the supervisors as ‘powerful’ and management as ‘supportive’. Importantly, the support was not lip-service, in Amy’s example below she demonstrated that the senior managers were also ‘hands-on’: …our deputy head when we’ve had two homebirths going on at the same time, he on multiple occasion gone out to a homebirth himself you know? You know homebirth is very protected, it’s very sacred [7, 8].

Support Building on the previous points, this aspect relates to the everyday support needs of midwives, generally within their practice and specifically related to supporting alternative physiological births. Primarily, midwives need support that is accessible, timely and restorative [8]. For some of the participants, debriefing through or after challenging episodes of care was required. The UK now has a restorative supervision13 function carried out by midwives called ‘Professional Midwifery Advocates’ which uses the model ‘A-EQUIP’—an acronym for advocating and educating for quality improvement [50]. Broadly, the restorative component focuses on the emotional needs of staff and the development of their resilience [51] and may be provided in different ways (one-to-ones, drop-in sessions etc.) [52]. Whilst received positively, it is not compulsory for organisations to implement [51] but could be considered a vital source of support for midwives, particularly in the circumstances just stated. At other times, participants in the study outlined that sometimes support was as simple as calling a senior or consultant midwife for reassurance that a care plan was appropriate, or to brainstorm the situation which may have become unexpectedly complex. For example, Alice, an experienced homebirth midwife shared the helpful support from her labour ward colleagues. Knowing she could pick up the phone and discuss a situation, and get advice and support demonstrated a psychologically safe culture, in turn, enhanced the safety net around the women in 13

 At the time of data collection, the PMA model had only just been announced.

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their care. Furthermore, Alice pays this forward to her staff, especially those newly qualified or new to providing homebirth care, thus illuminating what accessible, timely and restorative support looks like: … I mean if I have any doubts or if I am unsure about something, usually we will have our second [midwife at home] with us unless it’s someone who is 4 cm, I would just pick up the phone and ring the matron or one of the other Band 7’s who is on. Sometimes, uh it can go either way, sometimes you can think a situation is worse than it is and someone goes ‘have you tried this?’ and you go ‘of course, you know she hasn’t had a wee in four hours, of course that’s what she needs’ and sometimes I think you can become complacent so you kind of phone and go ‘does this sound ok?’ and they’re ‘no that’s not right, she needs to come in’ so I think that’s valuable as well, never be completely on your own in somebody’s house, always phone and get that second opinion because someone will always spot something you haven’t, or calm you down if you’re panicking for no reason. And I will always say to people, when other midwives are on call I’ll say ‘never be afraid to ring me to come with you as your second, I can come at the beginning as well’ and a lot of us work like that, we’ll be happy to come at 4 cm to help the other person, because it’s not just about the woman, it’s about the midwives as well, making sure they’re feeling looked after and that they’re not on their own.

In other circumstances, support for women and birthing people’s decisions were cultivated through formalised care pathways, care planning proformas or guidelines—often (but not always) viewed as supportive mechanisms for midwives to support alternative physiological births. Such formalised approaches, where viewed positively, were seen as organisational support for midwives to support and facilitate birthing people’s decisions [7, 53]. In this way, midwives felt protected and that they were not going to be scapegoated should adverse outcomes occur [7, 53]. For midwives working to improve a woman-centredness culture, these organisational documents were developed to demonstrate that cultural shift and show the midwives they were supported in their practice [7, 53].14 Overall, the key message here is that midwives need to know they have the support of the organisation, from managers to Heads of Midwifery and beyond, to reduce the potential for stress or burnout and to enhance the psychological safety of midwives. Exemplifying this is James, one of the study participants, a senior midwife who worked in an organisation that had been proactively supportive of alternative physiological birth choices. However, when there were statutory changes to supervision in the UK,15 the team restructured the service to ensure midwives and women remained supported:  However, a caveat, the benefits of formalised pathways need to be researched and analysed from all perspectives, including birthing women and people’s to ascertain their usefulness—I identified this in my thesis as a limitation of the study [54]. Concerns of unintended consequences have been raised that formalised pathways are increasing the ‘hoops’ women must jump through and reducing some midwives’ autonomous practice (Private correspondence from multiple midwives). Therefore, should be treated cautiously. 15  For midwifery, supervision was a statutory responsibility which provides a mechanism for support and guidance to every midwife practising in the UK. The stated purpose of supervision of midwives was to protect women and babies by actively promoting a safe standard of midwifery practice, however, failings of this mechanism were found in the Francis Report which led to its statutory removal [55, 56]. 14

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5  What Midwives Need to Provide Skilled Heartfelt Practice I don’t know what’s happening elsewhere, because there was uncertainty before the PMA [Professional Maternity Advocate] role starts, we were very concerned as to what would happen cos our homebirth rates are really high, our homebirth rates sit between 8–9% but 15% of those women come into the high risk category, which was the issue, we were worried what would happen when supervision was no more and who was going to capture these group of women, and because I had a bit of an interest in it alongside a colleague of mine, we spoke to our Head of Midwifery … she was quite keen to hear what we were going to do, so we decided to set up a Maternity Care Choices clinic… so then the way we’ve done that we have devised a referral form, because I am a manager I sent out an email to all the community midwives saying what the plan was going to be now so they felt supported, because originally we were going to push it out to the community and say to midwives to do their own risk assessment and anything really complicated escalate it to me as the manager, but our IT systems in the community are a nightmare… so again instead of these women falling through the net, they’ve got a referral, they send a referral to our email account uhm and then we will have a look at what the women’s issues are, and if it’s fairly minor I’ll just give a little bit of advice to the community midwife to then give back to the woman, but then we can call the women and offer our service…

