Choice, continuity and control: changing midwifery, towards a sociological perspective

Choice, continuity and control: changing midwifery, towards a

sociological perspective

female-dominated occupations (Witz 1990, 1992, Walby et al 1994, Davies 1995). A current study of maternity care reveals firstly, the extent to which the traditional boundaries of midwifery and medical practice are being challenged and negotiated, secondly, that constraints from state policy are crucial in deciding whether women's and midwives' demands are realised, and thirdly, that these changes may either result in a feminist-inspired paradigm of partnership with women and/or the creation of a new midwifery elite with the associated casualisation of employment for those midwives on the periphery.

POLICY CHANGES

Jane Sandall In this paper sociological theories of the professions and the organisation of work are drawn on to explain current developments in the organisation of maternity care. Utilising the literature on the sociology of the professions and general trends in health policy and labour markets, possible reasons for the current renaissance in midwifery and some implications for midwives are discussed. Thus, whilst some women and midwives may be building a paradigm of 'womancentred' practice based on an equal partnership, for other midwives, the result may be a divided workforce consisting of an elite core and casualised periphery based on the ability to give a full-time flexible commitment to work. The implications of excluding those midwives who are unable to combine fulltime work with their own domestic commitments are discussed.

INTRODUCTION

Jane Sandall BSc, MSc, RN, RM Post graduate student, Department of Sociology, University of Surrey, Guildford GUW 5XH, UK (Requests for offprints to JS) Manuscript accepted 3 May 1995

In this paper some implications of recent changes in maternity policy in the UK are examined. The aim of the paper is to draw on sociological theories of the professions and the organisation of work to understand current developments in the organisation of midwifery work. Current changes in midwifery are interesting when viewed from a sociological perspective as there is an increasing amount of literature examining the professionalisation of

Midwifery (1995) I I, 201-209 © 1995PearsonProfessionalLtd

One of the most commonly expressed wishes of expectant women is that they have continuity of caret, i.e. that they be attended during their pregnancy, labour and postnatal period by a midwife with whom they have established a relationship (Department of Health 1993:14). This has been the key theme in two recent reports on maternity care (House of Commons 1992, Department of Health 1993). These reports differed from past reports (Social Services Committee 1980) in that they have critically reassessed the roles of health professionals and for the first time taken into account the views and experiences of women and consumer organisations who had always been active and vocal before making policy recommendations. The reports also contain similarities in that both the Short Report (Social Services Committee 1980) and Changing Chidbirth (Department of Health 1993) have acknowledged the evidence but not taken any action concerning the wider socio-economic context of childbirth. For example, the Short Report recognised the association between poverty and an increased perinatal mortality rate (Social Services Committee 1980) and assumed that obstetric intervention could compensate for adverse social circumstances (Russell 1982). Similarly, although the Winterton Committee expressed concern about the financial needs of parents living in poverty and made recommendations about benefit levels (House of Commons 1992), the Cumberlege Report (Department of Health 1993) has no remit outside National Health Service (NHS) care and contains an assumption that social support and increased choice and control on the part of women may partly compensate for poverty (Streetly 1994). This is in spite of evidence documenting the widening gap of socio-economic differentials

202

Midwifery

in health in the 1980s (Davey Smith & Egger 1993), the continued association between poverty and higher perinatal mortality rates (OPCS 1993, Tables 7a:7 8: 8,) and the fact that by 1993, 30% of children were born into families on means tested benefits (Maternity Alliance 1993). Changing Childbirth (Department of Health 1993) has been welcomed by the National Association of Health Authorities and Trusts (NAHAT 1993) and all regions, districts and trusts in England have been instructed to review their maternity services in 1994/1995 (National Health Service Management Service Executive 1994) and develop a strategy to implement the ten key indicators of success within five years.

POLICY

BACKGROUND

Since the early 1980s, there has been an increasing emphasis on cost effectiveness of medical care (National Audit Office 1990). Economic assessments in this country (Mugford 1990), but also in the USA (Annandale 1989) and Canada (Romalis 1985), were beginning to show that centralisation of maternity units was not based on good evidence about the cost-effectiveness of the policy. Furthermore, research found that the outcome for women in terms of satisfaction and infant and maternal morbidity appeared to be no worse in midwife run schemes than obstetric schemes and might even be improved (Flint et al 1989). Also, reviews of the evidence on place of birth suggested that planned home birth for women at low obstetric risk had similar (Campbell & Macfarlane 1987) or even better outcomes (Tew 1985, 1990) than those of a woman at equally low obstetric risk delivered in an obstetric unit. Accompanying the concern with escalating costs were doubts about the contribution high technology scientific medicine was making to health. For example, a report from the World Health Organization described the adverse impact of increasing medicalisation of childbirth on perinatal and maternal morbidity (World Health Organization 1986). Furthermore, the first systematic meta-analysis of research in the fields of reproductive medicine and maternity care was published in 1989 (Chalmers et al 1989). This provided further evidence that for many interventions there was no proven benefit and others caused harm. The 'cultural critique' of medicine informed by the writings of McKeown (1976), and the more radical claims of medical iatrogenesis of Illich (1977) and feminist attacks on medicine

