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Swedish midwives' care of women who are at high obstetric risk or who have obstetric complications
Swedish midwives’care of women who are at high obstetric risk or who have obstetric complications Marie Berg and Karin Dahlberg Objective: to describe how midwives experience the care of women who are at high obstetric risk or who have an obstetric complication during pregnancy, childbirth and early parenthood. Design: a qualitative approach using a phenomenological method. Participants: 10 Swedish midwives, recognised as highly skilled clinicians with at least ¢ve years of clinical experience in the studied context, from four di¡erent hospitals. Findings: the essence of midwifery when caring for women at high obstetric risk or with a manifested complication was de¢ned as ‘a struggle for the natural process’. Women’s transition, physically as well as emotionally, during pregnancy, childbirth and early parenthood, was described as a genuinely natural process.The midwives’ struggle consisted of encouraging and preserving this process within each woman. It was based on embodied knowledge and included a balancing between the medical and natural perspectives. Prerequisites, and therefore part of the struggle for the natural process, were sensitivity to the spontaneous, mutual interaction with the woman and enduring presence. Key conclusions and implication for practice: the midwives’ responsibility is to promote the natural process during pregnancy, childbirth and puerperium within every woman at high obstetric risk or with obstetric complications.The ¢ndings could serve as a basis for re£ection on the professional role of midwives, and on the organisation of modern maternity care. & 2001 Harcourt Publishers Ltd
INTRODUCTION
Marie Berg, Lic.Med. Sci., MNSc, MPH, RNM, Lecturer, Department of Health Sciences, University of Sk˛vde, Box 408, 541 28 Sk˛vde, Sweden Karin Dahlberg, RN, PhD, Professor, BorÔs University College, School of Health Sciences, 501 90 BorÔs, Sweden (Correspondence to MB) Received 15 February, 2001 Revised 29 March 2001, 24; May 2001 Accepted for publication 18 June, 2001
Maternity care has undergone great changes during recent centuries in western industrialised countries. In Sweden, major changes began in 1663 when the Collegium Medicum (CM) was established by a group of university-trained doctors and a new form of maternity care with rules and regulations was established. Successively, midwifery was placed under the supervision of CM. In Sweden, the hospitalisation of women at childbirth began at the end of the 18th century (Ho¨jeberg 1991, O¨berg 1996, Romlid 1998). As a consequence of this, childbirth was moved from being secret and hidden, to be public (Ho¨jeberg 2000). As in other industrialised countries, the approach to pregnancy and birth in Sweden has gradually changed from that Midwifery (2001) 17, 259^266 & 2001 Harcourt Publishers Ltd doi:10.1054/midw.2001.0284, available online at http://www.idealibrary.com on
of folk medicine and normality to a medical, scientific perspective (Ho¨jeberg 2000). The organisation of Swedish maternity care has changed during the last decades as a result of political decisions based on medical considerations and the health economy (Socialstyrelsen 1996). In many hospitals, the care has been differentiated into two levels: 1) care of women with normal processes during pregnancy and childbirth with the definition of normal birth as a base (WHO 1996, Socialstyrelsen 2001), and 2) care of women at high obstetric risk or who have obstetric complications. The midwives are responsible for the care of women with normal processes but in the case of abnormality or high obstetric risk they lose some of their autonomy, as the obstetricians take over the responsibility. Even if the midwives, providing care to women
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with abnormal processes, are still engaged in giving care in pregnancy, childbirth and the puerperium, they work under supervision and assist the obstetricians in obstetric interventions and specialised investigations. Nevertheless a lot of midwives are specialised in different fields, as for example in ultrasound and diabetes care, and may be given a certain delegated responsibility. The boundary between normality and highrisk/complication is not fixed. It is socially defined and changes over time. For women at high obstetric risk, the risk for complications is higher for either themselves or the expected/ newborn baby. They may for example have a chronic disease that may influence the process or have a history of previous severe obstetric complication. This definition has increasingly been filtered through scientific and medicotechnological advances. The extreme standpoint is to treat every pregnancy and childbirth as a risk until the opposite is proved (Downe 1996). As a consequence of changes and advances in maternity care, the midwives have continuously revised their professional role and identity. By tradition and according to current views Swedish midwives have an influential status and a wide field of activity (SOSFS 1995, Socialstyrelsen 1996). In spite of this, the focus towards risk and complications in childbirth (Downe 1996) has indirectly limited their professional role and domain of responsibility. One main question is whether midwives have a defined responsibility of their own in high-risk obstetric care, or only have the role of assistants to the obstetricians. The objective of this study was to describe how midwives experience the care of women during pregnancy, childbirth and early parenthood when the situation is characterised as high-risk from an obstetric point of view or when a complication is manifested for the woman and/or the unborn/newborn baby.
METHOD To achieve a deeper understanding of how midwives experience ‘‘midwifery’’ in this special context, a phenomenological method, based on a lifeworld approach, was chosen (Dahlberg et al. 2001). This approach focuses on the everyday world of experience prior to any theories. In the present study, the focus was on midwives’ lifeworld. During the analysis of data, Giorgi’s (1997) phenomenological research method, built on three criteria, was followed. First it includes a descriptive step, which means that the analysis is based on detailed concrete descriptions of a specific experience. The claim for description also means that the researcher and thus the analysis should not be interpretive. Secondly, phenomenological research operates through
what Giorgi calls ‘phenomenological reduction’, which means that the researcher must withhold past knowledge about the studied phenomenon in order to be fully attentive to the concrete instance of the phenomenon as experienced and presented by the informants (Giorgi 1997, p244). Consequently there is a need for openness and pliability on the behalf of the researcher so that implicitly understood experience can be articulated (Dahlberg & Drew 1997). Thirdly, there is a search for what Giorgi (1997) defines as a ‘scientific essence’ (p244), that is, a general structure of the phenomenon.