E: Empathy and Compassion The midwife participants demonstrated high levels of empathy and compassion for the women in their care (explored in Chaps. 2 and 3). Moved by the women’s accounts, which were often distressing, stimulated empathic concern in the study participants. This concern created a mother–midwife allegiance for midwives working in unsupportive environments where the relationships with women provided some level of mitigation against their challenging workplaces [53]. Moreover, empathic concern ‘compelled them to act’ in the birthing person’s interest and was a driver to facilitate birth choices as much as possible (see Chaps. 2 and 3). Such emotional attunement that resulted in empathic responses to serve the women’s needs can be viewed as ‘compassionate midwifery care’ [56]. As explored in Chap. 3, this is a core but often hidden midwifery skill and practice that requires high levels of emotional intelligence [57]. As threaded throughout this book, I have placed much emphasis on emotional intelligence—that is, self-awareness, self-­ reflection and self-regulation [57] as it is through emotional connections in which trust, and therefore, safety is cultivated (see Chap. 3). However, without self-­ awareness or reflection, emotional attunement is limited, trust and safety are reduced as we may either perpetuate stereotypes or biases risking hurting those in our care [58]; or through over-identifying and disempowering others [57]; or not be aware of our limitations risking undue stress and/or burnout [59]. Therefore, given the high emotional demands of midwifery [60, 61], self-understanding, self-compassion, and self-care practices are required. As such, emotional intelligence skills and safe spaces to explore our emotional selves need to be embedded within the university education and organisations to ensure safe, respectful and dignified care is provided.16

16

 The PMA model previously mentioned is one such way but there are others.

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For example, Susan, an experienced midwife (in all settings) reflected on the needs of women during labour, where midwives need to ‘hold the space’ for birthing women and people. However, with heightened self-awareness she realised she had to learn to hold the space for her own ‘big feelings to be felt’, specifically learning to recognise, acknowledge and let go of her ‘fears and attachments’ to avoid detrimentally influencing those in her care; particularly those making choices ‘outside of guidelines’. Through self-awareness practices such as mindfulness, Susan has learnt to identify feelings that may be coming from her own needs, rather than what the clinical situation is calling for. Furthermore, she includes practising self-compassion: I see the biggest obstacle to facilitating women’s choice is my own fears and attachments. Especially attachments to being right, being needed, being able to make things better, being important etc., and the fear of being judged by my peers and the establishment is the strongest feeling. I can see how my practice in the past was led by these fears and attachments. I now attend to these feelings with compassionate awareness. This manifests as giving myself time, when I feel a need to do something [intervene in a labour/birth] I bring my attention to my breath to become truly present and then assess if there is an actual need or was it just my need. I find that this helps me to act more appropriately and with more authenticity.

These aspects also apply to workplace environments where cultures must be based on empathy and compassion, so staff are afforded the respect and dignity they deserve. This includes empathy and compassion from their colleagues and managers to foster greater relational inter and intra-working [21, 25, 29]. Within an empathic and compassionate model of working, resistance to ‘blame cultures’ [21, 62] is more easily attained. In turn, this enhances a ‘transparency culture’ that is well-evidenced as a safer culture for all [63, 64].

T: Trusting Relationships In maternity care research, the importance of women having trust in their midwives, other caregivers and the service as a whole, has been acknowledged as vitally important [65–67]. Other research has also highlighted that women want to feel trusted by their caregivers, which in turn, increases the trust they place in their caregivers [65]. This study extends these insights, that trust was seen as the ‘glue’ within the mother-midwife relationship and the midwives recognised they needed to be deemed trustworthy by those in their care [32]. This was viewed as a significant responsibility, particularly when supporting alternative physiological births, to which the midwives made great efforts to convey their support for birthing people’s decisions, to demonstrate their trustworthiness (see Chap. 3). Furthermore, unique to this research was that trust was viewed as reciprocal; and when midwives trusted those in their care, they reported feeling more confident and willing to support the birthing decisions. In contrast, another study has found situations where midwives do not feel mutual trust is present, it was viewed as a significant risk to the provision of safe care, especially for those with complex pregnancies seeking alternative

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physiological birth care [68]. Therefore, mutual trust is the cornerstone of safe care, as highlighted by Lucy (see p. X for more insights from Lucy): So you have to build a relationship with them cos they don’t know us and it’s all about them and their experience and what they want to gain from it, and I think when people [staff] go in guns blazing making it sound like the woman’s wrong, their guard goes up, and once that happens that’s it, they’re not going to listen to what you’re saying in an emergency situation, they’re not going to trust that it is an emergency because they think that you’re you know, coercing them to do what you think is right and that’s where I found the issues arose in my previous experience the woman has to feel as though they can trust you, otherwise it’s not going to work.

Additionally, issues of trust (or mistrust) were not the sole domain of the mother– midwife relationship in this study. The participants, through sharing their polarised workplace experiences, revealed the importance of trust within their working relationships [7, 8]. The absence of trust was a precursor to heightened vulnerability, threat and negative workplace experiences [7, 8]. Trust from their employers, be it from the midwives’ immediate managers, wider multidisciplinary teams and/or senior staff was an influential factor in how the midwives experienced providing personalised care [7, 8]. Where trust was present, this created positive, enabling workplace environments, which is central to psychological safety [7, 8] and therefore, enhances safe practice and improved outcomes [49]. Such enabling environments support the midwives’ needs as per the King’s Fund [21]; autonomy, belonging and contribution and as per this ASSET model [1]. Therefore, trust can be viewed as the glue for all relationships and is the foundation for thriving and flourishing. So, organisations must work to create trusting environments for and between all professional groups to maximise women’s experiences of respectful maternity care.