as sustaining patriarchy (Ehenreich & English 1973) challenged the legitimacy of the professional's authority which coincided with the neo-liberal view concerned about restricting consumer choice (Green 1988). These critiques were sustained by empirical evidence and comment from medical sociologists (Comoroff 1977, Macintyre 1977, Cartwright 1979, Oakley 1980, Graham & Oakley 1981). But it has been consumer organisations such as local Community Health Councils (Robinson 1974), the National Childbirth Trust and the Association for Improvements in Maternity Services which have also played a key role in this debate around childbirth (Durward & Evans 1990, Kitzinger 1990). All this created a climate where it was valid for politicians, the public and the media to question the effectiveness and efficiency of medical care, particularly in an area such as maternity where consumer voices had been particularly vocal and litigious about its shortcomings (Ennif 1991). It was also occurring in a context of a government that sought to challenge unacceptable professional power (Department of Health & Social Security 1983), shift acute services into the community (Department of Health 1989b) and emphasise the rhetoric of consumer choice (Department of Health 1989a, Department of Health 1991, Department of Health 1992). These themes can all be seen in the key themes of the Changing Childbirth report (Box 1) (Department of Health 1993).

CONTINUITY

OF

CARER

Why is continuity of carer so important? It has been recognised that the social aspects of the professional-client/patient relationship can play a vital role in client/patient satisfaction and that this has been directly associated with improved health status (Fitzpatrick et al 1983). For example, continuity of care was found to have beneficial effects for patients and providers in the specialty ofpaediatrics (Becker et al 1974). Furthermore, research of social support in pregnancy (Oakley et al 1990), and more particularly birth (Hodnett 1993),

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Changingmidwifery 203 suggest that supported w o m e n feel less anxious, more in control and more satisfied with their care and that this translates into better physical and psychological outcomes for mother and baby.

supporting complete continuity o f care, why has it become so important for midwives?

A SOCIOLOGICAL PERSPECTIVE W H A T DOES C O N T I N U I T Y OF CARER MEAN IN PRACTICE? The concept o f continuity of care has been very poorly defined (Murphy-Black 1992). Team midwifery developed as a way of organising care to increase continuity ofcarer and the current pattern of maternity care has been mapped by the Institute of Manpower Studies (Wraight et al 1993). This national survey of all maternity units in England and Wales listed five key indicators for the 14 'genuine' teams which were defined as: 1. no more than six midwives in a team; 2. defined caseload; 3. total continuity from 'booking' to postnatal period; 4. midwives working in hospital and c o m m u nity depending on the woman's needs; 5. at least 50% of w o m e n delivered by a known midwife. 'Known' midwife is not defined in the report. Furthermore, one o f the arguments for community-based midwifery care is that women at high obtetric risk (as deemed in the medical sense) benefit as much, if not more, from continuity of midwifery care (Middlemiss et al 1989, Oakley et al 1990). This has been the rationale behind community-based teams of midwives who provide care to all w o m e n in a geographical area regardless of 'risk' status, either on their own responsibility or in association with an obstetrician (House o f Commons 1992). Apart from the difficulties in implementing new ways of working in the way that was intended, there is limited evidence as to what continuity of care actually means in practice to midwives and w o m e n (Lee 1994) and some evidence that continuity does not automatically equate with good quality care (Reid et al 1983). A woman's experience o f team continuity may vary significantly from 'getting care from known caregivers at crucial times' (Garcia 1995 p.96). Garcia's (1995) review of the evidence concerning women's views of continuity indicate that, although continuity of care matters to most women, it depends how the question is asked and that to focus on continuity may neglect other aspects of care that are equally important. If there has been limited evidence