Participants Midwives were selected from four hospitals where the care of women at high obstetric risk or with obstetric complications was in some way differentiated from the care of women under normal conditions. Midwives with at least five years of clinical experience in the studied context and recognised as being highly skilled clinicians, were chosen following the proposal of the head of each maternity ward. Because a small number of participants is often recommended in phenomenological research (cf. Dahlberg et al. 2001) 11 midwives were invited, representing a diversity of work experience in the actual context. Ten midwives agreed to participate.
Interviews Consent to conduct and record the interviews was obtained from each midwife, who were all assured that all information would be treated confidentially. Ethical approval and permission to undertake the study was obtained from the Research Ethics Committee, Go¨teborg University. A total of 10 tape-recorded interviews, with duration of 45–120 minutes, were carried out between January and May 2000, in a private setting at the hospitals. The interviews began with an open question: Please describe your experience as a midwife in the care of women in obstetric high-risk and/or when a complication is manifested for the woman or her unborn baby? The midwives were asked to describe the experience as closely as possible even using examples of women cared for. Questions of great importance touched upon the intersubjective encounter and the co-operation with obstetricians. The interviews were characterised by an open approach with a receptive, perceptive, sensitive and reflective stance (Dahlberg & Drew 1997). Statements made by interviewees could be explored in depth by clarifying and exemplifying as much as possible. Thus the researcher posed questions such as: ‘What do you mean?’, ‘Can you give an example?’, ‘Please express your feelings’.
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Data analysis
Sensitivity for the spontaneous
The goal of the analysis phase was to explicate the implicit, to discover, articulate, illuminate and describe the tacit knowledge, without interpreting. The phenomenon was the midwives’ experiences of caring for women with obstetric complications or at high obstetric risk. Giorgi’s (1997) phenomenological method was used with the aim of finding a scientific essence of the phenomenon. The interviewer (MB) began by transcribing the interviews. The analysis began with reading the transcribed interviews in order to gain a general sense of the whole statement. The text was then reread with the aim of organising and expressing the data from the disciplinary perspective, ‘meaning units’ were marked. The transformed ‘meaning units’ were synthesised and summarised and an essence/ general structure of the phenomenon was formulated and expressed with its variations through different constituents. Finally the findings were translated into English. An open attitude was maintained even in the analysis process by repeatedly returning to the data in order to look beyond what had already been seen. Since the interviewer (MB) is a midwife it was important for her to protect an open approach by a reflective stance in the research. The other researcher is not a midwife, which contributes to objectivity.
The midwives had a special sensitive openness towards the spontaneous, natural process within the women during pregnancy, childbirth and the puerperium. They performed a mindful, active search for this inborn ability in every woman:
FINDINGS The age range of the participants was 41–52 years and they had between 9 and 29 years midwifery experience. The range of experience of providing care to women at high obstetric risk or with obstetric complications was five to eight years. The essence of midwifery in the care of women at high obstetric risk or with a manifested complication was defined as ‘a struggle for the natural process’. Women’s transition, physically as well as emotionally, during pregnancy, childbirth and early parenthood, was described as being a, by origin, natural process. The midwives’ struggle consisted of encouraging and preserving this process within each woman. It was based on embodied knowledge and included a balancing between the medical perspective on the one hand and the natural perspective on the other hand. Prerequisite, and therefore a part of the struggle for the natural process, was the midwife’s relationship with the woman. Constituents of the essence were sensitivity for the spontaneous, mutuality, enduring presence, balancing and embodied knowledge. Direct quotations from the data are used to illustrate points and to maintain anonymity identifiers are used, for example M1 is the abbreviation for midwife one.
Then it is important to keep her in focus, she herself, keep her in view. She is not the complication in itself but rather the person who has complications. (M3) Medico-technical interventions and examinations, necessitated by the woman’s or the fetal conditions, were experienced as disturbing. The midwives felt an increased responsibility to: . . . focus and see the woman more, not just the machines, tests and everything surrounding her. (M1) Midwives’ support of the natural process was integrated as a common part of the care, no matter what circumstances. During childbirth, the promotion of the natural process could imply letting the delivery go on with as few interventions as possible. ‘Machines shouldn’t be any problem’ (M6) and women were encouraged to let the birthing process go on and to use their inherent strength. The expectations and wishes of the woman/couple, often disregarded in complicated or high-risk situations, were encouraged. Even in the care of a woman with a newly discovered advanced cervical cancer the midwife could promote the natural process. She focused on the baby and parenthood and influenced the routines so woman–baby contact was established before the start of the cancer operation: They were both so happy because suddenly they were to be parents, it wasn’t just all about cancer. (M10) Sensitivity for the spontaneous also included openness to a mother’s natural capacity to breast feed, even if her baby had little chance of survival: So long as there is a chance of survival we want to encourage the normal and the usual (M10). When a baby was stillborn, there was still parenthood for the midwives to confirm. They wanted to give the parents as good an experience of the baby as possible, helping them to see, touch and keep the baby in their minds: . . . so that they have a child they can mourn. To help parents to meet their child. Despite whether it is alive or not, despite what it looks like. . .. it’s important that I cuddle it and with tenderness so as to show the parents that I
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accept their child and that they may also dare to do likewise. (M9)