5.4 Safe, Relational Care as a Collective Responsibility This chapter has reoriented the midwives’ skilled heartfelt practice within their workplace environments, highlighting the importance and influence (positive or negative) of these cultures. The insights from this study, and others, emphasise that personalised, humanised and ethically driven care requires a systems approach. For example, it is extremely damaging to birthing people if they are supported antenatally to assert their agency, and make personalised decisions, only to be told ‘they are not allowed’ something when in labour. Or, conversely, not be supported antenatally and feel forced to opt out of maternity care altogether as in the case of freebirthing. Additionally, when a midwife absorbs sole responsibility for supporting women in their chosen care and is not supported herself, this paves the way for mental, emotional and physical stress/distress, leads to burnout and eventually risks them leaving the profession [3, 5, 7]. Therefore, to retain midwives, amongst other issues related to professional/organisational distress, they must be provided with the enabling environments to fulfil their role, to provide a meaningful contribution, have autonomy and agency, and fundamentally, be trusted as professionals [69, 70].

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Supporting midwives is the solution to ensuring birthing people have access to equitable and meaningful personalised care [2, 39, 71, 72]. This can only be achieved from a systems approach. And for midwives who are reluctant or fearful of supporting truly personalised care, then I argue, the systems approach is even more vital. Embedding psychologically safe and woman/person-centred cultures, access to different ways of working (e.g. midwifery-led settings), mentoring, witnessing and being exposed to why women make the choices they do,17 may facilitate professional changes. The participants in this study have illuminated how instrumental different working experiences have been, as not all set out to practice skilled heartfelt midwifery, rather they ‘stumbled’ across different ways of working that changed their approach. Additionally, this study has shown many positive examples of a systems approach, which is truly heartening and demonstrates what is possible even within the current constraints. Therefore, front-line midwives need to be supported within non-punitive, open and learning cultures where their autonomy is respected. A supportive work environment is an enabling factor for providing true woman-­ centred care and creating the space for full-scope midwifery. The benefits to women are well documented, therefore, could be used to enhance women’s psychological and physiological birth outcomes. Ideas to help achieve this are provided below, aimed at senior midwives, managers and executive boards: • Organisation-wide education regarding women’s childbirth legal rights (to include senior medics, midwives, trust board directors and legal department). • To offer structured, formalised supportive education and pathways to support midwives less aligned with this practice to help encourage them to support all birthing people’s choices. • Consider formalised documentation that reflects women’s human rights in childbirth, with the responsibilities of all maternity staff to ensure dignity and respect for women’s autonomy clearly identified. Such documentation could include guidance with common scenarios, to ensure that staff are reminded that, whatever their views about the decisions made, if the woman is properly informed (and not pressured with biased or repeated information) her decision should always override that of her attendants unless she has, in a legal sense, lost competence, which is rare. • To stimulate positive change that enhances women’s access to meaningful choices could include the development of a co-created toolkit (informed by all maternity staff, representation from all practice settings, and birthing people) that has the support of senior management.

 Several of the participants who were consultant midwives (or similar), their role was to support women, helping co-create care plans, and often would be privy to women’s rationale for the decision-­making. The participants would offer shadowing to the front-line midwives (particularly those concerned by the care plans they were expected to deliver), to help them see and understand why women make these choices. A viable and possible way to help front-line midwives learn and grow. 17

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• And/or an ‘Alternative birth choice bundle’ could be developed, a toolkit designed to help support women, midwives and trusts to provide safe, woman-­ centred care where choices are outside of guidelines. • Identify a lead midwife (in the absence of a consultant midwife) who could be the liaison between maternity staff, the multidisciplinary team, legal and managerial teams. • Set up supportive learning sessions for multidisciplinary teams to discuss what has worked well when supporting/facilitating women’s alternative birthing choices. • Establish ‘open door’ sessions for junior/inexperienced staff to discuss ongoing cases with senior/experienced midwives. These can be used to provide support, and/or identify gaps in knowledge or skill sets. This could generate a co-created action plan for staff skill development, where both the individual midwife and the trust are obligated to fulfil training needs. • Offer debriefing sessions to all/any staff automatically after challenging experiences—not just related to adverse outcomes, but issues of relationships with women or their families breaking down, issues of poor communication between staff, inappropriate care etc. • Provide ongoing feedback from women who have requested alternative birth choices. Inviting women after their birth to share their stories with staff could provide beneficial learning opportunities and validation of the service provision.