Many midwives, w o m e n and consumer groups have welcomed these recommendations (Page 1993) which represent a radical shift in policy from the past. Implicit in this enthusiasm for the ideology o f continuity o f care are the following assumptions which may explain why current changes in maternity care can be seen as a process o f professionalisation within midwifery: 1. that midwives who provide continuity of care will regain the professional autonomy that has been lost by working in a hierarchical setting dominated by medicine, and that job satisfaction will increase correspondingly; 2. that a female dominated occupation such as midwifery will provide more nurturant 'woman-centred' care than has been the case in the past; 3. that greater choice and control for women is contingent upon midwives also having greater occupational autonomy over their practice and organisation o f work. These assumptions all need to be critically examined and one o f the advantages of a sociological perspective is that it can provide a historical understanding which may throw light on the present and also provide a critical understanding when we examine social change. The sociology of professions has often used medicine as a paradigm for the analysis of the role o f professions in society (Parsons 1954). Using historical sources writers have explained that professional power and status have been achieved through a process of professionalisation, for example either by a Weberian process of occupational monopoly and closure (Larkin 1983, Freidson 1970) or a Marxist notion of a privileged position in the class structure (Johnson 1972, Larson 1977). This could be defined as the struggle for occupational advancement at the expense o f related occupations and everyone else (Walby et al 1994). These analyses have been criticised from a feminist perspective for establishing a paradigm of the professions as the study of male dominated occupations and therefore inappropriate to explain the position and professionalisation of female-dominated occupations. Furthermore, until recently they have ignored the role that gender and patriarchy have played in divisions of labour within health care (Crompton & Sanderson 1990) and have rendered female

204 Midwifery occupations in health care either invisible or inaccurately represented (Carpenter 1993). The concept of patriarchy is now used by contemporary feminist scholars to refer to gender relations in which men are dominant and women subordinate. It thus describes a societal wide system of social relations of male dominance (Witz 1992:3). Witz (1992) extends Parkin's model of exclusionary closure (Parkin 1979) to explain the various professionalisation strategies adopted by dominant and subordinate occupations. Because of their lack of access to privileges and power that male dominated occupations were able to draw upon, the strategies used by midwives at the turn of the century in the UK were described as those of dual closure, i.e. usurping traditional boundaries set by medical men and excluding other non-accredited women from their sphere of practice. For midwives, this was achieved by a process of licensing and credentialism, the culmination of which was the Midwives' Act of 1902 (Donnison 1988).

MIDWIVES' NEW PROFESSIONAL PROJECT Dingwall et al (1988) also argued that midwifery emerged in the 20th century within the context of specific social and economic conditions, which united the provision of a cheap service to the poor with the desire of some middle-class women to establish female control over childbirth, They suggest this alliance kept the ideology of a midwife as an independent practitioner alive during the 20th century, whilst in practice its economic and clinical sphere of practice was being eroded (see Fox 1993). Midwives have always suffered demarcationary closure from medical men and this increased during the 20th century as boundaries between normal and abnormal pregnancy and birth were redefined. There has also been continuing concern expressed by midwives that their traditional remit has been eroded by an increasing medical dominance of birth since the 1960s (Robinson 1990). Partly in response to these events, but also influenced by feminism and an altruistic empathy with consumer unhappiness about their experience of childbirth (Weitz 1987), midwives began to develop their new 'professional project' (Sandall 1991). The Association of Radical Midwives (ARM) was formed in 1976 expressing a concern for the erosion of the midwives' role and the resulting poor quality of care offered.

Originally started as a study and support group for student midwives, A R M has evolved into a political action group, both in alliance with organisations in the maternity rights movement and within midwifery. A R M proposed a radical change in the division of labour, arguing for greater autonomy for midwifery practice and increased choice and autonomy for women. In 1986, A R M published The Vision (ARaM 1986), a draft proposal for the future of maternity services, proposing that 70% of midwives would work in community based group practices, giving continuity of care in conjunction with teams attached to consultants. By 1989, in a response to Workingfor Patients (Department of Health 1989a), A R M were proposing that the group practices would contract for services with the new purchaser health authorities, emphasising the cost effectiveness of midwifery care. By 1992, these principles can be seen as having influenced mainstream policy (House of Commons 1992, Department of Health 1993), as in 1902, as midwives were tightly constrained by three sets of power relations: the managerial relations of control within the NHS, the inter-occupational ones between doctors and midwives, and intra-occupational relations of control within midwifery. The others are between the professionalisers and the rank and file midwife who will live and work with the implications of the policy change. For example, the new proposals for maternity care issued three challenges to existing occupational boundaries: 1. by proposing that midwives become self employed and set up in their own group practices and contract their labour to the new health purchasing authorities they challenged the managerial and medical domination within the NHS; 2. by reclaiming their role in providing continuity of care for all women and providing care without a general practitioner referral, they claim a primacy of a 'special' relationship with women over the doctor's; 3. by providing continuity of care to all women in a geographically defined area regardless of risk categorisation and having admission rights to midwifery beds in hospital they challenge the traditional demarcationary boundaries of the medical profession. These claims contain usurpationary dimensions and the ideology of continuity of care schemes reasserts control over the heart (in a metaphorical sense too) of the practice of midwifery. Thus, midwives are claiming a discrete sphere of knowledge and expertise, legitimated by a

Changingmidwifery 205 desire for a more equal partnership with women in an area where medical care has been criticised.