Mutuality In the midwives’ descriptions, mutuality in the relationship between midwife and woman was delineated as a necessary basis for good care. Essential components in this mutual relationship were the reciprocal giving of oneself, respect, openness, susceptibility for whatever comes from the other and a wish to understand. By this, trust, security and confidence could evolve: A meeting cannot just be one-sided. It must be mutual. . . . The most important thing is to build a relationship, to build bridges. . . . Create reliability and security out of chaos. . . . I must establish a line of communication so that she can learn to trust and understand me. Feel safe with what I’ve got to offer and trust in it so that we can work together. That is a mutual trust. . .. But even in the other direction, that she dares to show me what she’s feeling. Her worries or whatever, her happiness, that she dares to show it. But this means that I must create a confidence in this, too. Make it plain that I see her. (M5) In order to be open to a woman’s needs in the actual caring situation, the midwife had to understand and know the woman’s general lifesituation, her everyday life. The openness also involved attuning to the manner of every single woman both in the way of talking and the way of being: You have to listen your way into the everyday life of the patients, you might say. That’s how you create a good relationship (M8). Mutuality included openness towards personal feelings. Midwives’ did not ‘fear to show their own feelings’ (M1). Rather they found it necessary to be open, as the women observed their feelings. Caring for a woman with preeclampsia exemplified this. When her symptoms became aggravated, midwives came more often to observe her, measuring blood pressure and taking blood tests: She is worried anyway. . . .It is better to be forthright and explain what we are feeling, why, and what we are doing about it, what we are planning. (M4)
Enduring presence Midwives practised providing an enduring presence. That is they wanted to be close and accessible to the woman, no matter how the process developed. They felt a special challenge
and responsibility to be there, with the woman. This ‘enduring presence’ included nearness, both in an emotional and a physical sense. As women at risk of, or with, complications had an increased need of care, it could consist of several caring encounters where each midwife had her own relationship with the individual woman. But midwives superseded and completed each other and thus formed an enduring presence for every woman cared for: ‘everyone helps to keep things running smoothly’ (M2). In order to strive for continuity, the midwives tried ‘to minimise the number of persons around every woman’ (M7). The beginning and end of every relationship was given special attention. Mentally, preparation for the first encounter with a woman could imply slowing down, appeasing hunger and leaving other assignments to colleagues. In the last encounter there was need for ‘finishing up nicely’ (M6). Enduring presence even included availability in terms of time. Multiple assignments and work under stress were defined as obstacles to the relationship and sometimes the midwives even had to fight for suitable conditions: I give her my time; show her that I have time for her. I stop and I sit down, . . . this is quality time that you are working with, as so many others are making demands upon you. (M5) The enduring presence also implied an advocating and influencing act as taking pains to maintain the woman’s integrity and if necessary being a shield from the ‘threatening surroundings’ which could be both other carers and relatives/visitors: We often defend the patients and stand by them so that their experience will be as good as possible. (M2)
Balancing There was a duality embedded in the midwives’ ‘struggle for the natural process.’ They promoted and showed an increased sensitivity for the natural process but were at the same time aware that obstetricians had the final word as regards the care of women at high-risk or with complications. For the midwives, the balancing act implied finding a level where both natural and medical perspectives could exist side by side. Focusing upon the natural process did not mean removing the reason for the special treatment but included a struggle to let nature take its course, ‘to see childbirth and maternity time from the point of view of the normal.’ (M6) Midwives believed that balance could be reached when there was a relationship between midwives and obstetricians based on mutual
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respect and confidence, both professions striving for the same goal, ‘to help the mother to get through this pregnancy and birth with as little sickness and complication as possible’ (M2). They sometimes perceived an internal conflict between, on the one hand simply carrying out the obstetricians’ prescriptions and on the other hand advocating women’s rights to a natural course of events, ‘watch over the patient, protect the patient a little’ (M2), by seeing to it that medical and technical interventions were as few as possible. The midwives were convinced that every ‘woman has an inborn strength which we may support so that natural process is promoted’ (M8). They even felt that the demands upon them were higher, that ‘the midwife is more important’ (M6) in the care of women at risk or with complications when permitting and promoting the natural process, than when caring for women in normal processes.
Embodied knowledge Good knowledge was described by the midwives as being essential in the care of women at high risk or with obstetric complications. The knowledge consisted of good theoretical obstetric and medical knowledge, good practical experience and ‘sensitive knowledge,’ a developed ability to use one’s senses. Knowledge became embodied, lived out and thus a part of daily work, when it was integrated within the midwife. It developed over time and increased with extended working experience: One learns new things all the time that sink in, leaving room for more learning. This is deeprooted knowledge. (M9) Insufficient obstetric and medical knowledge as well as a shortage of practical experience meant that too much time and energy were wasted on examinations of the special condition. On the other hand, increased obstetric and medical knowledge about complicated conditions and intercurrent diseases gave midwives a feeling of security and safety in their professional role, making it easier to guide women through the natural course of events and thus avoid unnecessary ‘pathologisation.’ In this way, midwives could successively raise the limit for what they considered as normal, without losing attentiveness for the occurrence of acute situations: I have reconsidered my views as to what sickness is and what health is. One would have thought that one would become fixated with the complicated, but it has been rather the opposite. I have raised the limit for what I consider as normal. (M7) Through ‘sensitive knowledge,’ midwives could understand the woman’s needs better.
