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Public policy, ‘men's time’ and power: The work of community midwives in the British National Health Service
Women's Studies International Forum 33 (2010) 91–98
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Women's Studies International Forum j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / w s i f
Public policy, ‘men's time’ and power: The work of community midwives in the British National Health Service☆ Valerie Bryson, Ruth Deery ⁎ Division of Midwifery, The University of Huddersfield, Queensgate, Huddersfield HD1 3DH, United Kingdom
a r t i c l e
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Available online 27 November 2009
s y n o p s i s This article links theoretical work on time and gender to a case study of community-based midwives in the British National Health Service in England. While it rejects universalism or essentialism, the article argues that continuing social differences make it meaningful to talk about ‘women's time’ (cyclical, qualitative, relational, and natural time, particularly associated with private life and care) and ‘men's time’ (linear, quantitative, commodified, and clock time, particularly associated with the capitalist workplace). It also argues that gendered time cultures are bound up with gender differences in power. The case study finds that midwives experience a damaging clash between hegemonic ‘men's time’ and the time needs of women. It also finds that, despite some recent women-friendly changes in maternity care at the level of rhetoric, market-driven reforms have consolidated an inappropriate ‘time is money’ rationality. The article concludes that we need to reassert the value of ‘women's time’ in the interests of us all. Crown Copyright © 2009 Published by Elsevier Ltd. All rights reserved.
This article is jointly written by a political theorist (Valerie Bryson) and a practicing and academic midwife (Ruth Deery). Despite our very different academic backgrounds, we have both come to see the differences between women's and men's use and experience of time as central to the understanding of gender inequalities. We both initially saw the ‘problem of time’ as a relatively straightforward issue: Valerie Bryson was interested in the extent to which women's lack of disposable time might limit their ability to participate as citizens, while Ruth Deery was concerned with the time pressures experienced by community midwives in an era of ‘efficiency savings’ and the rationalization of resources. Soon, however, we found that the problems go much deeper, involving complex issues around the meaning and nature of time.
☆ Some of the theoretical ideas discussed in this article are developed further in Bryson (2007). Some of the case study material is also discussed in Deery (2008). ⁎ Corresponding author.
The theoretical starting-points of this article are outlined in the first section, which argues that ‘time cultures’ are bound up with power and control, that it is meaningful to talk about ‘women's time’ and ‘men's time’, and that the subordination of ‘women's time’ in contemporary Western societies reflects and sustains the privileged ‘normality’ of men's perceptions, priorities and needs. The second section draws on this analysis to show that midwives experience the clash between ‘women's time’ and ‘men's time’ in particularly acute form, and that recent market-driven public sector reforms have increased the inappropriate hegemony of ‘men's time’. The third section illustrates this with a case study of community-based midwives in the British National Health Service (NHS). It finds that although recent government policies aim at supporting women, they are undermined by the ‘time is money’ rationality of NHS reforms in practice, with detrimental effects for both midwives and birthing women. The article concludes that the experience of community midwives provides a wider and increasingly urgent message about the need to reassert the role and value of ‘women's time’ in the interests of all.
0277-5395/$ – see front matter. Crown Copyright © 2009 Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.wsif.2009.11.004
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Theoretical starting-points A number of anthropologists, historians and sociologists have shown that our human experience, perception and understanding of time are to a large extent socially and culturally produced, rather than ‘natural’ (for a recent overview, see Bryson, 2007). The meaning of time therefore varies over history and between and within contemporary societies, and we can identify a range of different ‘time cultures’. In simplified terms, this means, for example, that workers' relationship with time in pre-industrial rural societies can be described as predominately natural, task-oriented and cyclical, with work time dependent on the weather, the seasons and jobs that had to be done. In contrast, industrial capitalism required factory workers to clock on at regular times regardless of the weather or the season, and they were paid for the hours they spent at work, rather than for completing a task. It is this latter form of time, the time of the capitalist workplace that continues to dominate in contemporary Western societies. In such societies, time is experienced as linear: instead of the endless cycle of the seasons, time's arrow points towards future outputs and growth and instead of an indeterminate flux of simultaneous activities, tasks are scheduled sequentially as a series of discrete events. Time is also quantified and commodified: it is treated as an abstract commodity that can be objectively measured by the clock and that can therefore be bought, sold, invested, wasted and accounted for. This does not mean that time cultures can be classified in dichotomous terms or that individuals experience time in any unitary way. As Barbara Adam (1995) says, we all inhabit a multiplicity of times, and any individual is inevitably caught both in the moment of the present and in a complex web of interconnected hopes, fears, plans, memories, experiences and expectations. ‘Other’, non-capitalist times also persist, times that are more ‘natural’, relational, task-oriented and/or cyclical. None of us can escape the natural rhythms of our bodies: we get jet lag when we cross time zones; we get hungry when we go too long without food and we are most likely to be born or die at particular times of day. Time spent on housework is primarily task-oriented and often highly repetitive (as the US comedian Joan Rivers famously said ‘You make the beds, you do the dishes — and six months later you have to start all over again’). It is also clear that personal relationships have their own rhythms, as does caring for others. These rhythms are often unpredictable and openended and cannot be readily slotted into pre-arranged time slots (you change a baby's nappy when it is dirty, not because it is four o'clock; you comfort a friend because they are distressed, not because you have a free half hour). In Barbara Adam's words, ‘… times of caring, loving and educating, of household management and maintenance, and their female times of menstruation, pregnancy, childbirth and lactation are not so much time measured, spent, allocated and controlled as time lived, time made and time generated’ (Adam, 1995:95), while Karen Davies (1994) has coined the useful concept of ‘process time’ to describe the plural, relational and context-linked nature of the time that caring for others involves. Although multiple times co-exist, all times are not equal, and the dominant temporal logic of capitalism and the market
economy forgets that ‘Not all time is money. Not all human relationships are exclusively governed by the rationalized time of the clock’ (Adam, 1995:94). The result is that we have lost touch with other temporalities, and Madeleine Bunting (2004:16) has identified a clash of ‘two different time frames: the timelessness required by their employer and the “timeliness” required by intimate relationships’. Particular tensions arise when the time-discipline of capitalism is extended into family life and paid care work: for example when parents have to rush small children through breakfast to get them to nursery on time, or when care workers are allocated 15 min to check on the welfare of an elderly person who takes 5 min to open the door and whose most pressing wish is for a leisurely chat. As will be seen in this article, midwives who work in the NHS are similarly expected to work both timelessly, treating time as an abstract commodity amenable to forward planning and strict time-keeping, and with ‘timeliness’, using time in response to immediate needs. This creates acute tensions for a community midwife who has 3 h in the morning to undertake numerous postnatal appointments, and where she is constantly hoping that women will not require long for breastfeeding or other support. Davies (1990:107) describes such tensions as a clash between the ‘technical–administrative rationality’ that controls the organization of paid employment, including care work, and the ‘nurturing rationality’, rooted in process time, that good care requires (1990:107). Edward Hall (1989) identifies a related clash between the monochronic, one-thing-after-another time of paid employment, and the polychronic time of family life, in which many activities are jumbled together. ‘Men's time’ and ‘women's time’ This article does not see women and men as closed or unified categories, and we do not claim that all women share a common time culture, let alone one that is based in biology. Even if, as some writers claim, the experiences of menstruation and childbirth can generate a particular sense of temporality, this is not one shared by all women, and it is important to remember that men too can be subject to hormonal rhythms and that the experience of parenthood can lead them to a concern for the future, rather than leaving them “isolated in their individual historicity, the dimensions of their own lifespan” (O'Brien, 1981:53. See also O'Brien (1989a,b) and Forman (1989)). In terms of social roles, it is also clear that there has been a long-term trend to gender convergence in time use, with women steadily increasing their workplace participation while men play a greater role in the home (Gershuny, 2000); it would therefore be inaccurate to claim simply that men live within the capitalist time of paid employment while women ‘attend …to other human tides’ (Thompson, 1999:382). Nevertheless, many women share temporal experiences and perspectives based around the physical processes of reproduction from which men are excluded. Western societies also remain characterised by a clear gender division of labour, with men spending more time than women in paid employment and less in the home, and women disproportionately responsible for meeting society's caring needs, both as paid care workers and through their unpaid domestic role. Here the growing field of time use studies provides evidence for