5.5 A Conclusion, and a Heartfelt Thank You This book has focused on the skills, qualities, attributes and skills the midwife study participants demonstrated when supporting alternative physiological births. Collectively, their midwifery care has been reconceptualised as ‘skilled heartfelt practice’. Whilst similar to notions of woman/person-centred care or relational care, this reframing serves to explicitly illuminate what midwives do and how. As identified in Chap. 2, midwives are not a homogenous group of professionals. Whilst working under the same umbrella philosophy, and protected title, the evidence demonstrates a variation of beliefs, values and philosophies— all of which influence their caregiving. Therefore, skilled heartfelt midwifery practice can be used to define and explain the orientation of specific midwives as the integration of a midwife’s attitudes, beliefs and philosophy in support of women’s autonomy, aligned with values of relational care and expert clinical skills [53]. Whilst these components have been unpacked individually (Chaps. 2–4), it is important to remember skilled heartfelt practice is the coalescence of these components together. This is aligned with the ICM’s definition of midwifery philosophy [73] and is closely related to the relational continuity model as per the Cochrane reviews [74, 75]. However, what is unique within this work, is demonstrating what relational care within a midwifery-oriented philosophy looks like in practice. Using an array of examples, grounded in those birthing decisions ‘outside of guidelines’—a sure test of one’s philosophy of woman or

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person-centredness, these midwives show how such care can be achieved. Moreover, many of the midwives in this study were not in continuity models of care yet endeavoured to apply this approach to all those in their care and this book reveals how they managed it. This just leaves a final word from me, and that is a heartfelt thank you to all of you midwives, obstetricians, neonatologists, anaesthetists and support workers who have maintained a person-centred approach to their practice. You are working in incredibly tough situations, still recovering from the COVID-19 pandemic and many are working within extremely challenging political contexts (micro and macro levels). It is easy to lose heart and wonder whether your practice is worth it but speaking to birthing women and people who have felt safe in your care, who felt seen, heard and supported, I promise that you are making an enormous difference. It is often the little moments, the little things that you/we do that have great impact— a warm smile, a gentle touch, encouragement, saying ‘yes, I’ll help you’ all make a bigger difference than is often realised. For students currently in education, I thank you for joining the profession(s) in such a challenging time. The educational journey is difficult in ‘normal’ times but to join a university during COVID-19 is extraordinary. I would hope to say that surely the context couldn’t ever be more difficult than it is now, but I would not want to jinx things! And finally, I hope for all of you practicing skilled heartfelt care, that this book helps you feel seen and acknowledged. Thank you. Personal Reflective Activity

Using the ASSET model above, can you identify what is working well and not so well within your current working conditions? Second, you could consider your workplace environment, what is working well in terms of the ASSET model, and what needs more development. Having explored what is working well and not so well, can you identify some immediate and longer-term actions for your personal professional practice? Can you also identify a way in which you may contribute to supporting the culture, and the system?

Further Resources 1. Case studies—see Chap. 6. 2. King’s Fund The courage of compassion: Supporting nurses and midwives to deliver high-quality care (ABC model)—https://www.kingsfund.org.uk/publications/courage-­compassion-­supporting-­nurses-­midwives 3. For ways to support your own flourishing within challenging maternity contexts, see Kate Greenstock’s book ‘Flourish: A practical and emotional guidebook to thriving in midwifery.’ 4. For ways to support your staff with workplace wellbeing, see Jan Smith’s book ‘Nurturing Maternity Staff: How to tackle trauma, stress and burnout to create a positive working culture in the NHS.’

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References 1. Feeley C (2022) The asset model: what midwives need to support alternative physiological births (out with guidelines). Pract Midwife 25(2):26–30 2. UNFPA, ICM and WHO (2021) The state of the world’s midwifery: 2021. https://www.unfpa. org/sites/default/files/pub-­pdf/21-­038-­UNFPA-­SoWMy2021-­Report-­ENv4302_0.pdf 3. Hunter B, Henley J, Fenwick J, Sidebotham M, Pallant J (2018) Work, health and emotional lives of midwives in the United Kingdom: the UK WHELM study. Cardiff University. https://www.rcm.org.uk/sites/default/files/UK%20WHELM%20REPORT%20final%20 180418-­May.pdf 4. Hunter B, Fenwick J, Sidebotham M, Henley J (2019) Midwives in the United Kingdom: Levels of burnout, depression, anxiety and stress and associated predictors. Midwifery 79:102526. https://doi.org/10.1016/j.midw.2019.08.008 5. RCM (2016) Why midwives leave revisited. https://www.rcm.org.uk/sites/default/files/ Why%20Midwives%20Leave%20Revisted%20-­%20October%202016.pdf 6. Moncrieff G, Cheyne H, Downe S, Maxwell M (2023) Mapping factors that may influence attrition and retention of midwives: a scoping review protocol. medRxiv. https://doi. org/10.1101/2023.06.13.23291365 7. Feeley C, Downe S, Thomson G (2021) ‘Stories of distress versus fulfilment’: a narrative inquiry of midwives’ experiences supporting alternative birth choices in the UK National Health Service. Women Birth 35(5):e446–e455. https://doi.org/10.1016/j.wombi.2021.11.003 8. Feeley C (2023) Supporting physiological birth choices in midwifery practice the role of workplace culture, politics and ethics. Taylor & Francis, London 9. NHS England (2021) Maternity transformation programme. https://www.england.nhs.uk/ mat-­transformation/ 10. Birthrights (2020) Consenting to treatment. https://www.birthrights.org.uk/factsheets/ consenting-­to-­treatment/ 11. Royal College of Obstetricians and Gynaecologists (2015) Obtaining valid consent. https:// www.rcog.org.uk/globalassets/documents/guidelines/clinical-­governance-­advice/cga6.pdf 12. Royal College of Midwives (2018) Midwifery care in labour guidance for all women in all settings. https://www.rcm.org.uk/media-­releases/2018/november/ new-­guidance-­for-­midwifery-­care-­in-­labour/ 13. Royal College of Midwives (2022) Care outside guidance caring for those women seeking choices that fall outside guidance. https://www.rcm.org.uk/media/5941/care_outside_ guidance.pdf 14. NICE (2021) Antenatal care NICE guideline [NG201]. National Institute for Healthcare and Excellence. https://www.nice.org.UK/guidance/ng201 15. Wines (2016) Could the midwives of British Columbia benefit from a model of midwifery supervision? MSc thesis, University of Central Lancashire 16. Zolkefli ZHH, Mumin KHA, Idris DR (2020) Autonomy and its impact on midwifery practice. Br J Midwifery 28(2):120–129. https://doi.org/10.12968/bjom.2020.28.2.120 17. Newnham E, Kirkham M (2019) Beyond autonomy: care ethics for midwifery and the humanization of birth. Nursing Ethics 26(7–8):2147–2157. https://doi.org/10.1177/0969733018819119 18. OBoyle C (2013) ‘Just waiting to be hauled over the coals’: home birth midwifery in Ireland. Midwifery 29(8):988–995. https://doi.org/10.1016/j.midw.2012.12.010 19. Jenkinson B, Kruske S, Kildea S (2017) The experiences of women, midwives and obstetricians when women decline recommended maternity care: a feminist thematic analysis. Midwifery 52:1–10. https://doi.org/10.1016/j.midw.2017.05.006 20. Kruske S, Young K, Jenkinson B, Catchlove A (2013) Maternity care providers’ perceptions of women’s autonomy and the law. BMC Pregnancy Childbirth 13:184. https://doi.org/10.118 6/1471-­2393-­13-­84 21. King’s Fund (2020) The courage of compassion: supporting nurses and midwives to deliver high-quality care. King’s Fund. https://www.kingsfund.org.uk/sites/default/files/2020-­09/ The%20courage%20of%20compassion%20full%20report_0.pdf