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When the natural process was hindered by obstacles within the pregnant or birthing woman, the use of this ‘sensitive knowledge’ could ‘open doors’ for her: I have to hear what she’s saying. I have to hear, I have to feel, absorb what it is she wants, what she’s afraid of, what she’s going through just now and all that. . . . I can feel it in the air, feel it in the vibrations, you can see it in her body language; hear how she breathes, speaks. (M3) More experienced midwives acted as advisers and supporters for the less experienced. Reflecting about given care together with colleagues functioned as guidance and a basis for personal growth and increased security: One needs to reflect on things with one’s colleagues. One learns new things all the time that sink in, leaving room for more learning. This is deep-rooted knowledge. (M9) Midwives also spoke about a more integrated level of embodied knowledge, which could develop as professional experience increased. It was called ‘intuition’ by several midwives and was seen as an unparalleled tool to understand and determine a woman’s condition and needs. Based on the impressions one received in the encounter with the woman it could appear when ‘an unexpected course of events’ arose. It could also be expressed as ‘sense of worry or uneasiness’ or as ‘ feeling that things were not quite right’ (M 7). Midwives stressed that they needed courage to live out this more integrated level of embodied knowledge. The decision to have the courage to act in accordance with intuition was often based on previous experience of not having had the courage to act upon intuition: It has something to do with experience and sensitivity, which I also think has something to do with intuition. It is something that only midwives have, midwife-intuition, midwifesense. . . .I do not think we should be afraid of trusting these feelings. We often feel things long before anyone else notices anything. (M6)
DISCUSSION In the present study, midwifery is explored through the descriptions of experienced midwives. ‘A struggle for the natural process’ emerged as the essence of midwifery in the care of women at high obstetric risk or with a complication. It runs all through the interviews and seems to be an ethical demand deeply embedded within midwifery in this context. However, there are limitations to the study.
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The interviewed midwives are not representative of all midwives, and the organisation of maternity care in the studied context differs. The findings do not describe deeply enough the struggle midwives make in an attempt to achieve normality when caring for women at high risk or with a manifested complication. This struggle for the natural process is probably not recognised by midwives themselves, they just live it. To go further, a methodological multiplicity including both video observations and recordings of encounters between midwives and women, might be needed in order to deepen the knowledge of how the natural process is promoted. The word ‘natural’ is central in the findings. The midwives themselves mentioned the word ‘normal’ several times. The analysis revealed a wider perspective of the phenomenon which is mirrored by ‘natural.’ It explicates the very meaning of the midwives’ descriptions. In addition ‘normal’ is something that changes over time and culture (Downe 1996). According to etymological and dictionary analysis (Collins English Dictionary and Thesaurus 1993) ‘natural’ is something which belongs to one’s nature, not acquired, not supernatural, artificial or constructed by man but lifelike, innate, genuine, usual and spontaneous. Synonymous with ‘natural’ are real, unaffected, pure, unrefined, whole, simple, common, legitimate, logical, normal, ordinary, regular, typical, essential, inborn, indigenous, inherent, innate, instinctive, intuitive, ingenuous and open. To maintain health and regard pregnancy as a natural condition is the main task for the Swedish midwives (Svenska barnmorskefo¨rbundets policyprogram 1995). This task is probably not limited only to the Swedish context but is a main, universal element in exemplary midwifery practice. This task, however, seems threatened in the present findings. The word ‘struggle’ in the findings points to this and this is not something new. History certifies that Swedish midwives’ struggle has gone on for centuries (Ho¨jeberg 1991, Romlid 1998, O¨berg 1996). The present findings describe the internal conflict midwives may perceive. The natural process seems threatened, put aside and sometimes even totally repressed by the medico-technical perspective when risks and complications are focused upon. This makes one think of Reynolds’s description (1991) of the technocratic culture where ‘natural bodies’ are replaced with man-made bodies. In a technocratic culture only technologically obtained medical knowledge is said to be authoritative (Davis-Floyd 1994). Reynolds (1991) declares that a society’s core value system is nowhere more evident than in the treatment of the human body, particularly when that body is giving birth to new social members. It is obvious that childbirth is particularly under the domain
of technocracy when risks or complications are more frequent. Mercantile forces behind the technicalisation often strengthen its power. Technical developments offer opportunities to improve maternity care. But they also entail new risks. With advanced technology, the woman’s body risks being placed outside her self, impossible to understand even for herself (Ho¨jeberg 2000). This is typical for modern science, which aims at being master of nature in order to control it (von Wright 2000). This does not contradict the fact that it is intended to be good for human life. One meaning of the midwives’ struggle was their effort to obtain a balance between the natural and medical perspective. According to Bla˚ka Sandvik (1997) two different discourses exist in modern maternity care, ‘the medical science of birth’ which emphasises that all births have a pathological potential, and ‘the traditionally based knowledge’ which includes a natural perspective. Midwifery is practised at the point of intersection between these two discourses. The fact that several times the midwives used the word ‘patient’ in this study could signify that maternity care is still governed by medical science. Bla˚ka Sandvik (1997) emphasises that the midwives must be allowed to give care based on their own standpoint and proposes that they have to take into account both discourses when creating a new self-image in modern maternity care. The findings show that a ‘mutual relationship’ between midwife and woman was defined as the basis for the care of these women. Mutuality, or reciprocity, is according to Dahlberg (1996), crucial in a confirming, caring relationship as it bestows the patient a place ‘to be’. The constituent ‘enduring presence’ illuminates another feature of the relationship. ‘Enduring’ means continuing, durable, lasting and persisting and points to the nature of the ‘presence’ of the midwives. ‘Presence’ is found to be a universal element of interpersonal phenomena and a central concept in caring (Gilje 1992). Presence is ‘being here and not elsewhere’. It is being with, which means closeness in a physically, psychological, emotional and spiritual sense. It is nearness in time, space, amount or resemblance (Paterson & Zderad 1988). The midwives want to be constantly present, an enduring presence, if not physically so at least mentally. Together, as colleagues, the team of midwives contributed to this but at the same time the interviewed midwives stressed the need for there to be as few people as possible around the woman, to reach a higher degree of continuity. It is important as Thomson (1980) stated as early as 1979 that the specialisation of obstetric care has led to a fragmentation of care for the women treated by many different midwives and doctors.