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the gendered nature of the public/private divide and women's continuing family responsibilities, although it should be noted that the studies themselves reflect a particular view of time as a quantifiable series of discrete activities. As such, they lose sight of the intangible ‘being there’ nature of caring for others and the extent that care can disappear in a mass of simultaneous activities; they therefore probably underestimate the time women spend caring for others (Bryson, 2008). Although the hegemonic time culture is often experienced as oppressive by men, both as a source of economic exploitation and as a barrier to involvement in family life, women's socially ascribed caring role means it is they who are most likely to have to ‘straddle multiple temporalities’ (Everingham, 2002:338). Women therefore experience the clash of time cultures most frequently and acutely as they strive to reconcile the physical and emotional rhythms of family life and interpersonal care with the rigid imperatives of the clock. This clash occurs in a world in which the values of the private life are subordinated to those of the public sphere. Many birthing women also encounter particular problems when the processes of labour are expected to conform to the temporal logic of medicalized childbirth (Fox, 1989; Kahn, 1989; Simonds, 2002). It is in this context that it is meaningful to identify a contrast between ‘women's time’ and ‘men's time’. The former (cyclical, natural, qualitative, relational, and process time) is the time of reproduction, the family and personal relationships, and the latter (linear, abstract, quantifiable, and commodified clock time) is ‘men's time’, the time of paid employment. This shorthand draws attention to the gendered nature of our experience of time and its association with the public/private divide, without assuming that these categories are either biologically given or exclusive (for criticisms of the ‘men's s time/women's s time’ distinction see Adam, 1995; Odih, 1999; for a defence see Bryson, 2007, pp. 138–140). As Davies (1990) (who labels the dominant time culture ‘male time’) says, it also enables us to link the marginalisation of ‘women's time’, forced into the ‘shadow’ of male time, to the more general marginalisation of women in male-dominated societies, in which women lack a public voice and in which their economic subordination limits their negotiating power both at home and in the workplace. In such societies, men's experiences, perceptions and priorities are treated as unproblematically ‘normal’, while qualities and roles associated with women are devalued, and women can be ‘equal’ only if they conform to male norms. This means that gender differences in time are bound up with the unequal distribution of resources and power between women and men, and that ‘The lack of recognition for different definitions of time other than quantifiable time represents yet another manifestation of inequality between men and women’ (Carrasco & Mayordomo, 2005:233). It also means that asserting women's temporal needs represents a challenge to the entire economic and gender order. The implications for midwifery The theories considered above suggest that members of any caring profession will be torn between the conflicting demands of two time cultures, and that the widespread
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subordination of ‘women's time’ will have negative effects on both their ability to do their work and their own job satisfaction. As early as 1989, Davies reported that care work in Sweden was being treated as a form of assembly line production within a system whose temporal logic ‘means simply that costs should be kept down and that the largest possible amount of care work should be carried out in the least possible time’ (1990:107); in a later study (1994) of Swedish day nursery workers she found such problems exacerbated by both severe cuts in staffing and by the increased use of quantifiable indicators and questionnaires to measure the quality of childcare provision. Davies (1994:289) found that the resulting over-rigid prioritization of clock over process time is to the detriment of the children (so that staff found themselves giving children ‘quick efficient hugs’, or bundling them into their outdoor clothes for a scheduled session of outdoor activity rather than letting them learn to manage buttons and zips for themselves). However she also argues that the staff were often swamped by the immediate, process time demands of the children, leaving them little opportunity for time to discuss or reflect on their work; she argues both that such ‘time out’ is important and that it would be helpful to impose clock time in order to find and defend it. The market-led reforms that Davies describes in 1990s Sweden have gone much further in the delivery of public services in the UK, where care workers, including midwives, face an increased emphasis on quantifiable targets, efficiency savings and the rationalization of service delivery along with processes of reorganization that combine to produce a constant barrage of change and upheaval. One result is simply overwork, and workplace practices that leave workers swamped by immediate demands and unable to afford the time to stand back and reflect on how they work (Deery 2005); another more fundamental result is the strengthening of a time culture that directly conflicts with the often intangible and unquantifiable processes that the provision of good quality care requires. Feminist theories of time suggest that the pressures on midwives will be particularly acute, as childbirth is in many ways the paradigm case of ‘women's time’. Although it has a history, childbirth is often felt to be a ‘natural’ and organic event, and most women experience childbirth as a complex emotional process rather than a simple act of production. Its timing and duration cannot be accurately predicted and it remains resistant to attempts at scheduling and control (Simonds, 2002); even if labour is induced it may not go according to plan, and even the most organized woman cannot have a successful five month pregnancy. In linking the mother to the continuation of the species, the experience of giving birth can also challenge her sense of time as something to be individually owned and used and provide a source of temporal understanding that goes beyond linearity (O'Brien, 1989b). However, childbirth in Western societies is largely controlled by the medical profession, which has until recently been overwhelmingly male, and feminist critics claim that modern obstetric practices have turned childbirth into a form of ‘assembly line manufacture’, a process that is expected to be ‘effective, productive, time-saving’ and in which ‘Waiting for the baby becomes a discrete, temporally precise, event’ whose timing is imposed on the erratic emotional and physical processes of labour (Fox, 1989:128, 129, 131. See also Adam, 1995; Kahn, 1989; Simonds, 2002).
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Midwifery in England One of the authors of this article (Ruth Deery) has managed to combine an academic career with the clinical practice of midwifery, and thus has firsthand experience of the issues discussed in this section. Since 1972, when her career in the health service began, there have been massive changes to both the organizational context in which health professionals work, and the nature of the work they are expected to undertake. Until the late 1960s, midwifery was practiced mainly in a community setting, with midwives supporting mothers who gave birth at home (nearly a third in 1960 — Macfarlane, 2008) and providing antenatal and postnatal care in the home to other mothers before and after hospital birth. In line with a general spirit of efficiencydriven reforms, the 1970 Peel Report (SMMAC, 1970) advocated an end to home births (Jenkins, 1995; Savage, 2000), and by 1987 ninety nine out of every hundred babies were born in hospital (Macfarlane, 2008). While the stated aim of the Peel Report was to reduce risk, ‘it was doing little more than rubber stamping a change which had already taken place’ (Macfarlane, 2008) and its recommendations were not evidence-based; critics have seen it as reinforcing compliance with a medical model of care that denies women control over the birthing process. Partly in response to pressures from midwives and women's organizations, policy has since moved full circle: there is now a move to increase the rate of home births and midwife-led care in hospitals, where the childbearing woman is the focus of the midwife's work and there is an expectation that a woman is supported emotionally and practically throughout pregnancy, childbirth and the postnatal period (Deery and Kirkham, 2006). However, as described later in this article, services which are described as ‘woman-centred’ are sometimes still run according to an industrialized conveyor-belt model with no continuity of relationship between midwife and mother. Since 1993, the British government has set further difficult challenges (see DOH 1993, 1999, 2000). The National Service Framework for Children, Young People and Maternity Services (DOH, 2004) has also set out a programme of change and improvement for the maternity services, requiring both national standards in all NHS organizations and new commissioning structures and strategies to reflect the needs of the local population. In 2007, Maternity Matters (DOH 2007) highlighted the government's commitment to developing a high quality, safe and accessible maternity service through the introduction of a new national choice guarantee for women. This recommends that by the end of 2009, all women will have a choice around the type of care that they receive, together with improved access to services and continuity of midwifery care and support. Most recently, the High quality care for all: NHS Next Stage Review (DOH 2008), which is about shaping the NHS over the next decade, endorses the agenda within Maternity Matters (DOH 2007), and again stresses the importance of giving midwives an increased role in the provision of women-centred care. Here the aim is to ensure that health care will be personalized and equitable within a safe system, for example increasing breastfeeding rates and offering more choices to women about place of birth, their access to midwives, the place and time of postnatal care and the choice and place of antenatal care.