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Appendix: Case Studies

This book was designed to demonstrate the principles of skilled heartfelt practice drawing on and distilling vast amounts of data to illustrate the qualities, attributes and broader skills the midwife participants possessed. However, for readability purposes and to ensure each chapter retained a tight focus, many details and examples were not included. Therefore, to support further learning, I have included several case studies that correlate to Chaps. 2–5 in this section. These can be read alongside the corresponding chapter or in their own entirety.

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. Feeley, Skilled Heartfelt Midwifery Practice, https://doi.org/10.1007/978-3-031-43643-7

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Laura: Motivations for Her Practice ‘I feel it is my duty, to, as a midwife, to be her advocate. And, I feel, I mean I feel that we have the opportunity to do it, so I think that helps. Whereas in other settings, you don’t really have time to really get to know the women uhm and you are probably, the women are probably seeing 2/3 different midwives who don’t have the same ethos and that makes a difference. But when you are in a clinic, and you are only seeing the woman for 15 min you can’t really get to know her. But whereas, we can, in a sense [continuity model], spend as much time we want with one woman because it is on our time. If we work for 12 h, that is on, that is kind of on us rather than being pressured, obviously we are pressured if we have a really busy day, we can’t spend however long with every woman but… I think it is because having worked in a hospital, and then really just not liking it, the way it is a conveyor belt where you have one woman in and one woman out and it is constant. I just hated that way of working uhm, when I didn’t know the women and I didn’t even have the opportunity to know the women and I’d never see them again. And, I just hated that, uhm and also because I didn’t know women who were coming onto delivery suite, I didn’t know what they wanted but when you caseload you know all that, you know these women inside and out … we have had someone who declined all monitoring in labour at all. But we had discussed this beforehand, and we know she didn’t want us in the room and, we kind of just go ‘this is what you want, that is absolutely fine’ and we just discuss so that she is fully aware but on the day she’s not freaked out, we’re not freaked out and it’s fine. Uhm, so I just, I don’t know, I don’t know what has made me work this way but I just think it is what SHOULD happen. And, what a midwife should be doing. I know it is more than in terms of politics and time pressures all that but I have the opportunity to be able to do that in our team. So yea, it is what makes me happy and fulfilled in my work and it helps me sleep at night a bit better’.

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. Feeley, Skilled Heartfelt Midwifery Practice, https://doi.org/10.1007/978-3-031-43643-7

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 eorgina: Values Informed by Personal G and Professional Experiences ‘I think I have been a natural feminist who is a fierce protector of her own autonomy and when you combine that with empathy, you become a fierce protector of other people’s autonomy. Ever since I was a teenager I made a conscious decision for not to take on the mantel of body shame that I felt others wanted me to carry and certainly in my own birthing decisions, … after my first son was born [at home before being a midwife] I did have a massive obstetric haemorrhage … so it was a big haemorrhage, you know I don’t think I have looked after someone with that big a haemorrhage in my 13 years of midwifery. It was scary but I actually felt, I felt I was completely supported to do what I needed to do … I was completely and utterly supported to do what I needed to do and where I needed to it and how I needed to do it, I didn’t feel traumatised at all, my perineum was in terrible shape but emotionally I was intact … when I needed people to help to me, they helped me … I get it, the thing is now I am a midwife, with my third and fourth I was a midwife so I get it from both sides … because you know you make decisions out of your own values and I know what it feels like to say ‘these are my values, this is what I feel able to do, this is how I am going to do it’ and to be blessed with people who did actually did support those decisions, the midwives, and to feel like even though they didn’t make a big song and dance about it. I know some of them would have been secretly standing up for me … I feel grateful that they protected me and my decision-making space in that way, so I guess it’s a combination of kind of predisposing, inherent kind of feminist factors and also the empowerment I felt from the care I received from having my own babies which made me feel like, then I went to some mum and baby groups and I thought you know ‘I’ve had an experience that should technically be traumatic’ you know people have nightmares and flashbacks from near death experiences but that isn’t at all the way I experienced it, yet I would go to mum and baby groups and hear the trauma that women felt which I felt came a lot out of not being listened to and not feeling in control and I felt that I was strong enough to help people navigate that …’