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Continuity of midwifery care, on the other hand, is associated with lower intervention rates than standard maternity care (Waldenstro¨m 1998). ‘Presence’ is also the influencing act of intervention including active and passive strategies intending to control situations (Gilje 1992). This is also obvious in the present study. The midwives expressed their advocating action for the woman cared for. According to Hildingsson and Ha¨ggstro¨m (1999), advocacy of the woman is essential in supportive midwifery during pregnancy. ‘Embodied knowledge’ was another constituent in the findings. It consisted of practical, theoretical and sensitive knowledge. This kind of knowledge is described as important in an applied discipline (Benner et al. 1999). Practical knowledge is ‘know-how’ - knowledge, theoretical knowledge is ‘know-that’ knowledge and the sensitive knowledge described in the findings is the same as ‘perceptual knowledge’. The more integrated level of embodied knowledge described by the midwives is similar to what Benner (1984) defines as expert nurses’ ‘intuitive grasp’ (p295). It relies on perceptual capacity and is defined as a ‘direct apprehension of a situation based upon a background of similar and dissimilar situations and embodied intelligence or skill’ (p295). Vague hunches, such as ‘a sense of uneasiness’ or ‘a feeling that things are not quite right,’ expressed by the midwives, are similar to common characteristics of an ‘expert nurse.’ The intuitive grasp is a useful tool and ‘may lead to early identification of problems and the search for confirming evidence’ (Benner 1984, pxix). The midwives told how their personal decision to dare to use and act according to their inner feelings was often based on a specific caring experience when they had been lacking in this courage. This responds to what Benner et al. (1999) call a ‘paradigm-case’ (p568), a clinical episode that alters one’s way of understanding and perceiving future clinical situations. Guidance by colleagues was described as a necessary ingredient in the developing of embodied knowledge. This is concordant with one of the constitutions (SOSFS 1995:15) for Swedish midwife’s work which states that the nurse/ midwife needs time for reflection and analysis of different problems together with colleagues and other professionals in order to deepen their experiences from daily work. This reflection and discussion of the art itself is probably really important as it contributes to a uniform professional identity, which fortified the midwives to promote the natural process. However, over the last few years a wide range of organisational changes in Sweden has led to a diminishing work force with a subsequent loss of time for reflection. Due to this situation there is less time for
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informal discussions with colleagues, a fact that probably increases midwives’ difficulties in promoting the natural process.
Conclusion and practical implications The present study focuses upon midwifery in Sweden but there are probably many common points of reference with midwifery in other western, technocratic countries. The division of maternity care into normality and abnormality may contribute to a reductionistic view of the woman in need of care. It may also lead to a marginalisation of the midwife’s role. The findings show that the midwives providing care for women at high obstetric risk or who have obstetric complications, have undoubtedly a special responsibility as promoters of women’s natural life processes during pregnancy and childbirth. The struggle to preserve childbirth as a natural process is an essential part of human existence. Through the midwives’ sensitivity for the spontaneous, the mutual relationship with the woman cared for, an enduring presence and the constant struggle to achieve a balance between the medical and natural perspectives, this is possible. Crucial for midwifery and the care of at risk women or those with complications, is ‘embodied knowledge.’ Using this, midwives may recognise an early development of complications and thus be more prepared for these events. They may also feel secure in supporting the natural process even if a woman is at high risk or has a complication. REFERENCES Benner P 1984 From novice to expert. Addison-Wesley Publishing Company, Menly Park Benner P, Kyriakidis PH, Stannard D 1999 Clinical wisdom and interventions in critical care. W.B. Saunders Company, Philadelphia Bla˚ka Sandvik G 1997 Moderskap och fo¨dselarbeid (Motherhood and labour) Fagbokforlaget, BergenSandviken Collins English Dictionary and Thesaurus 1993 HarperCollins, Glasgow Dahlberg K 1996 Intersubjective meeting in holistic caring: a Swedish perspective. Nursing Science Quartely 9(4): 147–151 Dahlberg K, Drew N 1997 A lifeworld paradigm for nursing research. Journal of Holistic Nursing 15(3): 303–317 Dahlberg K, Drew N, Nystro¨m M 2001 Reflective lifeworld research. Lund, Studentlitteratur Davis-Floyd RE 1994 The technocratic body: American childbirth as cultural expression. Social Science Medicine 38(8): 1125–1140 Downe S 1996 Concepts of normality in maternity services: applications and consequences. In: Frith L (ed) 1996. Ethics and midwifery. Butterworth-Heinemann, Oxford Gilje F 1992 Being there: an analysis of the concept of presence. In: Gant D.A. (ed) The presence of caring in nursing. National League for Nursing, New York