These changes all mean that midwives are being expected to extend their roles even further, take on more responsibility and change their ways of working and all within the same time-frame. They have come to be seen as interchangeable workers who must prioritize keeping the system running (Deery and Kirkham, 2006) like clockwork. Recent changes have also to be understood in the context of the more general reorganization of the NHS. Following on from Margaret Thatcher's introduction of internal competition, the new Labour government established Primary Care Trusts (PCTs) in 1998. These organizations, which cover all parts of England and receive budgets directly from the Department of Health, are responsible for commissioning services from primary and secondary care providers for the populations they serve. Since 2002, Strategic Health Authorities (SHAs) have monitored performance and standards, providing potential ‘customers’ with guidance on available clinical care and also specifying how, and by whom, this care should be delivered. Intended to enhance quality, efficiency, value for money and choice, the shift to internal competition within the NHS has involved a programme of change and improvement for the maternity services, requiring both national standards in all NHS organizations and new commissioning structures and strategies to reflect the needs of the local population (DOH, 2004, 2006a). In addition to providing women with a more individualized service and the opportunity to choose between competing providers (DOH, 1993, 2006b), these strategies include a greater focus on vulnerable women in deprived areas, screening programmes for women and children and the provision of smoking cessation services (DOH, 2000). Although both these recent changes and the ‘new’ midwifery's focus on midwife–mother relationships (Page, 2000) are clearly intended to support birthing women, they also increase temporal stresses on midwives. Most obviously, while the development of a personal relationship between midwives and mothers requires an investment in time, organizational and bureaucratic pressures are reducing the time available for this (Kirkham, 2004). Ruth Deery has firsthand experience of the effects of increased pressures in the hospital environment, where only eight midwives may be in attendance in a ward of seventeen labouring women (with doctors only accessed when medically needed) and where midwives may now be expected to clean rooms and equipment and restock cupboards during slack periods; when Ruth Deery said that she could not attend to two high risk women at the same time, the shift leader said that as she was unable to ‘knit midwives’ there was no alternative. She has also observed that midwives are torn between their wish to provide good quality one-to-one care, their reluctance to walk away from any of the women who need them at a given moment and their sense of responsibility to colleagues whose burden would be increased if they refused to spread themselves too thinly. While many midwives are stressed because their working hours are more intense and their pattern of work has changed, the problem is not simply one of work overload, but also of contradictory temporal pressures. Thus, while the ‘new’ midwifery challenges the ‘men's time’ rationality of the workplace, a stress on audits, performance targets and risk reduction strengthens a ‘scientific–bureaucratic’ approach to
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work (Checkland, 2004; Ruston, 2003), in which personal relationships are invisible, and ‘payment by results’ rewards volume not quality of service provision (DOH, 2006a). For example, midwives are often expected to help their hospital meet its target for the numbers of women taking the triple test (for Down's syndrome), rather than providing women with the unbiased information they need to make this choice for themselves. More generally, the reforms have strengthened a culture of ‘protocolisation’ (Walsh, 2002) that appears to police midwifery practice in the guise of attempting to evaluate the quality of care provided by the maternity services, while ‘informed compliance’ (Kirkham, 2004) substitutes for genuinely informed choice. All this means that the inappropriate ‘time is money’ rationality of ‘men's time’ has strengthened its hold just as the importance of personalized emotional and practical support is being recognized; in other words, midwives are increasingly being expected to provide the kind of woman-centred service that ‘men's time’ makes so difficult. In this context, midwives find it hard to develop the kind of relationshipbased care that they want, and caring for women becomes more of a ‘human relations’ approach rather than an authentic concern to provide genuine care (Fisher and Owen, 2008) (Does the midwife say “How are you coping with the pain” because that is what she is expected to say or because she is really concerned about the woman's ability to cope with pain?). Any attempt at discussing and understanding such problems, with a view to resolving them, will also run into difficulties, as stressed and overworked people cannot find the time to think about why they are so stressed. The result is that midwives develop ways of coping that cannot be sustained and become detrimental to their health; ways that are bound by clock time culture to meet the targets and demands of the organization (see Deery 2005, Deery and Kirkham, 2006). Some of the emotional exhaustion (see Hunter and Deery, 2009) that the midwives are experiencing may be because they are carrying out the emotional work (genuine care) that remains largely unacknowledged in a world where relationships are often reduced to the mantra of human relations. In this context, it is unsurprising that around a third of those who leave the profession do so because they find that they cannot provide the type of care that women and babies deserve (Ball et al., 2002). Partly because so many are leaving, there is also now a shortage of midwives (Kirkham et al., 2006); this of course produces further pressures on those who remain. Temporal pressures are particularly apparent in a hospital setting, where midwives are ‘at the end of a fast medical conveyor belt’ (Dykes, 2009:92)and there is a clear ‘dissonance between the much advocated low-tech, womancentred, one-to-one focus and the reality of a medicalized, hierarchical, fragmented form of institutionalized midwifery’ (Dykes 2009:97). At first sight, we might expect pressures to be less acute for community midwives, who are employed by NHS Trusts and may be attached to the surgeries of general practitioners; such midwives care for women at home rather than working shifts on hospital wards. However, community midwives too have been subject to constant organizational change. Not only are they now expected to complete endless amounts of paperwork in a work culture that stresses getting through the most amount of work in the least possible time,
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but women are transferred from hospital to home much more rapidly (usually six hours after a ‘normal’ birth, three or four days after a caesarian section) than in the recent past; while many women welcome this, it is often viewed as a costcutting measure that increases the workload of community midwives. As a result, many now work extra shifts and oncalls; they also often work beyond their allotted clinical shifts (Deery, 2005; Kirkham et al. 2006). The often unpredictable and potentially open-ended nature of such work will clearly have disruptive effects on their family life. Ruth Deery has conducted research amongst community midwives in the north of England which gives voice to some of these women; her study and its findings are discussed in the next section. Case study: community midwives in the north of England The study was conducted between 1997 and 2000, and took an action research approach (McNiff, 2005) that involved working with a group of eight, white British, NHS community midwives in a collaborative, non-hierarchical and democratic way in order to achieve change (Deery and Kirkham, 2000). This accorded with a woman-centred approach to working with women that was being encouraged within midwifery at that time. The midwives, who all worked in the same team, were typical of many community-based midwives in England who were working in increasingly stressful, complex and changing environments. They all had varying levels of midwifery experience. The study's main aim was to explore community midwives' support needs and how these might be met; although it did not focus on time directly, this emerged as a significant theme. Action research facilitated the midwives devising, and putting into practice, their own model of clinical supervision (Deery, 2005). This model of supervision is described in the nursing literature as a supportive mechanism meant to create time, space and safety (Butterworth and Faugier, 1998) in order to discuss ‘casework moments’ (Wilkins, 1998:189). Each midwife was interviewed twice; before and after the experience of clinical supervision. They also participated in two focus groups before clinical supervision. In-depth individual interviews lasted up to 2 h, as did the focus groups. The interviews and the focus groups were taped, transcribed and then analyzed using a relational voice-centred methodology (Mauthner and Doucet, 1998). The “relational ontology” (Mauthner & Doucet, 1998, p.125) that is central to the voicecentred relational method focuses on understanding individuals in their social contexts and the complexities of their relationships with other people in relation “to the broader social, structural and cultural contexts within which they live” (Mauthner and Doucet, 1998, p.126). Within this method there are four or more readings of each interview transcript. Deery (2003, 2005) also used the same approach when she was analyzing data from both focus groups. This method of data analysis also complemented the feminist approach that Ruth Deery took to her work as a practicing midwife and researcher by enabling women's voices to be heard as well as facilitating connections between the individual life histories of the midwives and their work situation. The study provides a clear evidence that community midwives are indeed increasingly stressed both by a lack of time to do their work properly and by the failure to recognize the distinctive temporal logic that relational care work involves. It
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also confirms that job satisfaction is declining, that daily work pressures make it difficult for midwives to take time out to reflect on their work and that they are adopting coping mechanisms that are increasingly unsustainable. As with hospital based midwives, stress clearly arises when a small number of community midwives are expected both to look after a large number of women and to keep detailed and accurate records; this stress is exacerbated when the ‘new’ midwifery's focus on relationship building is combined with an insistence on effective time management and delivery. The effect of recent changes is clear in the words of several of the midwives who participated in the study: We used to spend hours with them in their homes and you know you were really their friend...but you're so busy now...that personal touch is lost. (Frances) I get myself all worked up…I'm coming in to work late… you keep putting things off that you should be doing there and then…so at the end of the week you've got a pile of stuff that needs sorting out…you're always off late at night and then when you get home you've forgotten to do something so you have to sit down and do it at home… in your own time… (Rachel) I mean there's all this government stuff and everybody gets a copy in their notes and they're [the women] all told what they should expect and they're all told they'll get a named midwife and they'll be seen at the time of their appointment time and the midwife will come and see you when you get home and if you arrive late they say “where have you been…I've been waiting for you”…you can't do eleven visits between 9 and 12…how can you possibly do that…not and give quality care to somebody… (Kathy) we've got four hundred women between us…we have to give a time when we visit…and if not we ring the person and give a reasonable excuse as to why not… (Stella) I went home and I sat in the chair for about an hour and a half…just like zombified…thinking about what had gone on…and if I had done everything… (Lisa) These women are describing a work situation that has become untenable and stressful; some clearly feel resentful and further stressed because work related issues have intruded into home life, with no scope for work-life counterbalancing. The problem is not simply that there are too few community midwives for too many women, but that midwives are subject to directly contradictory temporal pressures. On the one hand, the government supported a ‘with woman’ approach that expects midwives to offer choice and plan care for women and their families on the basis of needs identified through collaboration and partnership. The development of such relationships requires an investment of time that cannot be pushed neatly into a slotted timetable or work schedule; it therefore implies that midwives will not always be able to adhere to strict work organization or clock time. On the other hand, they are under pressure to ensure that all women receive appropriate antenatal and postnatal care, and to keep to a scheduled timetable of visits. The study clearly
shows that midwives gain great job satisfaction from building relationships with women and see this as leading to good clinical outcomes. However, like other studies, it also shows that stress and anxiety build up when they lack the flexible time that this requires (Kirkham and Stapleton, 2000; Kirkham et al., 2006; Deery, 2005). One strategy to resolve these tensions is simply to work longer hours, and midwives often find themselves working beyond their contract hours for no extra pay. This can lead to exhaustion, while further stress is created when work spills over into family life. Another strategy is to recognize that there is a problem and invest time in attempting to solve it. This strategy was attempted during the course of the research project, which helped the midwives devise a model of supportive clinical supervision that would help them reflect upon their work situation and, hopefully, address some of their difficulties. Although the midwives agreed that this ‘time out’ was needed, midwifery managers did not set aside any time for this; ongoing work pressures therefore meant that they were reluctant to spend time attending sessions, which came to seem like just another demand on their time. As one said of the midwives stated: it was like well what's the point of it [clinical supervision], we just haven't got time for it and yet I suppose if there was ever a time we needed it, it was at that time. (Helen) Another strategy is conforming more rigidly to ‘clock time’ and sideline the process time that relationship building requires. This can seem the most rational response when working in an organization that fails to invest time in, or give more time for, relationality and midwives' well-being. The study showed that a number of midwives were following this strategy and showing a commitment to what can best be described as ‘industrialized obstetrics’, treating support for mothers as a set of tasks to be achieved within a clear timeframe, with an emphasis on time-keeping and maximization of tasks performed. Such an industrialized conveyor-belt model, which suggests a commitment to the organization rather than to mothers, can be a coping mechanism in a NHS culture of constant reorganization and the “never ceasing demands of care work” (Davies, 1994:297), and helps protect ‘private’ time from intrusion by work. However, such rationalization of midwives' time use does not respond to the needs of the women who are being cared for; this requires a more generous, less predictable and more responsive spending of time. As indicated above, it allows no scope for addressing midwives' own clinical needs; indeed, one participant in the study (Stella) commented that ‘I don't think you include yourself in women's needs’. All this means that, because it runs counter to the ethos and needs of care work, rationalized time creates its own tensions: all the midwives in the study saw the value of investing time in relationships with mothers and colleagues; but many were unwilling or unable to do this in practice, and they became ‘obedient technicians’, viewing time as an increasingly scarce commodity rather than a creative human resource. Unable to invest relational time in the women they worked for or themselves as practitioners, the priority for many was simply to adhere to the pressures of clock time and get through their workload.