Chapter 3

Isabel: Safety Means Something Different to Individuals ‘I mean safety is different to everybody, it can mean physical safety, it can mean emotional safety, it can mean mental safety, safety is such a broad term. And I think often in obstetrics we do break it down into simply physical safety … there is a lot of work going on around mental health but ultimately conversations with women are around physical safety and that’s not always the most important thing to them, you know they’re, if they feel very scared or vulnerable in a hospital and they don’t feel it’s of benefit to them [being in hospital] then it’s very difficult to argue with that, I mean you do present them with the you know ‘you have had a caesarean section and this is how we would support you’ you know and then you do the reverse with the benefits of what they’re choosing, uhm and making them safe it’s just knowing that. I mean my whole job is bringing women on board as much as I possibly can, to give them as much as I possibly can, as much as they will possibly accept from us uhm, you know if they cross the border where we can’t, you know they’re refusing care and we have to turn midwives away then that’s something completely different so it is about trying to make it as safe as possible, you know for example some women may want to have a homebirth as their only option and I have done a lot of work around negotiating well if at least if someone with a previous PPH who wants to birth at home, if she at least is at the birth centre then I’ve got a crash team next door so if she bleeds then the least we can do is put a canula in and fluids up, whereas at home that might not be as much of an option. So it’s you know a balancing act, so you can’t decide what her risks are and what she is willing to accept and what facilities midwives are able to provide really … I did a talk with students, and I said ‘I sleep at night knowing I have given information to women for them to make their own choices, and ultimately they decide the outcomes, not me …’

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. Feeley, Skilled Heartfelt Midwifery Practice, https://doi.org/10.1007/978-3-031-43643-7

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 usan: Creating, and Holding an Emotionally Safe S Birthing Space [in response to colleagues labelling Susan ‘one of those midwives’ e.g., who are prepared to care for women seeking alternative physiological birth care] #From my perspective I maybe, that they thought I was perceived maybe more tolerant, is not the word, having more patience I suppose. Some people I guess thought I was kinder or just, or just I was more normal focussed maybe? In that way I dunno even going to the X [hospital] [other units within same trust] they’d say ‘oh you are the labour whisperer’, I think not yeaa I find it ridiculous, I find, you know it’s weird to try and pin it down in that way because I find it all a bit ridiculous cos all you do is go in and you basically do fuck all (laughs) … You just talk nicely to people labouring women/people you go to that place where they are, rather than expecting them to somehow meet you on your plane, it’s theirs, it’s their space it’s their experience and you go to where they are or or and if they’re not in a place that is conducive for for labour cos they’re in a heightened state of anxiety or feeling they have to be very talky to make me feel comfortable cos they’re meeting a new person or they’re in a strange environment. So you go in and you put yourself in that space, you talk softer and and you respond less, you respond to make them feel comfortable so if they are very talky you might be slightly more talky at the beginning but consciously talking less and less, being ok with silence so they get that feeling without you saying ‘it’s ok not to talk now’ [loud] (laughs) that they get that sense that this is ok, this is about them, you make it all about them and because the place where labour happens best. So I find it annoying and a bit silly that people say these things I don’t think by any means that I am the only midwife that does that but I think maybe well what does that mean? What are you being in your room if you’re not being [like] that? Researcher: And would you say that is what you mean by your oxytocic voice? What a lovely phrase Yea, yea even if I am talking uhm to women on the phone who are ringing in because they’re in early labour, you know you bring your voice down (whispering) that’s all fantastic, your body is doing wonderful things, it is all moving in the right direction and just focus on that lovely out breath’ (softly speaking) and your tone is soft and then I put the phone down and whoever has been in the office says ‘oh I could have fallen asleep to that’ and that’s, it’s not rocket science this is our bread and butter, this is basic midwifery this is how labour happens and it is kind of like this, these are the easiest, you don’t need fancy gadgets it doesn’t cost you money and it doesn’t really take any more time or effort, it it, very simple ways, cos what they receive, well no the communication is not really about the words you are saying, very little about the words that you say but about the intent and the feeling and the tone and all these thousand and one things that they pick up more subliminally than through direct you know perception that’s gonna to help create that space for them or make them feel valued, make them feel like they’re the centre of your care, make them feel safe and this is all ok and I can just let myself go into this place where people aren’t used to going, not used to going to that intimate space within yourself in front of other people and a stranger so yea that’s what I mean by oxytocic voice (laughs)’.

