Portal de Periódicos da CAPES

Editorial: Roles in midwifery

2011; Wiley; Volume: 20; Issue: 5-6 Linguagem: Inglês

10.1111/j.1365-2702.2010.03306.x

1365-2702

Mette Madsen,

Primary Care and Health Outcomes

Midwifery and the midwives’ roles have developed over 25 years in many western countries. Influences include evidence-based practise, organisational changes, a change in society and demands from clients (Hurley 1998, Kirkham 1999, Cluett & Bluff 2000, Cliff 2002, Blaaka & Schauer 2008, Bryson & Deery 2009, Larsson et al. 2009). Evidence-based care is setting the standards for how clinicians should perform their work (Murphy 1997, Kennedy & Lowe 2001), and this means the understanding and use of research are important for midwives to provide best care. Therefore, I wonder why some midwives resist or reject research while seeming to think that it is important. These are my observations during working as a midwife, and it is supported in various scientific articles (Hicks 1995, Meah et al. 1996, Rees 1997, Hurley 1998, Richens 2002). The answer may be found in the fact that midwives seem to work between belief systems. Midwifery is embedded in a phenomenological and holistic tradition (Blaaka & Schauer 2008), but most midwives in the western world work in hospitals or in hospital settings where a biomedical tradition is dominant. The medical paradigm is dominant; therefore, midwives consider their own traditions and identity to be valued less. Skills and knowledge are not being acknowledged because scientific knowledge is prioritised (Kirkham 1999, Blaaka & Schauer 2008, Larsson et al. 2009). Jordan (1997) states that authoritative knowledge can result in powerful sanctions because of its persuasive nature. It can define the work of others, such as midwifery being defined by medicine. In her analysis of the midwifery culture in the NHS, Kirkham (1999) found that midwives have traits corresponding to an oppressed group. Midwives struggle to maintain their professional identity. They experience decreasing influence over childbirth, changes in professional identity and changed relationships with women, who have adjusted needs and demands to the medical paradigm (Kennedy & Lowe 2001, Larsson et al. 2009). This makes midwives feel less valued as professionals, resulting in low self-confidence and a feeling of a poorer professional identity (Kirkham 1999, Blaaka & Schauer 2008, Larsson et al. 2009). This can influence participation and uptake of research. Meah et al. (1996) reported that reasons for midwives to participate in research were determined by time, motivation and the effect on care and academic ability. Barriers to participate in and use of research are reported to be doctors and the medical dominance in childbirth, policies and procedures, fear, lack of skills and knowledge, support and motivation (Hicks 1995, Meah et al. 1996, Richens 2002). The dominant paradigm is making midwives feel inadequate to do research (Meah et al. 1996), but there may be other factors contributing to the lack of self-confidence and lack of participation in research projects. Oppression results in midwives losing their professional identity (Kirkham 1999). It might be possible that midwives are having difficulty defining their identity, finding their voice and being an autonomous profession because they are constantly joggling between different belief systems. It seems that midwives are trying to choose a side between the different belief systems where they can feel confident and define their identity. This is supported by the divergence reported in attitudes towards research performed by doctors and midwives (Hicks 1995, Meah et al. 1996, Larsson et al. 2009). The fact that two different cultures can be found in midwifery supports this notion. One group of midwives work more according to the medical paradigm, using research, technology in their care, and another group who emphasise tradition and knowledge described (Meah et al. 1996, Stapleton et al. 2002, Larsson et al. 2009). One reason is reported to be lack of skills to use research, thus creating a gulf between those with knowledge of research and those without the knowledge (Larsson et al. 2009). This contributes to the lack of participation in research. The different cultures in midwifery can reinforce the horizontal violence, which stem from the oppression of midwives (Leap 1997, Kirkham 1999, Stapleton et al. 2002). This means that, amongst midwives, there are conflicts that stem from conflicting research paradigms and result in collective bullying of the midwives who try to fit in to the medical paradigm or those who are ‘true to tradition’. Working between different belief systems is reinforcing this oppression; however, I wonder if the oppression has become self-perpetuating and has made midwives take the role of a victim, thus seeing only harm coming from biomedicine and quantitative research. The feeling of control from the medical paradigm is without a doubt real for many midwives. The differences between the two paradigms are distinctly, thus midwives are not able to work in congruence with their core values and ideologies. Nevertheless, I cannot help feeling that the blame of oppression from medicine can be used as an excuse for not taking on research projects and using research in midwifery. Midwives identify barriers to research to be medical dominance, doctors, lack of time and support, policies and procedures. More personal barriers such as fear and lack of skills and self-confidence are also identified. The former is related to the medical paradigm and the latter is caused by the former, thus it all comes down to the dominance of medicine in childbirth. Undoubtedly, quantitative research brings changes to midwifery because of its hypothesis testing and interventive nature. If midwives find themselves in the ‘room of struggle’ and a ‘threatened world’ (Kirkham 1999, Blaaka & Schauer 2008), they will most likely resist changes to maintain status quo (Coghlan 1993). However, changes in health care are inevitable. The evidence-based movement has had an impact on midwifery. Biomedicine and quantitative research have a strong influence on midwives’ practice in form of protocols and guidelines. Clients demand safe and individualised care, and Changing Childbirth (DH 1993) aims midwifery care to be more woman centred (Meah et al. 1996, Hurley 1998, Kirkham 1999, Bryson & Deery 2009). Midwives have to be sharp, up-to-date professionals who can act on a matter of life and death when normal pregnancy and birth turn pathological. They also need to be caring, empathic and supportive with the woman giving birth, collaborating with the woman and her family and providing individualised care to each client. Midwives must adapt to changes in relation to both paradigms, and they have the responsibility to use research giving birth for them to provide evidence-based care (Pope & Mays 1995). Childbirth is changing and so is midwifery. Midwives must redefine themselves as professionals; take responsibility and not let the oppression become a pretext for doing nothing. The conflict in professional role and identity is being reinforced by research and with midwives lacking the skills, self-confidence and motivation to take on research or to use research in practise, it becomes a vicious circle. Midwives must gain self-confidence and claim their worth as an autonomous profession and as contributors to service delivery in the 21st century’s culture of childbirth.