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Conclusions The importance of personalized care in the NHS is increasingly recognized by policy makers and, as the recent High quality care for all: NHS Next Stage Review (DOH 2008) says, this requires a move from quantity to quality that ‘cannot be mandated from above — it requires the unlocking of the talents of frontline staff’ (quoted in Smith (2008)). However, in the context of tight funding and a continuing shortage of midwives (Carlisle, 2008) it is difficult to see how this can be translated into practice in relation to maternity provision. Midwives like those quoted above are spending all their energies on simply getting through the day. Rather than being sent on training courses to ‘unlock their talents’, they need more time — time to talk with mothers, time to engage in genuine relationships, and time to reflect on their work. They also need access to a different kind of time, time that is more flexible, responsive and open-ended, time that facilitates genuine care. The experience of NHS midwives provides a clear illustration of a much more general problem that arises when ‘men's time’ considerations of cost effectiveness are applied too rigidly to care work, squeezing out the relational time that this properly involves. As many Western societies apparently head for economic recession and profit margins narrow, pressure on all workers is likely to increase. The effects on those who give and receive care will be particularly detrimental. It is therefore essential to reassert the values associated with ‘women's time’ and to see this as part of a wider strategy of empowering women in the interests of society as a whole. In this context, this article has sought to give voice to a particular group of women whose experiences have lessons for us all. Acknowledgments We would like to thank Dr Pamela Fisher, University of Huddersfield, and the two anonymous referees for their constructive comments and advice. References Adam, Barbara (1995). Timewatch, the social analysis of time Oxford: Blackwell Publishers. Ball, Linda, Curtis, Penny, & Kirkham, Mavis (2002). Why do midwives leave? London: The Royal College of Midwives. Bryson, Valerie (2007). Gender and the politics of time. Feminist theory and contemporary debates. Bristol: The Policy Press. Bryson, Valerie (2008). Time-use studies: A potentially feminist tool? International Journal of Feminist Politics, 10(2), 135−153. Bunting, Madeleine (2004). Willing slaves: How the overwork culture is ruling our lives. London: HarperCollins. Butterworth, Tony, & Faugier, Jean (1998). Supervision for life. In Tony Butterworth, Jean Faugier, & Burnard Philip (Eds.), Clinical supervision and mentorship in nursing (pp. 215−231), 2nd ed. Cheltenham: Nelson Thornes Ltd. Carlisle, Daloni (03 July 2008). Will Darzi bring about a renaissance in maternity services? Health Service Journal. Carrasco, Cristina, & Mayordomo, Marbel (2005). Beyond employment: Working time, living time. Time and Society, 14, 231−259. Checkland, Kath (2004). National Service Frameworks and UK general practitioners: Street-level bureaucrats at work? Sociology of Health and Illness, 26(7), 951−975. Davies, Karen (1990). Women, time and the weaving of the strands of everyday life. Aldershot: Gower Publishing Company Limited.
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Davies, Karen (1994). The tensions between process time and clock time in care-work, the example of day nurseries. Time and Society, 3, 277−303. Deery, Ruth, & Kirkham, Mavis (2000). Moving from hierarchy to collaboration: The birth of an action research project. The Practising Midwife, 3, 25−28. Deery, Ruth (2003). Engaging with clinical supervision in a community midwifery setting: An action research study, Unpublished PhD thesis, University of Sheffield, UK. Deery, Ruth (2005). An action research study exploring midwives' support needs and the effect of group clinical supervision. Midwifery, 21(2), 161−176. Deery, Ruth, & Kirkham, Mavis (2006). Supporting midwives to support women. In Lesley Page & Rona McCandlish (Eds.), The new midwifery: Science and sensitivity in practice (pp. 125−140), 2nd edition. London: Elsevier Ltd Chapter 6. Deery, Ruth (2008). The tyranny of time: Tensions between relational and clock time in community based midwifery. Social Theory and Health, 6(4), 342−363. doi:10.1057/sth.2008.13. Department of Health. (1993). Changing childbirth, part 1 (Report of the Expert Maternity Group). London: HMSO. Department of Health. (2000). The NHS plan: A plan for investment, a plan for reform. London: HMSO. Department of Health. (1999). Making a difference: Strengthening the nursing, midwifery and health visiting contribution to health and healthcare. London: HMSO. Department of Health. (2004). National service framework for children, young people and maternity services. London: DOH publications. Department of Health. (2006). Modernising maternity care. London: Department of Health. Department of Health. (2006). Our health, our care, our say: A new direction for community services. London: Department of Health. Department of Health. (2007). Maternity Matters: Choice, access and continuity of care. London: Department of Health. Department of Health. (2008). High quality care for all, NHS Next Stage Review final report. London: Department of Health. Dykes, Fiona (2009). ‘No time to care’: Midwifery work on postnatal wards in England. In Billie Hunter & Ruth Deery (Eds.), Emotions in midwifery and reproduction (pp. 1−13). London: Palgrave Macmillan. Everingham, Christine (2002). Engendering time: Gender equity and discourses of workplace flexibility. Time and Society, 11(2/3), 335−351. Fisher, Pamela, & Owen, Jenny (2008). Empowering interventions in health and social care: Recognition through ‘ecologies of practice’. Social Science & Medicine, 67, 2063−2071. doi:10.1016/j.socscimed.2008.09.035. Forman, Frieda (1989). Feminizing time: An introduction. In Frieda Forman & Caoran Sowton (Eds.), Taking our time: Feminist perspectives on temporality (pp. 1−9). Oxford: Pergamon Press. Fox, Meg (1989). Unreliable allies: Subjective and objective time in childbirth. In Frieda Forman & Caoran Sowton (Eds.), Taking our time: Feminist perspectives on temporality (pp. 123−134). Oxford: Pergamon Press. Gershuny, Jonathan (2000). Changing times: Work and leisure in postindustrial society. Oxford: Oxford University Press. Hall, Edward (1989). The dance of life, the other dimension of time. New York: Anchor Books Editions. Hunter, Billie, & Deery, Ruth (2009). Emotions in midwifery and reproduction. London: Palgrave MacMillan. Jenkins, Rosemary (1995). The law and the midwife. Oxford: Blackwell Science Ltd. Kahn, Robbie (1989). Women and time in childbirth and during lactation. In Frieda Forman & Caoran Sowton (Eds.), Taking our time. Feminist perspectives on temporality. (pp. 20−36). Oxford: Pergamon Press. Kirkham, Mavis, & Stapleton, Helen (2000). Midwives' support needs as childbirth changes. Journal of Advanced Nursing, 32, 465−472. Kirkham, Mavis (2004). Choice and bureaucracy. In Mavis Kirkham (Ed.), Informed choice in maternity care (pp. 265−287). Hampshire: Palgrave Macmillan. Kirkham, Mavis, Morgan, Rachel, Davies, Caoran (2006). Why do midwives stay? Department of Health via Bedfordshire and Hertfordshire Workforce Development Confederation. Macfarlane, Alison (2008). Reconfiguration of maternity units — What is the evidence?Radical Statistics, 96, 77−86 can also be accessed at http:// radstats.org.uk/no096/Macfarlane96.pdf Mauthner, Natasha, & Doucet, Andrea (1998). Reflections on a voice-centred relational method. Analysing maternal and domestic voices. In Jane Ribbens & Rosalind Edwards (Eds.), Feminist dilemmas in qualitative research, public knowledge and private lives (pp. 119−146). London: Sage publications. McNiff, Jean (2005). All you need to know about action research. London: Sage Publications. O'Brien, Mary (1981). The politics of reproduction. Boston, MA: Routledge and Kegan Paul.