Chapter 4

 lice: Using Discernment and Judgement During A Intrapartum Care ‘[in response to what constitutes to safe practice] obviously observations and a fetal heart that’s in normal parameters, a labour that is progressing, I wouldn’t expect a cm an hour for a primip but at least half a cm you know, if it’s meeting those, and I don’t think you necessarily have to transfer [from home] in at the first sign, if you listen in and the fetal heart is a little tachycardia [too fast], then give them some fluids, get them out of the pool, see what happens and you know if it is still raised when you’ve done all that then take them in. But I just think if you’ve got good fetal movements and a good fetal heart and a mum that is progressing nicely, generally you can stay at home … But also the thing is, as much as we say safety should be objective against a set criteria, I also think everybody has, because we all practice from our own experiences I think everyone has their own judgments of when they would or you know take actions with some things. I think midwives who have been doing homebirths for 30 years will have a different idea of what constitutes a reason to transfer in than somebody who has been doing it for a year so I think it’s quite difficult to quantify exactly, obviously you do need the criteria but it can be quite difficult cos you will always meet someone who says ‘oh no that’s fine I know what to do about that’ and some people are happy to ARM [artificial rupture of the membranes] at home, some aren’t and I think it varies quite a lot depending on experience.’ (Alice)

Trish: Careful Care Planning in Action [facilitating a birthing plan for a waterbirth for a woman expecting twins with gestational diabetes and previous pregnancy-induced hypertension] We talked about the reasons she did not want to be in hospital for the birth. Most of them stemmed from the fear that she would have her choices taken away and that care would have to follow the guidelines whether or not they were appropriate in her specific case.

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. Feeley, Skilled Heartfelt Midwifery Practice, https://doi.org/10.1007/978-3-031-43643-7

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Far from the reckless woman I had been led to expect her points seemed entirely reasonable to me … We then went on to discuss possible birth scenarios and ways she may be able to help herself achieve the birth she wanted. We talked about healthy diet during pregnancy, relaxation and reducing the time she spent in her stressful job. I felt it was important for her to feel she had done all she could to keep her blood pressure stable. She agreed that this would also give her some feeling of control during the pregnancy. I was worried it might not help and she would feel she had failed making things even worse so made sure to tell her it was only a chance that it would make a difference. In fact, her blood pressure remained normal throughout the pregnancy. I started from the point that we would work together to achieve the birth she was hoping for, and that any deviation would be fully discussed with her and would not happen without her consent and her agreement that it was the best course of action at the time. An important request was that she would be able to use the birth pool for labour. We talked about the practical issues of having twins in the pool whilst following the guidelines our Trust uses. These included continuous foetal monitoring, syntocinon infusion for the second twin and maintaining the position of the second twin by manually supporting the abdomen as it descends after the first twin is born. I had recently tested this by mocking the action of a colleague sitting in the pool and was aware that it was physically a very difficult thing to do due to bending over and not being able to reach properly. I had gone through the guidelines before I went and read up on the research about as much of it as I was able in preparation. This meant that we were able to talk about the pros and cons and look at different situations where she would want to consent to interventions and where she would not. I also knew that if I had to advocate for her with the obstetric team I had better make sure I knew what I was talking about. Knowing the latest evidence and the reasons behind the guidelines made it possible to have a conversation about which aspects she was prepared to accept and which she was not. She did not want to be restricted by a CTG machine but did consent to telemetry … We did not write a birth plan that day as we had talked about so many options. I asked her to make a list of absolute non-negotiable points, important points and icing on the cake wishes. I did get some criticism for this from colleagues … The things that were non-negotiable though were not to do with clinical care. She wanted everyone who came into her room to introduce themselves, no one to touch her without asking permission and all changes to the plan to be explained to her first. I really believe these can be achieved in any situation unless the woman is unconscious. We met a couple more times during the pregnancy. She wrote a plan and there were a couple of bits we needed to talk about. We talked about what might not go to plan and how to mitigate this as best as possible. I always talk to women about all the different possibilities and what to expect and we make plans to cover these eventualities as well … In the end, this woman went into spontaneous labour at 35 weeks. She did not get in the pool but only because her babies were both born within 15 min of arriving in the labour ward. She was upright and the birth was not interfered with in any way. She felt that she was listened to and was very happy with the birth.

Chapter 4

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Maria: Safe Care Is Personalised Care ‘I had a woman once who had a really high BMI, a BMI of 51 and she was having her third baby and I didn’t know her until the second pregnancy when I turned up on her doorstep, and it was before we started looking at BMI in a significant way, she was … she delivered while I was stood on the doorstep. I took the husband’s blood pressure because he was more shocked than she was (laughs) and everything was fine, but the thing was she got pregnant again, and we’d introduced the concept of BMI as you know, risk, so what happened was, she’d heard that we’d started doing the BMI calculation, she didn’t present with us until she was about 30 odd weeks and she came into the antenatal clinic and the consultant who was really keen on risk and BMI who saw her and she said to him ‘I think I’m going to have a homebirth, I had one last time’ he said ‘no you’re not, you’re going to die’ and she cried and she said ‘but I am sure Maria will look after me’ and he said I’m sure she won’t as she wouldn’t want to’. So it was a horrible situation, this girl was in clinic crying her eyes out and somebody came and found me and said ‘oh I think you know this girl, can you go and see her’ so anyway her BMI was 51 I think and she had essential hypertension and just not in a good place, diabetic and all those kind of things. So I looked after her at home, I just didn’t bring her back to the clinic, it just wasn’t the right place for her, every time she came in her blood pressure was sky high, so I did all her care at home and planned for everything you know, she was diet controlled diabetic, her sugars were fine, her blood pressure was normal for her, it was normal for us but it was [also] in the range of normality for her … she laboured in the pool and had a waterbirth and … and it was the best outcome for her, if she’d come in she’d have been treated as a hypertensive patient and I am not sure if she would have had this outcome.’