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IMPLICATIONS

FOR MIDWIVES

Historical evidence suggests that one result of a professionalisation process in midwifery (Heagerty 1990, Leap & Hunter 1993) and nursing (Abel Smith 1960) has been an increase in divisions of labour along the lines of ethnicity (King Edward's Hospital Fund for Nursing 1990), class (Robinson 1992, Carpenter 1993) and domestic commitments (Robinson 1993). Robinson (1992) and Salvage (1988) have both argued that a division into a core and peripheral workforce may be occurring in primary nursing and Walby et al (1994) suggest such changes may reflect a general trend in the NHS and labour markets in general, although this may be too simplistic (see Gilbert et al 1992). Walby et al's (1994) study of inter-professional relations between doctors and nurses in an acute hospital setting suggests that the organisation of work in the NHS contains examples of both a traditional Fordist labour process, i.e. one that subdivides tasks to less skilled workers who are paid less and supervised more in order to increase efficiency (Aglietta 1979) and a post-Fordist labour process, i.e. highly trained, consumer focused, committed and autonomous workers whose jobs are loosely defined and flexible (Piore & Sabel 1984). One drawback of this post-Fordist flexibility has been the development of a two-tier workforce where the skilled committed core workforce is differentiated from the peripheral workforce who are employed on short-term and temporary contracts and part-time work (Atkinson & Meager 1986, Bagguley et al 1990). The working practices required to implement Changing Childbirth suggest that the new midwife will fit the post-Fordist model, i.e. creative, committed, flexibile and focused on the consumer. But will there also be the corollary, the elite core workforce and the casual periphery, and who will be in these two groups? Providing continuity of care requires a radical change in the way that many midwives work at the moment in terms of increased flexibility and the impact of regular on-call work on midwives' personal lives 0ackson 1995) and research in progress should provide evidence as to sustainability and implementation of policy into practice, one possibility is that the rhetoric has changed but the reality stays the same (National Perinatal Epidemiololgy Unit 1995,

Sandall 1994). Fifty three per cent of midwives are estimated to have dependent children (Buchan & Stock 1990) and the number of midwives who work part time has been increasing in the last five years to approximately 40% (English National Board 1993). Thus, this issue is of particular importance to an occupation where midwives who have experienced birth and childrearing themselves could potentially have much to bring to their work. Robinson's longitudinal study of midwives' careers (Robinson 1993, Robinson & Owen 1994) has suggested the possibility that midwives with domestic responsibilities will be excluded from this potentially higher status and higher paid work, particularly since antipathy towards women who cannot pursue full-time work has always operated within midwifery. For example, discrimination against women with children attempting to train as midwives (Braun 1990), downgrading of midwives returning to work part time and a reluctance to implement job sharing (McDowall 1990). Furthermore, recent national surveys of midwifery found inconsistencies in the grading of salary scales and the development of two tiers of midwives, those who could work flexibly and those who were limited to shifts and part time work (Stock & Wraight 1993, Lewis 1995). In general, the emphasis on the single woman's career path has disadvantaged those women who could not pursue a full-time career (Davies 1990). The exclusion of women with domestic commitments has been legitimated by the perception that such women have a less than full-time commitment to their work (Lorber 1985) and replicates findings from other studies of women in the NHS (Davies & Rosser 1986, Mackay 1989, Equal Opportunities Commission 1991). This notion of gendered jobs and gendered organisations has been explored by Acker (1990) who argues that 'the concept of a job assumes a particular gendered organisation of domestic life and social production'. Thus, the gendered notion of a job is modelled on the full time male career pathway and female career pathways that require career breaks and part time work are a nuisance and disadvantage (Davies 1995) and the asssociated benefits rarely recognised (Warwick 1995).