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O'Brien, Mary (1989). Reproducing the world: Essays in feminist theory. Boulder, CO: Westview Press. O'Brien, Mary (1989). Periods. In Frieda Forman & Caoran Sowton (Eds.), Taking our time: Feminist perspectives on temporality (pp. 11−18). Oxford, NY: Pergamon Press. Odih, Pamela (1999). Gendered time in the age of deconstruction. Time and Society, 8, 9−38. Page, Lesley (2000). The new midwifery, science and sensitivity in practice. London: Churchill Livingstone. Ruston, Dave (2003). Volunteers, helpers and socialisers: Social capital and time use. London: Office for National Statistics. Savage, Jan (2000). The culture of ‘culture’ in National Health Service policy implementation. Nursing Inquiry, 7, 230−238. Simonds, Wendy (2002). Watching the clock: Keeping time during pregnancy, birth, and postpartum experiences. Social Science and Medicine, 55, 559−570. SMMAC. (1970). Domiciliary midwifery and maternity bed needs: Report of the sub-committee. London: HMSO.
Smith, Richard (2008). Ideas alone can't reform the NHS : Guardian June 30th, 2008. http://www.guardian.co.uk/commentisfree/2008/jun/30/ nhs.health Thompson, Edward (1999). Time, work-discipline and industrial capital. In Edward P. Thompson (Ed.), Customs in common (pp. 352−403). London: Penguin Books 1967. Walsh, Denis (2002). Perspectives on stand-alone midwifery-led/GP units since 1970 — Resisting bureaucratisation and obstetric hegemony, Paper presented at Birthing and bureaucracy: The history of childbirth and midwifery Conference, 11/12 October, 2002, University of Sheffield. Wilkins, Peter (1998). Clinical supervision and community psychiatric nursing. In Tony Butterworth, Jean Faugier, & Philip Burnard (Eds.), Clinical supervision and mentorship in nursing (pp. 189−204), 2nd edition. Cheltenham: Nelson Thornes Ltd.
Contents lists available at ScienceDirect
Women's Studies International Forum j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / w s i f
Public policy, ‘men's time’ and power: The work of community midwives in the British National Health Service☆ Valerie Bryson, Ruth Deery ⁎ Division of Midwifery, The University of Huddersfield, Queensgate, Huddersfield HD1 3DH, United Kingdom
a r t i c l e
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Available online 27 November 2009
s y n o p s i s This article links theoretical work on time and gender to a case study of community-based midwives in the British National Health Service in England. While it rejects universalism or essentialism, the article argues that continuing social differences make it meaningful to talk about ‘women's time’ (cyclical, qualitative, relational, and natural time, particularly associated with private life and care) and ‘men's time’ (linear, quantitative, commodified, and clock time, particularly associated with the capitalist workplace). It also argues that gendered time cultures are bound up with gender differences in power. The case study finds that midwives experience a damaging clash between hegemonic ‘men's time’ and the time needs of women. It also finds that, despite some recent women-friendly changes in maternity care at the level of rhetoric, market-driven reforms have consolidated an inappropriate ‘time is money’ rationality. The article concludes that we need to reassert the value of ‘women's time’ in the interests of us all. Crown Copyright © 2009 Published by Elsevier Ltd. All rights reserved.
This article is jointly written by a political theorist (Valerie Bryson) and a practicing and academic midwife (Ruth Deery). Despite our very different academic backgrounds, we have both come to see the differences between women's and men's use and experience of time as central to the understanding of gender inequalities. We both initially saw the ‘problem of time’ as a relatively straightforward issue: Valerie Bryson was interested in the extent to which women's lack of disposable time might limit their ability to participate as citizens, while Ruth Deery was concerned with the time pressures experienced by community midwives in an era of ‘efficiency savings’ and the rationalization of resources. Soon, however, we found that the problems go much deeper, involving complex issues around the meaning and nature of time.
☆ Some of the theoretical ideas discussed in this article are developed further in Bryson (2007). Some of the case study material is also discussed in Deery (2008). ⁎ Corresponding author.
The theoretical starting-points of this article are outlined in the first section, which argues that ‘time cultures’ are bound up with power and control, that it is meaningful to talk about ‘women's time’ and ‘men's time’, and that the subordination of ‘women's time’ in contemporary Western societies reflects and sustains the privileged ‘normality’ of men's perceptions, priorities and needs. The second section draws on this analysis to show that midwives experience the clash between ‘women's time’ and ‘men's time’ in particularly acute form, and that recent market-driven public sector reforms have increased the inappropriate hegemony of ‘men's time’. The third section illustrates this with a case study of community-based midwives in the British National Health Service (NHS). It finds that although recent government policies aim at supporting women, they are undermined by the ‘time is money’ rationality of NHS reforms in practice, with detrimental effects for both midwives and birthing women. The article concludes that the experience of community midwives provides a wider and increasingly urgent message about the need to reassert the role and value of ‘women's time’ in the interests of all.