Chapter 5

Rachel: Learning as a Lifelong Process ‘… and I want to understand everything. I want somebody, unless you know obviously it was to save my life, if somebody went ‘you’re going to do this’, I would only do that if I understood why I was doing and if that was the right thing to do. I suppose it’s over the years of being a midwife, I trained a long time ago, over the course of, you meet people who have something like a third-degree tear. You meet somebody who has a third-degree tear, and they say to you they are so worried it would happen again, you think ‘well what are the chances of it happening again?’ And actually, is there is anything we could do additionally that could stop it happening again, so then you think well there must be evidence out there … I did a diploma, then I did the degree and then I thought ‘ok I’ll do my Master’s’, and … it’s just that want for more information for more knowledge. I think I may have qualified a long time ago, but I am always learning, there is so much other stuff I am sure I don’t know. And you know I meet with midwives for their supervisory annual review and some of them doing it a long time now are like ‘there is nothing I need to know, there is nothing I need to do now’ and I think that is such a shame because you constantly evolving and learning and there is new information comes out all the time. I just think you just have to, and women are changing, they have changed hugely in the last 20 years, and I think you just have to move with it. It’s just, that sort of probing mind, and if women are asking questions, I mean I will say I don’t know … I will go say ‘I don’t know enough about this, I’ll talk to somebody and come back to you’ and I’ll go away and read loads about it kind of thing, I need to understand that better …’

J enna: Using a Systems Approach to Support Midwives to Facilitate Personalised Care Highlighting a system-led approach to supporting midwives is Jenna, a senior midwife who shared how she led a cultural change in her organisation towards greater woman and person-centredness. However, in implementing the changes to improve © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 C. Feeley, Skilled Heartfelt Midwifery Practice, https://doi.org/10.1007/978-3-031-43643-7

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women’s access to their birth choices, the midwives on the ground were fearful and required a lot of emotional and psychological support with this change. Jenna combines notions of professional (psychological) safety, empathy and compassion and trust for her staff, actively listening and addressing their concerns, supporting their needs with the purpose to improve their wellbeing and that of women’s access to the care they desire: ‘[in relation to fears and reluctance of front-line midwives when supporting alternative physiological births]’ ‘I’m going to up at the NMC, I’m going to lose my number’1 so that’s the thing, if we could get rid of the fear and that for me I say to midwives over and over again ‘have you done what you’re supposed to have done? Can you put your hand on your heart and say that you’ve done everything you’re supposed to, and you’ve documented it?’ ‘Yes? then you’re fine and if you haven’t done everything you’re supposed to or documented everything then say it now and we can address the situation and we can sort it out, and if something happens and it’s a poor outcome and you recognise that you haven’t done everything, be open and honest with the woman. You know we are looking for a fair and just culture, we’re not looking for a blame culture within our Trust [organisation] now we are doing a lot about human factors, and a lot of stuff about just culture. And I did a massive intervention with staff which we talked about debriefing after incidents, and what came out was the blame that they were feeling. So you know, the worry, you know some of the comments came out of being asked to do things in the home that they shouldn’t be doing, so midwives feel that they’re being moved away from normal birth to complex birth, they’re not, all they’re being moved away is the narrow field we used to be able to serve a woman is going to have her baby in the home regardless of what we say or what we do … That’s when they need to know that I will support them no matter what, no what the outcome, Jenna has put this plan together, Jenna will support us but I still have to give them wriggle room in that plan cos especially in the community, they are experts in the community when I put a plan together I am very strong in saying ‘do you think that will work?’ Delivery suite, I was a Matron and a Coordinator so things changed but not that much so for that I don’t feel the need as much ‘input with the care plans,’ but I do share my plans with all the Coordinators so I will say to the community midwives this is the plan, do you think it will work, is it feasible? and if not, what do you think will work? And gradually, I get emails all the time now like ‘this lady wants a homebirth and I think we can do a, b, c, d but I’m not sure about’ and I’m thinking ‘yes’ before I would just get emails ‘this woman wants a homebirth, can you go see her?’ it’s starting now to synthesise some of the stuff that I am feeding them so they’re not so reliant I think … [To support midwives to support women] People have to see you doing what you say you’re going to do number one, number two they have to feel safe, I call it professional safety, people have to feel safe in the role they’re doing, they have

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to know if they follow their role and what’s expected of them, they can’t be touched in a negative, way they need to know that otherwise they won’t do what you’re asking them to do because they’re too frightened. They’ve got to be safe, the woman has got to be safe but the midwife has got to be safe, the worst thing you can see if a midwife has a poor outcome … that’s why we’ve moved on in this Trust [organisation], there was a lot of punitive action I feel, it was the system, I was a part of that system, I was definitely a part of that system because I came in as a Matron, this is what you do, everybody is doing it, this is what you’re supposed to do then over the years I thought ‘no, there is something not right here, something not quite right’ and that’s where the human factors came in, human factors and complex birth is beautiful together, this situational awareness, you know am I being supported? What’s the process? Is the process right? Am I setting somebody up to fail? i.e. community midwives have I given you the right information? Have I given you the right birth plan? That’s a process and if I haven’t given them the right birth plan or helped them to write the right birth plan, then that’s a system’s failure and we failed before we’ve started so it’s about safety and preventing those systems failures and professional judgement, and there is a lot and now I know the community midwives that if I say something and say I am going to do something or be with them, then I will. They’re not so reliant, they’re more willing to try things and give me suggestions about what to do and they will say ‘Jenna says it is ok’ but they’ll stop saying that soon, because it will just be ok that will be the evolution I am looking for …’