266 Midwifery Giorgi A 1997 The theory, practice, and evaluation of the phenomenological method as a qualitative research procedure. Journal of Phenomenological Psychology 28(2): 235–260 Hildingsson I, Ha¨ggstro¨m T 1999 Midwives’ lived experiences of being supportive to prospective mothers/parents during pregnancy. Mifwifery 15: 82–91 Ho¨jeberg P 1991 Jordemor (Midwife). Carlssons, Stockholm Ho¨jeberg P 2000 Tro¨skelkvinnor (Women on the threshold). Carlssons, Oskarshamn O¨berg L 1996. Barnmorskan och la¨karen (The midwife and the physician). Ordfronts fo¨rlag, Stockholm Paterson J, Zderad L 1988 Humanistic nursing. National league for Nursing, New York Reynolds P 1991 Stealing fire: the mythology of the technocrazy. Iconic Anthropology Press, Palo Alto Romlid C 1998 Makt, motsta˚nd och fo¨ra¨ndring (Power, resistance and change). Bromma-Tryck AB, Stockholm Socialstyrelsen 1996 Kompetensbeskrivning fo¨r sjuksko¨terskor och barnmorskor (National Board of Health and Welfare; Guidlines for nurses and midwives). Grafotext, Stockholm
Socialstyrelsen 1996 Ha¨lsova˚rd fo¨re, under och efter graviditet (National Board of Health and Welfare; Health care before, during and after pregnancy). SoSrapport 1996:7. Socialstyrelsen, Stockholm. Socialstyrelsen 2001 Handla¨ggning av normal fo¨rlossning. (National Board of Health and Welfare; Normal birth - state of the art). Socialstyrelsen, Stockholm SOSFS 1995 Kompetenskrav fo¨r tja¨nstgo¨ring som sjuksko¨terska och barnmorska (National Board of Health and Welfare; Qualifications for nurses and midwives). 1995:15. Socialstyrelsen, Stockholm Svenska barnmorskefo¨rbundets policyprogram 1995 I livets tja¨nst ( Serving life). Svenska barnmorskefo¨rbundet och Va˚rdfo¨rbundet, AB Realtryck, Stockholm Thomson A 1980 Planned or unplanned? Are midwives ready for the 1980s. Midwives Chronicle 93(1106): 68–71 Waldenstro¨m U 1998 A systematic review comparing continuity of midwifery care with standard maternity services. British Journal of Obstetrics and Gynaecology 105: 1160–1170 von Wright G H 2000 Myten om framsteget (The myth of the future). Bonnier, Stockholm WHO 1996 Care in normal birth: a practical guide. Report of the Technical Working Group. WHO, Geneva
INTRODUCTION
Marie Berg, Lic.Med. Sci., MNSc, MPH, RNM, Lecturer, Department of Health Sciences, University of Sk˛vde, Box 408, 541 28 Sk˛vde, Sweden Karin Dahlberg, RN, PhD, Professor, BorÔs University College, School of Health Sciences, 501 90 BorÔs, Sweden (Correspondence to MB) Received 15 February, 2001 Revised 29 March 2001, 24; May 2001 Accepted for publication 18 June, 2001
Maternity care has undergone great changes during recent centuries in western industrialised countries. In Sweden, major changes began in 1663 when the Collegium Medicum (CM) was established by a group of university-trained doctors and a new form of maternity care with rules and regulations was established. Successively, midwifery was placed under the supervision of CM. In Sweden, the hospitalisation of women at childbirth began at the end of the 18th century (Ho¨jeberg 1991, O¨berg 1996, Romlid 1998). As a consequence of this, childbirth was moved from being secret and hidden, to be public (Ho¨jeberg 2000). As in other industrialised countries, the approach to pregnancy and birth in Sweden has gradually changed from that Midwifery (2001) 17, 259^266 & 2001 Harcourt Publishers Ltd doi:10.1054/midw.2001.0284, available online at http://www.idealibrary.com on
of folk medicine and normality to a medical, scientific perspective (Ho¨jeberg 2000). The organisation of Swedish maternity care has changed during the last decades as a result of political decisions based on medical considerations and the health economy (Socialstyrelsen 1996). In many hospitals, the care has been differentiated into two levels: 1) care of women with normal processes during pregnancy and childbirth with the definition of normal birth as a base (WHO 1996, Socialstyrelsen 2001), and 2) care of women at high obstetric risk or who have obstetric complications. The midwives are responsible for the care of women with normal processes but in the case of abnormality or high obstetric risk they lose some of their autonomy, as the obstetricians take over the responsibility. Even if the midwives, providing care to women
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with abnormal processes, are still engaged in giving care in pregnancy, childbirth and the puerperium, they work under supervision and assist the obstetricians in obstetric interventions and specialised investigations. Nevertheless a lot of midwives are specialised in different fields, as for example in ultrasound and diabetes care, and may be given a certain delegated responsibility. The boundary between normality and highrisk/complication is not fixed. It is socially defined and changes over time. For women at high obstetric risk, the risk for complications is higher for either themselves or the expected/ newborn baby. They may for example have a chronic disease that may influence the process or have a history of previous severe obstetric complication. This definition has increasingly been filtered through scientific and medicotechnological advances. The extreme standpoint is to treat every pregnancy and childbirth as a risk until the opposite is proved (Downe 1996). As a consequence of changes and advances in maternity care, the midwives have continuously revised their professional role and identity. By tradition and according to current views Swedish midwives have an influential status and a wide field of activity (SOSFS 1995, Socialstyrelsen 1996). In spite of this, the focus towards risk and complications in childbirth (Downe 1996) has indirectly limited their professional role and domain of responsibility. One main question is whether midwives have a defined responsibility of their own in high-risk obstetric care, or only have the role of assistants to the obstetricians. The objective of this study was to describe how midwives experience the care of women during pregnancy, childbirth and early parenthood when the situation is characterised as high-risk from an obstetric point of view or when a complication is manifested for the woman and/or the unborn/newborn baby.