0277-5395/$ – see front matter. Crown Copyright © 2009 Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.wsif.2009.11.004
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Theoretical starting-points A number of anthropologists, historians and sociologists have shown that our human experience, perception and understanding of time are to a large extent socially and culturally produced, rather than ‘natural’ (for a recent overview, see Bryson, 2007). The meaning of time therefore varies over history and between and within contemporary societies, and we can identify a range of different ‘time cultures’. In simplified terms, this means, for example, that workers' relationship with time in pre-industrial rural societies can be described as predominately natural, task-oriented and cyclical, with work time dependent on the weather, the seasons and jobs that had to be done. In contrast, industrial capitalism required factory workers to clock on at regular times regardless of the weather or the season, and they were paid for the hours they spent at work, rather than for completing a task. It is this latter form of time, the time of the capitalist workplace that continues to dominate in contemporary Western societies. In such societies, time is experienced as linear: instead of the endless cycle of the seasons, time's arrow points towards future outputs and growth and instead of an indeterminate flux of simultaneous activities, tasks are scheduled sequentially as a series of discrete events. Time is also quantified and commodified: it is treated as an abstract commodity that can be objectively measured by the clock and that can therefore be bought, sold, invested, wasted and accounted for. This does not mean that time cultures can be classified in dichotomous terms or that individuals experience time in any unitary way. As Barbara Adam (1995) says, we all inhabit a multiplicity of times, and any individual is inevitably caught both in the moment of the present and in a complex web of interconnected hopes, fears, plans, memories, experiences and expectations. ‘Other’, non-capitalist times also persist, times that are more ‘natural’, relational, task-oriented and/or cyclical. None of us can escape the natural rhythms of our bodies: we get jet lag when we cross time zones; we get hungry when we go too long without food and we are most likely to be born or die at particular times of day. Time spent on housework is primarily task-oriented and often highly repetitive (as the US comedian Joan Rivers famously said ‘You make the beds, you do the dishes — and six months later you have to start all over again’). It is also clear that personal relationships have their own rhythms, as does caring for others. These rhythms are often unpredictable and openended and cannot be readily slotted into pre-arranged time slots (you change a baby's nappy when it is dirty, not because it is four o'clock; you comfort a friend because they are distressed, not because you have a free half hour). In Barbara Adam's words, ‘… times of caring, loving and educating, of household management and maintenance, and their female times of menstruation, pregnancy, childbirth and lactation are not so much time measured, spent, allocated and controlled as time lived, time made and time generated’ (Adam, 1995:95), while Karen Davies (1994) has coined the useful concept of ‘process time’ to describe the plural, relational and context-linked nature of the time that caring for others involves. Although multiple times co-exist, all times are not equal, and the dominant temporal logic of capitalism and the market
economy forgets that ‘Not all time is money. Not all human relationships are exclusively governed by the rationalized time of the clock’ (Adam, 1995:94). The result is that we have lost touch with other temporalities, and Madeleine Bunting (2004:16) has identified a clash of ‘two different time frames: the timelessness required by their employer and the “timeliness” required by intimate relationships’. Particular tensions arise when the time-discipline of capitalism is extended into family life and paid care work: for example when parents have to rush small children through breakfast to get them to nursery on time, or when care workers are allocated 15 min to check on the welfare of an elderly person who takes 5 min to open the door and whose most pressing wish is for a leisurely chat. As will be seen in this article, midwives who work in the NHS are similarly expected to work both timelessly, treating time as an abstract commodity amenable to forward planning and strict time-keeping, and with ‘timeliness’, using time in response to immediate needs. This creates acute tensions for a community midwife who has 3 h in the morning to undertake numerous postnatal appointments, and where she is constantly hoping that women will not require long for breastfeeding or other support. Davies (1990:107) describes such tensions as a clash between the ‘technical–administrative rationality’ that controls the organization of paid employment, including care work, and the ‘nurturing rationality’, rooted in process time, that good care requires (1990:107). Edward Hall (1989) identifies a related clash between the monochronic, one-thing-after-another time of paid employment, and the polychronic time of family life, in which many activities are jumbled together. ‘Men's time’ and ‘women's time’ This article does not see women and men as closed or unified categories, and we do not claim that all women share a common time culture, let alone one that is based in biology. Even if, as some writers claim, the experiences of menstruation and childbirth can generate a particular sense of temporality, this is not one shared by all women, and it is important to remember that men too can be subject to hormonal rhythms and that the experience of parenthood can lead them to a concern for the future, rather than leaving them “isolated in their individual historicity, the dimensions of their own lifespan” (O'Brien, 1981:53. See also O'Brien (1989a,b) and Forman (1989)). In terms of social roles, it is also clear that there has been a long-term trend to gender convergence in time use, with women steadily increasing their workplace participation while men play a greater role in the home (Gershuny, 2000); it would therefore be inaccurate to claim simply that men live within the capitalist time of paid employment while women ‘attend …to other human tides’ (Thompson, 1999:382). Nevertheless, many women share temporal experiences and perspectives based around the physical processes of reproduction from which men are excluded. Western societies also remain characterised by a clear gender division of labour, with men spending more time than women in paid employment and less in the home, and women disproportionately responsible for meeting society's caring needs, both as paid care workers and through their unpaid domestic role. Here the growing field of time use studies provides evidence for
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the gendered nature of the public/private divide and women's continuing family responsibilities, although it should be noted that the studies themselves reflect a particular view of time as a quantifiable series of discrete activities. As such, they lose sight of the intangible ‘being there’ nature of caring for others and the extent that care can disappear in a mass of simultaneous activities; they therefore probably underestimate the time women spend caring for others (Bryson, 2008). Although the hegemonic time culture is often experienced as oppressive by men, both as a source of economic exploitation and as a barrier to involvement in family life, women's socially ascribed caring role means it is they who are most likely to have to ‘straddle multiple temporalities’ (Everingham, 2002:338). Women therefore experience the clash of time cultures most frequently and acutely as they strive to reconcile the physical and emotional rhythms of family life and interpersonal care with the rigid imperatives of the clock. This clash occurs in a world in which the values of the private life are subordinated to those of the public sphere. Many birthing women also encounter particular problems when the processes of labour are expected to conform to the temporal logic of medicalized childbirth (Fox, 1989; Kahn, 1989; Simonds, 2002). It is in this context that it is meaningful to identify a contrast between ‘women's time’ and ‘men's time’. The former (cyclical, natural, qualitative, relational, and process time) is the time of reproduction, the family and personal relationships, and the latter (linear, abstract, quantifiable, and commodified clock time) is ‘men's time’, the time of paid employment. This shorthand draws attention to the gendered nature of our experience of time and its association with the public/private divide, without assuming that these categories are either biologically given or exclusive (for criticisms of the ‘men's s time/women's s time’ distinction see Adam, 1995; Odih, 1999; for a defence see Bryson, 2007, pp. 138–140). As Davies (1990) (who labels the dominant time culture ‘male time’) says, it also enables us to link the marginalisation of ‘women's time’, forced into the ‘shadow’ of male time, to the more general marginalisation of women in male-dominated societies, in which women lack a public voice and in which their economic subordination limits their negotiating power both at home and in the workplace. In such societies, men's experiences, perceptions and priorities are treated as unproblematically ‘normal’, while qualities and roles associated with women are devalued, and women can be ‘equal’ only if they conform to male norms. This means that gender differences in time are bound up with the unequal distribution of resources and power between women and men, and that ‘The lack of recognition for different definitions of time other than quantifiable time represents yet another manifestation of inequality between men and women’ (Carrasco & Mayordomo, 2005:233). It also means that asserting women's temporal needs represents a challenge to the entire economic and gender order. The implications for midwifery The theories considered above suggest that members of any caring profession will be torn between the conflicting demands of two time cultures, and that the widespread
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subordination of ‘women's time’ will have negative effects on both their ability to do their work and their own job satisfaction. As early as 1989, Davies reported that care work in Sweden was being treated as a form of assembly line production within a system whose temporal logic ‘means simply that costs should be kept down and that the largest possible amount of care work should be carried out in the least possible time’ (1990:107); in a later study (1994) of Swedish day nursery workers she found such problems exacerbated by both severe cuts in staffing and by the increased use of quantifiable indicators and questionnaires to measure the quality of childcare provision. Davies (1994:289) found that the resulting over-rigid prioritization of clock over process time is to the detriment of the children (so that staff found themselves giving children ‘quick efficient hugs’, or bundling them into their outdoor clothes for a scheduled session of outdoor activity rather than letting them learn to manage buttons and zips for themselves). However she also argues that the staff were often swamped by the immediate, process time demands of the children, leaving them little opportunity for time to discuss or reflect on their work; she argues both that such ‘time out’ is important and that it would be helpful to impose clock time in order to find and defend it. The market-led reforms that Davies describes in 1990s Sweden have gone much further in the delivery of public services in the UK, where care workers, including midwives, face an increased emphasis on quantifiable targets, efficiency savings and the rationalization of service delivery along with processes of reorganization that combine to produce a constant barrage of change and upheaval. One result is simply overwork, and workplace practices that leave workers swamped by immediate demands and unable to afford the time to stand back and reflect on how they work (Deery 2005); another more fundamental result is the strengthening of a time culture that directly conflicts with the often intangible and unquantifiable processes that the provision of good quality care requires. Feminist theories of time suggest that the pressures on midwives will be particularly acute, as childbirth is in many ways the paradigm case of ‘women's time’. Although it has a history, childbirth is often felt to be a ‘natural’ and organic event, and most women experience childbirth as a complex emotional process rather than a simple act of production. Its timing and duration cannot be accurately predicted and it remains resistant to attempts at scheduling and control (Simonds, 2002); even if labour is induced it may not go according to plan, and even the most organized woman cannot have a successful five month pregnancy. In linking the mother to the continuation of the species, the experience of giving birth can also challenge her sense of time as something to be individually owned and used and provide a source of temporal understanding that goes beyond linearity (O'Brien, 1989b). However, childbirth in Western societies is largely controlled by the medical profession, which has until recently been overwhelmingly male, and feminist critics claim that modern obstetric practices have turned childbirth into a form of ‘assembly line manufacture’, a process that is expected to be ‘effective, productive, time-saving’ and in which ‘Waiting for the baby becomes a discrete, temporally precise, event’ whose timing is imposed on the erratic emotional and physical processes of labour (Fox, 1989:128, 129, 131. See also Adam, 1995; Kahn, 1989; Simonds, 2002).