Autonomyversus

stress

There is a suggestion that providing continuity of care results in increased autonomy which improves job satisfaction (ShohamYakubovich et al 1989) but there is also evidence of increased stress in midwifery

206 Hidwife~ generally (Carlisle et al 1994). Stock and Wraight (1993) found that midwives were trading off increased autonomy and job satisfaction with greater intrusion into their personal lives and increased demands for flexibile work hours. Some evaluations o f team midwifery have confirmed that some midwives felt 'burnt out' by the stressful on-calls, poor sick cover and interprofessional conflict (Watson 1990). Some o f these midwives shared the characteristics identified in a survey o f US midwives suffering 'burn out' (Beaver et al 1986) in that they were young, qualified in the last five years and worked alone sometimes without adequate support. Furthermore, evidence from the Netherlands suggests that Dutch midwives face similar problems combining a private life with a job that requires total dedication and continuous availability (Benoit 1991). Indeed, midwifery could be characterised as a 'greedy profession', i.e. where great commitment, loyalty, time and energy are required (Coser 1974, Segal 1986) but where the rewards are great.

IMPLICATIONS FOR W O M E N It has been assumed that because midwifery is a female-dominated occupation, midwives will guard the rights and interests of women and give a more holistic, empathetic and egalitarian style o f care, which will ensure choice and control for women (House o f Commons 1992, Page 1993). But this assumption needs to be critically examined as there is little evidence to support this view. Lorber (1985) found that external structural factors influence professional behaviour regardless of gender and others have highlighted how organisational factors can curtail or enhance the giving of woman-centred care (Green et al 1986, Annandale 1987, Kirkham 1987). The issue o f whose interests are served is explored further by Oakley (1986) and Salvage (1988) who both suggest that the struggle by nurses to achieve professional status (in terms of a male-dominated paradigm as a professional model) may reproduce the unequal power relationship that already exists between the medical profession and many patients. Oakley suggests that a feminist inspired model o f partnership with users o f services is the way forward and both Stacey (1992) and Davies (1995) elaborate on what a client-centred paradigm of professional partnership and practice may look like. What needs to be remembered is that neither midwives nor w o m e n are homogenous groups about w h o m generalisations can be made.

CONCLUSION The ideology of continuity of care reasserts control over the heart (in a metaphorical sense too) of the practice o f midwifery. Thus, midwives are claiming a discrete sphere o f knowledge and expertise, legitimated by a desire for a more equal partnership with women in an area where medical care has been criticised. It has a powerful appeal to all the interest groups within midwifery, to the generalists by emphasising the primacy of the midwife/woman relationship, to the academic professionaliser by offering increased autonomy, and lastly, to government and managers (whose support is vital to implement change) by providing cost effective care (although economic data to support this assertion is scanty). Witz (1990) describes the strategy pursued by midwives in the 19th century as a 'female professional project' using a strategy of dual closure. Since 1902, the midwifery elite has pursued this same strategy at the expense o f those midwives who did not fit the model to create an occupational structure suitable for 'educated refined gentlewomen' (Witz 1990). The midwifery elite also used gendered exclusion until the 1973 Sex Discrimination Act made such tactics illegal (Donnison 1988). Midwives have always suffered demarcationary closure from medical men and this had been increasing over the 20th century as boundaries between normal and abnormal were redefined. Partly in response to these events, but also informed by feminism and altruistic empathy with consumer unhappiness about the organisation of maternity care, some midwives began to develop their new 'professional project'. This new strategy of dual closure contains usurpationary dimensions, as midwives reclaim their role in providing continuity of care for all women. Now, as in 1902, midwives are tightly constrained by the three sets of power relations, the managerial relations of control within the NHS, the inter-occupational ones between doctors and midwives, and intra-occupational relations o f control within midwifery between the 'elite' professionalisers and the rank and file and increasing consumer pressure to be partners in care. Current attempts to develop professional status are dependent on state mandate, funding and political expediency (White 1985). The interest shown by the U K Government in the cost effectiveness of midwife care and the alliance that has been forged with consumers may well mean that this female professional project may be successful but at the cost of dividing the midwifery workforce. A

Changing midwifery

sociological perspective suggests that midwifery as a f e m a l e - d o m i n a t e d be developing

a new

occupation

may either

feminist paradigm

profession in partnership with women,

of a

or once

a g a i n , as in t h e b e g i n n i n g o f t h e 2 0 t h c e n t u r y , a strategy of dual closure may exclude the rank a n d file m i d w i f e w h o m a y b e e x p e c t e d to p a y t h e p r i c e f o r t h e p r o f e s s i o n a l i s i n g elite.

ACKNOWLEDGEMENTS Jane Sandall is a Doctoral Research Scholar, Research Training Scheme, NHS Executive Research and Development Division.

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