METHOD To achieve a deeper understanding of how midwives experience ‘‘midwifery’’ in this special context, a phenomenological method, based on a lifeworld approach, was chosen (Dahlberg et al. 2001). This approach focuses on the everyday world of experience prior to any theories. In the present study, the focus was on midwives’ lifeworld. During the analysis of data, Giorgi’s (1997) phenomenological research method, built on three criteria, was followed. First it includes a descriptive step, which means that the analysis is based on detailed concrete descriptions of a specific experience. The claim for description also means that the researcher and thus the analysis should not be interpretive. Secondly, phenomenological research operates through
what Giorgi calls ‘phenomenological reduction’, which means that the researcher must withhold past knowledge about the studied phenomenon in order to be fully attentive to the concrete instance of the phenomenon as experienced and presented by the informants (Giorgi 1997, p244). Consequently there is a need for openness and pliability on the behalf of the researcher so that implicitly understood experience can be articulated (Dahlberg & Drew 1997). Thirdly, there is a search for what Giorgi (1997) defines as a ‘scientific essence’ (p244), that is, a general structure of the phenomenon.
Participants Midwives were selected from four hospitals where the care of women at high obstetric risk or with obstetric complications was in some way differentiated from the care of women under normal conditions. Midwives with at least five years of clinical experience in the studied context and recognised as being highly skilled clinicians, were chosen following the proposal of the head of each maternity ward. Because a small number of participants is often recommended in phenomenological research (cf. Dahlberg et al. 2001) 11 midwives were invited, representing a diversity of work experience in the actual context. Ten midwives agreed to participate.
Interviews Consent to conduct and record the interviews was obtained from each midwife, who were all assured that all information would be treated confidentially. Ethical approval and permission to undertake the study was obtained from the Research Ethics Committee, Go¨teborg University. A total of 10 tape-recorded interviews, with duration of 45–120 minutes, were carried out between January and May 2000, in a private setting at the hospitals. The interviews began with an open question: Please describe your experience as a midwife in the care of women in obstetric high-risk and/or when a complication is manifested for the woman or her unborn baby? The midwives were asked to describe the experience as closely as possible even using examples of women cared for. Questions of great importance touched upon the intersubjective encounter and the co-operation with obstetricians. The interviews were characterised by an open approach with a receptive, perceptive, sensitive and reflective stance (Dahlberg & Drew 1997). Statements made by interviewees could be explored in depth by clarifying and exemplifying as much as possible. Thus the researcher posed questions such as: ‘What do you mean?’, ‘Can you give an example?’, ‘Please express your feelings’.
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Data analysis
Sensitivity for the spontaneous
The goal of the analysis phase was to explicate the implicit, to discover, articulate, illuminate and describe the tacit knowledge, without interpreting. The phenomenon was the midwives’ experiences of caring for women with obstetric complications or at high obstetric risk. Giorgi’s (1997) phenomenological method was used with the aim of finding a scientific essence of the phenomenon. The interviewer (MB) began by transcribing the interviews. The analysis began with reading the transcribed interviews in order to gain a general sense of the whole statement. The text was then reread with the aim of organising and expressing the data from the disciplinary perspective, ‘meaning units’ were marked. The transformed ‘meaning units’ were synthesised and summarised and an essence/ general structure of the phenomenon was formulated and expressed with its variations through different constituents. Finally the findings were translated into English. An open attitude was maintained even in the analysis process by repeatedly returning to the data in order to look beyond what had already been seen. Since the interviewer (MB) is a midwife it was important for her to protect an open approach by a reflective stance in the research. The other researcher is not a midwife, which contributes to objectivity.
The midwives had a special sensitive openness towards the spontaneous, natural process within the women during pregnancy, childbirth and the puerperium. They performed a mindful, active search for this inborn ability in every woman:
FINDINGS The age range of the participants was 41–52 years and they had between 9 and 29 years midwifery experience. The range of experience of providing care to women at high obstetric risk or with obstetric complications was five to eight years. The essence of midwifery in the care of women at high obstetric risk or with a manifested complication was defined as ‘a struggle for the natural process’. Women’s transition, physically as well as emotionally, during pregnancy, childbirth and early parenthood, was described as being a, by origin, natural process. The midwives’ struggle consisted of encouraging and preserving this process within each woman. It was based on embodied knowledge and included a balancing between the medical perspective on the one hand and the natural perspective on the other hand. Prerequisite, and therefore a part of the struggle for the natural process, was the midwife’s relationship with the woman. Constituents of the essence were sensitivity for the spontaneous, mutuality, enduring presence, balancing and embodied knowledge. Direct quotations from the data are used to illustrate points and to maintain anonymity identifiers are used, for example M1 is the abbreviation for midwife one.