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Midwifery in England One of the authors of this article (Ruth Deery) has managed to combine an academic career with the clinical practice of midwifery, and thus has firsthand experience of the issues discussed in this section. Since 1972, when her career in the health service began, there have been massive changes to both the organizational context in which health professionals work, and the nature of the work they are expected to undertake. Until the late 1960s, midwifery was practiced mainly in a community setting, with midwives supporting mothers who gave birth at home (nearly a third in 1960 — Macfarlane, 2008) and providing antenatal and postnatal care in the home to other mothers before and after hospital birth. In line with a general spirit of efficiencydriven reforms, the 1970 Peel Report (SMMAC, 1970) advocated an end to home births (Jenkins, 1995; Savage, 2000), and by 1987 ninety nine out of every hundred babies were born in hospital (Macfarlane, 2008). While the stated aim of the Peel Report was to reduce risk, ‘it was doing little more than rubber stamping a change which had already taken place’ (Macfarlane, 2008) and its recommendations were not evidence-based; critics have seen it as reinforcing compliance with a medical model of care that denies women control over the birthing process. Partly in response to pressures from midwives and women's organizations, policy has since moved full circle: there is now a move to increase the rate of home births and midwife-led care in hospitals, where the childbearing woman is the focus of the midwife's work and there is an expectation that a woman is supported emotionally and practically throughout pregnancy, childbirth and the postnatal period (Deery and Kirkham, 2006). However, as described later in this article, services which are described as ‘woman-centred’ are sometimes still run according to an industrialized conveyor-belt model with no continuity of relationship between midwife and mother. Since 1993, the British government has set further difficult challenges (see DOH 1993, 1999, 2000). The National Service Framework for Children, Young People and Maternity Services (DOH, 2004) has also set out a programme of change and improvement for the maternity services, requiring both national standards in all NHS organizations and new commissioning structures and strategies to reflect the needs of the local population. In 2007, Maternity Matters (DOH 2007) highlighted the government's commitment to developing a high quality, safe and accessible maternity service through the introduction of a new national choice guarantee for women. This recommends that by the end of 2009, all women will have a choice around the type of care that they receive, together with improved access to services and continuity of midwifery care and support. Most recently, the High quality care for all: NHS Next Stage Review (DOH 2008), which is about shaping the NHS over the next decade, endorses the agenda within Maternity Matters (DOH 2007), and again stresses the importance of giving midwives an increased role in the provision of women-centred care. Here the aim is to ensure that health care will be personalized and equitable within a safe system, for example increasing breastfeeding rates and offering more choices to women about place of birth, their access to midwives, the place and time of postnatal care and the choice and place of antenatal care.
These changes all mean that midwives are being expected to extend their roles even further, take on more responsibility and change their ways of working and all within the same time-frame. They have come to be seen as interchangeable workers who must prioritize keeping the system running (Deery and Kirkham, 2006) like clockwork. Recent changes have also to be understood in the context of the more general reorganization of the NHS. Following on from Margaret Thatcher's introduction of internal competition, the new Labour government established Primary Care Trusts (PCTs) in 1998. These organizations, which cover all parts of England and receive budgets directly from the Department of Health, are responsible for commissioning services from primary and secondary care providers for the populations they serve. Since 2002, Strategic Health Authorities (SHAs) have monitored performance and standards, providing potential ‘customers’ with guidance on available clinical care and also specifying how, and by whom, this care should be delivered. Intended to enhance quality, efficiency, value for money and choice, the shift to internal competition within the NHS has involved a programme of change and improvement for the maternity services, requiring both national standards in all NHS organizations and new commissioning structures and strategies to reflect the needs of the local population (DOH, 2004, 2006a). In addition to providing women with a more individualized service and the opportunity to choose between competing providers (DOH, 1993, 2006b), these strategies include a greater focus on vulnerable women in deprived areas, screening programmes for women and children and the provision of smoking cessation services (DOH, 2000). Although both these recent changes and the ‘new’ midwifery's focus on midwife–mother relationships (Page, 2000) are clearly intended to support birthing women, they also increase temporal stresses on midwives. Most obviously, while the development of a personal relationship between midwives and mothers requires an investment in time, organizational and bureaucratic pressures are reducing the time available for this (Kirkham, 2004). Ruth Deery has firsthand experience of the effects of increased pressures in the hospital environment, where only eight midwives may be in attendance in a ward of seventeen labouring women (with doctors only accessed when medically needed) and where midwives may now be expected to clean rooms and equipment and restock cupboards during slack periods; when Ruth Deery said that she could not attend to two high risk women at the same time, the shift leader said that as she was unable to ‘knit midwives’ there was no alternative. She has also observed that midwives are torn between their wish to provide good quality one-to-one care, their reluctance to walk away from any of the women who need them at a given moment and their sense of responsibility to colleagues whose burden would be increased if they refused to spread themselves too thinly. While many midwives are stressed because their working hours are more intense and their pattern of work has changed, the problem is not simply one of work overload, but also of contradictory temporal pressures. Thus, while the ‘new’ midwifery challenges the ‘men's time’ rationality of the workplace, a stress on audits, performance targets and risk reduction strengthens a ‘scientific–bureaucratic’ approach to
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work (Checkland, 2004; Ruston, 2003), in which personal relationships are invisible, and ‘payment by results’ rewards volume not quality of service provision (DOH, 2006a). For example, midwives are often expected to help their hospital meet its target for the numbers of women taking the triple test (for Down's syndrome), rather than providing women with the unbiased information they need to make this choice for themselves. More generally, the reforms have strengthened a culture of ‘protocolisation’ (Walsh, 2002) that appears to police midwifery practice in the guise of attempting to evaluate the quality of care provided by the maternity services, while ‘informed compliance’ (Kirkham, 2004) substitutes for genuinely informed choice. All this means that the inappropriate ‘time is money’ rationality of ‘men's time’ has strengthened its hold just as the importance of personalized emotional and practical support is being recognized; in other words, midwives are increasingly being expected to provide the kind of woman-centred service that ‘men's time’ makes so difficult. In this context, midwives find it hard to develop the kind of relationshipbased care that they want, and caring for women becomes more of a ‘human relations’ approach rather than an authentic concern to provide genuine care (Fisher and Owen, 2008) (Does the midwife say “How are you coping with the pain” because that is what she is expected to say or because she is really concerned about the woman's ability to cope with pain?). Any attempt at discussing and understanding such problems, with a view to resolving them, will also run into difficulties, as stressed and overworked people cannot find the time to think about why they are so stressed. The result is that midwives develop ways of coping that cannot be sustained and become detrimental to their health; ways that are bound by clock time culture to meet the targets and demands of the organization (see Deery 2005, Deery and Kirkham, 2006). Some of the emotional exhaustion (see Hunter and Deery, 2009) that the midwives are experiencing may be because they are carrying out the emotional work (genuine care) that remains largely unacknowledged in a world where relationships are often reduced to the mantra of human relations. In this context, it is unsurprising that around a third of those who leave the profession do so because they find that they cannot provide the type of care that women and babies deserve (Ball et al., 2002). Partly because so many are leaving, there is also now a shortage of midwives (Kirkham et al., 2006); this of course produces further pressures on those who remain. Temporal pressures are particularly apparent in a hospital setting, where midwives are ‘at the end of a fast medical conveyor belt’ (Dykes, 2009:92)and there is a clear ‘dissonance between the much advocated low-tech, womancentred, one-to-one focus and the reality of a medicalized, hierarchical, fragmented form of institutionalized midwifery’ (Dykes 2009:97). At first sight, we might expect pressures to be less acute for community midwives, who are employed by NHS Trusts and may be attached to the surgeries of general practitioners; such midwives care for women at home rather than working shifts on hospital wards. However, community midwives too have been subject to constant organizational change. Not only are they now expected to complete endless amounts of paperwork in a work culture that stresses getting through the most amount of work in the least possible time,
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but women are transferred from hospital to home much more rapidly (usually six hours after a ‘normal’ birth, three or four days after a caesarian section) than in the recent past; while many women welcome this, it is often viewed as a costcutting measure that increases the workload of community midwives. As a result, many now work extra shifts and oncalls; they also often work beyond their allotted clinical shifts (Deery, 2005; Kirkham et al. 2006). The often unpredictable and potentially open-ended nature of such work will clearly have disruptive effects on their family life. Ruth Deery has conducted research amongst community midwives in the north of England which gives voice to some of these women; her study and its findings are discussed in the next section. Case study: community midwives in the north of England The study was conducted between 1997 and 2000, and took an action research approach (McNiff, 2005) that involved working with a group of eight, white British, NHS community midwives in a collaborative, non-hierarchical and democratic way in order to achieve change (Deery and Kirkham, 2000). This accorded with a woman-centred approach to working with women that was being encouraged within midwifery at that time. The midwives, who all worked in the same team, were typical of many community-based midwives in England who were working in increasingly stressful, complex and changing environments. They all had varying levels of midwifery experience. The study's main aim was to explore community midwives' support needs and how these might be met; although it did not focus on time directly, this emerged as a significant theme. Action research facilitated the midwives devising, and putting into practice, their own model of clinical supervision (Deery, 2005). This model of supervision is described in the nursing literature as a supportive mechanism meant to create time, space and safety (Butterworth and Faugier, 1998) in order to discuss ‘casework moments’ (Wilkins, 1998:189). Each midwife was interviewed twice; before and after the experience of clinical supervision. They also participated in two focus groups before clinical supervision. In-depth individual interviews lasted up to 2 h, as did the focus groups. The interviews and the focus groups were taped, transcribed and then analyzed using a relational voice-centred methodology (Mauthner and Doucet, 1998). The “relational ontology” (Mauthner & Doucet, 1998, p.125) that is central to the voicecentred relational method focuses on understanding individuals in their social contexts and the complexities of their relationships with other people in relation “to the broader social, structural and cultural contexts within which they live” (Mauthner and Doucet, 1998, p.126). Within this method there are four or more readings of each interview transcript. Deery (2003, 2005) also used the same approach when she was analyzing data from both focus groups. This method of data analysis also complemented the feminist approach that Ruth Deery took to her work as a practicing midwife and researcher by enabling women's voices to be heard as well as facilitating connections between the individual life histories of the midwives and their work situation. The study provides a clear evidence that community midwives are indeed increasingly stressed both by a lack of time to do their work properly and by the failure to recognize the distinctive temporal logic that relational care work involves. It
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also confirms that job satisfaction is declining, that daily work pressures make it difficult for midwives to take time out to reflect on their work and that they are adopting coping mechanisms that are increasingly unsustainable. As with hospital based midwives, stress clearly arises when a small number of community midwives are expected both to look after a large number of women and to keep detailed and accurate records; this stress is exacerbated when the ‘new’ midwifery's focus on relationship building is combined with an insistence on effective time management and delivery. The effect of recent changes is clear in the words of several of the midwives who participated in the study: We used to spend hours with them in their homes and you know you were really their friend...but you're so busy now...that personal touch is lost. (Frances) I get myself all worked up…I'm coming in to work late… you keep putting things off that you should be doing there and then…so at the end of the week you've got a pile of stuff that needs sorting out…you're always off late at night and then when you get home you've forgotten to do something so you have to sit down and do it at home… in your own time… (Rachel) I mean there's all this government stuff and everybody gets a copy in their notes and they're [the women] all told what they should expect and they're all told they'll get a named midwife and they'll be seen at the time of their appointment time and the midwife will come and see you when you get home and if you arrive late they say “where have you been…I've been waiting for you”…you can't do eleven visits between 9 and 12…how can you possibly do that…not and give quality care to somebody… (Kathy) we've got four hundred women between us…we have to give a time when we visit…and if not we ring the person and give a reasonable excuse as to why not… (Stella) I went home and I sat in the chair for about an hour and a half…just like zombified…thinking about what had gone on…and if I had done everything… (Lisa) These women are describing a work situation that has become untenable and stressful; some clearly feel resentful and further stressed because work related issues have intruded into home life, with no scope for work-life counterbalancing. The problem is not simply that there are too few community midwives for too many women, but that midwives are subject to directly contradictory temporal pressures. On the one hand, the government supported a ‘with woman’ approach that expects midwives to offer choice and plan care for women and their families on the basis of needs identified through collaboration and partnership. The development of such relationships requires an investment of time that cannot be pushed neatly into a slotted timetable or work schedule; it therefore implies that midwives will not always be able to adhere to strict work organization or clock time. On the other hand, they are under pressure to ensure that all women receive appropriate antenatal and postnatal care, and to keep to a scheduled timetable of visits. The study clearly
shows that midwives gain great job satisfaction from building relationships with women and see this as leading to good clinical outcomes. However, like other studies, it also shows that stress and anxiety build up when they lack the flexible time that this requires (Kirkham and Stapleton, 2000; Kirkham et al., 2006; Deery, 2005). One strategy to resolve these tensions is simply to work longer hours, and midwives often find themselves working beyond their contract hours for no extra pay. This can lead to exhaustion, while further stress is created when work spills over into family life. Another strategy is to recognize that there is a problem and invest time in attempting to solve it. This strategy was attempted during the course of the research project, which helped the midwives devise a model of supportive clinical supervision that would help them reflect upon their work situation and, hopefully, address some of their difficulties. Although the midwives agreed that this ‘time out’ was needed, midwifery managers did not set aside any time for this; ongoing work pressures therefore meant that they were reluctant to spend time attending sessions, which came to seem like just another demand on their time. As one said of the midwives stated: it was like well what's the point of it [clinical supervision], we just haven't got time for it and yet I suppose if there was ever a time we needed it, it was at that time. (Helen) Another strategy is conforming more rigidly to ‘clock time’ and sideline the process time that relationship building requires. This can seem the most rational response when working in an organization that fails to invest time in, or give more time for, relationality and midwives' well-being. The study showed that a number of midwives were following this strategy and showing a commitment to what can best be described as ‘industrialized obstetrics’, treating support for mothers as a set of tasks to be achieved within a clear timeframe, with an emphasis on time-keeping and maximization of tasks performed. Such an industrialized conveyor-belt model, which suggests a commitment to the organization rather than to mothers, can be a coping mechanism in a NHS culture of constant reorganization and the “never ceasing demands of care work” (Davies, 1994:297), and helps protect ‘private’ time from intrusion by work. However, such rationalization of midwives' time use does not respond to the needs of the women who are being cared for; this requires a more generous, less predictable and more responsive spending of time. As indicated above, it allows no scope for addressing midwives' own clinical needs; indeed, one participant in the study (Stella) commented that ‘I don't think you include yourself in women's needs’. All this means that, because it runs counter to the ethos and needs of care work, rationalized time creates its own tensions: all the midwives in the study saw the value of investing time in relationships with mothers and colleagues; but many were unwilling or unable to do this in practice, and they became ‘obedient technicians’, viewing time as an increasingly scarce commodity rather than a creative human resource. Unable to invest relational time in the women they worked for or themselves as practitioners, the priority for many was simply to adhere to the pressures of clock time and get through their workload.
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Conclusions The importance of personalized care in the NHS is increasingly recognized by policy makers and, as the recent High quality care for all: NHS Next Stage Review (DOH 2008) says, this requires a move from quantity to quality that ‘cannot be mandated from above — it requires the unlocking of the talents of frontline staff’ (quoted in Smith (2008)). However, in the context of tight funding and a continuing shortage of midwives (Carlisle, 2008) it is difficult to see how this can be translated into practice in relation to maternity provision. Midwives like those quoted above are spending all their energies on simply getting through the day. Rather than being sent on training courses to ‘unlock their talents’, they need more time — time to talk with mothers, time to engage in genuine relationships, and time to reflect on their work. They also need access to a different kind of time, time that is more flexible, responsive and open-ended, time that facilitates genuine care. The experience of NHS midwives provides a clear illustration of a much more general problem that arises when ‘men's time’ considerations of cost effectiveness are applied too rigidly to care work, squeezing out the relational time that this properly involves. As many Western societies apparently head for economic recession and profit margins narrow, pressure on all workers is likely to increase. The effects on those who give and receive care will be particularly detrimental. It is therefore essential to reassert the values associated with ‘women's time’ and to see this as part of a wider strategy of empowering women in the interests of society as a whole. In this context, this article has sought to give voice to a particular group of women whose experiences have lessons for us all. Acknowledgments We would like to thank Dr Pamela Fisher, University of Huddersfield, and the two anonymous referees for their constructive comments and advice. References Adam, Barbara (1995). Timewatch, the social analysis of time Oxford: Blackwell Publishers. Ball, Linda, Curtis, Penny, & Kirkham, Mavis (2002). Why do midwives leave? London: The Royal College of Midwives. Bryson, Valerie (2007). Gender and the politics of time. Feminist theory and contemporary debates. Bristol: The Policy Press. Bryson, Valerie (2008). Time-use studies: A potentially feminist tool? International Journal of Feminist Politics, 10(2), 135−153. Bunting, Madeleine (2004). Willing slaves: How the overwork culture is ruling our lives. London: HarperCollins. Butterworth, Tony, & Faugier, Jean (1998). Supervision for life. In Tony Butterworth, Jean Faugier, & Burnard Philip (Eds.), Clinical supervision and mentorship in nursing (pp. 215−231), 2nd ed. Cheltenham: Nelson Thornes Ltd. Carlisle, Daloni (03 July 2008). Will Darzi bring about a renaissance in maternity services? Health Service Journal. Carrasco, Cristina, & Mayordomo, Marbel (2005). Beyond employment: Working time, living time. Time and Society, 14, 231−259. Checkland, Kath (2004). National Service Frameworks and UK general practitioners: Street-level bureaucrats at work? Sociology of Health and Illness, 26(7), 951−975. Davies, Karen (1990). Women, time and the weaving of the strands of everyday life. Aldershot: Gower Publishing Company Limited.
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