Then it is important to keep her in focus, she herself, keep her in view. She is not the complication in itself but rather the person who has complications. (M3) Medico-technical interventions and examinations, necessitated by the woman’s or the fetal conditions, were experienced as disturbing. The midwives felt an increased responsibility to: . . . focus and see the woman more, not just the machines, tests and everything surrounding her. (M1) Midwives’ support of the natural process was integrated as a common part of the care, no matter what circumstances. During childbirth, the promotion of the natural process could imply letting the delivery go on with as few interventions as possible. ‘Machines shouldn’t be any problem’ (M6) and women were encouraged to let the birthing process go on and to use their inherent strength. The expectations and wishes of the woman/couple, often disregarded in complicated or high-risk situations, were encouraged. Even in the care of a woman with a newly discovered advanced cervical cancer the midwife could promote the natural process. She focused on the baby and parenthood and influenced the routines so woman–baby contact was established before the start of the cancer operation: They were both so happy because suddenly they were to be parents, it wasn’t just all about cancer. (M10) Sensitivity for the spontaneous also included openness to a mother’s natural capacity to breast feed, even if her baby had little chance of survival: So long as there is a chance of survival we want to encourage the normal and the usual (M10). When a baby was stillborn, there was still parenthood for the midwives to confirm. They wanted to give the parents as good an experience of the baby as possible, helping them to see, touch and keep the baby in their minds: . . . so that they have a child they can mourn. To help parents to meet their child. Despite whether it is alive or not, despite what it looks like. . .. it’s important that I cuddle it and with tenderness so as to show the parents that I
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accept their child and that they may also dare to do likewise. (M9)
Mutuality In the midwives’ descriptions, mutuality in the relationship between midwife and woman was delineated as a necessary basis for good care. Essential components in this mutual relationship were the reciprocal giving of oneself, respect, openness, susceptibility for whatever comes from the other and a wish to understand. By this, trust, security and confidence could evolve: A meeting cannot just be one-sided. It must be mutual. . . . The most important thing is to build a relationship, to build bridges. . . . Create reliability and security out of chaos. . . . I must establish a line of communication so that she can learn to trust and understand me. Feel safe with what I’ve got to offer and trust in it so that we can work together. That is a mutual trust. . .. But even in the other direction, that she dares to show me what she’s feeling. Her worries or whatever, her happiness, that she dares to show it. But this means that I must create a confidence in this, too. Make it plain that I see her. (M5) In order to be open to a woman’s needs in the actual caring situation, the midwife had to understand and know the woman’s general lifesituation, her everyday life. The openness also involved attuning to the manner of every single woman both in the way of talking and the way of being: You have to listen your way into the everyday life of the patients, you might say. That’s how you create a good relationship (M8). Mutuality included openness towards personal feelings. Midwives’ did not ‘fear to show their own feelings’ (M1). Rather they found it necessary to be open, as the women observed their feelings. Caring for a woman with preeclampsia exemplified this. When her symptoms became aggravated, midwives came more often to observe her, measuring blood pressure and taking blood tests: She is worried anyway. . . .It is better to be forthright and explain what we are feeling, why, and what we are doing about it, what we are planning. (M4)
Enduring presence Midwives practised providing an enduring presence. That is they wanted to be close and accessible to the woman, no matter how the process developed. They felt a special challenge
and responsibility to be there, with the woman. This ‘enduring presence’ included nearness, both in an emotional and a physical sense. As women at risk of, or with, complications had an increased need of care, it could consist of several caring encounters where each midwife had her own relationship with the individual woman. But midwives superseded and completed each other and thus formed an enduring presence for every woman cared for: ‘everyone helps to keep things running smoothly’ (M2). In order to strive for continuity, the midwives tried ‘to minimise the number of persons around every woman’ (M7). The beginning and end of every relationship was given special attention. Mentally, preparation for the first encounter with a woman could imply slowing down, appeasing hunger and leaving other assignments to colleagues. In the last encounter there was need for ‘finishing up nicely’ (M6). Enduring presence even included availability in terms of time. Multiple assignments and work under stress were defined as obstacles to the relationship and sometimes the midwives even had to fight for suitable conditions: I give her my time; show her that I have time for her. I stop and I sit down, . . . this is quality time that you are working with, as so many others are making demands upon you. (M5) The enduring presence also implied an advocating and influencing act as taking pains to maintain the woman’s integrity and if necessary being a shield from the ‘threatening surroundings’ which could be both other carers and relatives/visitors: We often defend the patients and stand by them so that their experience will be as good as possible. (M2)
Balancing There was a duality embedded in the midwives’ ‘struggle for the natural process.’ They promoted and showed an increased sensitivity for the natural process but were at the same time aware that obstetricians had the final word as regards the care of women at high-risk or with complications. For the midwives, the balancing act implied finding a level where both natural and medical perspectives could exist side by side. Focusing upon the natural process did not mean removing the reason for the special treatment but included a struggle to let nature take its course, ‘to see childbirth and maternity time from the point of view of the normal.’ (M6) Midwives believed that balance could be reached when there was a relationship between midwives and obstetricians based on mutual
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respect and confidence, both professions striving for the same goal, ‘to help the mother to get through this pregnancy and birth with as little sickness and complication as possible’ (M2). They sometimes perceived an internal conflict between, on the one hand simply carrying out the obstetricians’ prescriptions and on the other hand advocating women’s rights to a natural course of events, ‘watch over the patient, protect the patient a little’ (M2), by seeing to it that medical and technical interventions were as few as possible. The midwives were convinced that every ‘woman has an inborn strength which we may support so that natural process is promoted’ (M8). They even felt that the demands upon them were higher, that ‘the midwife is more important’ (M6) in the care of women at risk or with complications when permitting and promoting the natural process, than when caring for women in normal processes.
Embodied knowledge Good knowledge was described by the midwives as being essential in the care of women at high risk or with obstetric complications. The knowledge consisted of good theoretical obstetric and medical knowledge, good practical experience and ‘sensitive knowledge,’ a developed ability to use one’s senses. Knowledge became embodied, lived out and thus a part of daily work, when it was integrated within the midwife. It developed over time and increased with extended working experience: One learns new things all the time that sink in, leaving room for more learning. This is deeprooted knowledge. (M9) Insufficient obstetric and medical knowledge as well as a shortage of practical experience meant that too much time and energy were wasted on examinations of the special condition. On the other hand, increased obstetric and medical knowledge about complicated conditions and intercurrent diseases gave midwives a feeling of security and safety in their professional role, making it easier to guide women through the natural course of events and thus avoid unnecessary ‘pathologisation.’ In this way, midwives could successively raise the limit for what they considered as normal, without losing attentiveness for the occurrence of acute situations: I have reconsidered my views as to what sickness is and what health is. One would have thought that one would become fixated with the complicated, but it has been rather the opposite. I have raised the limit for what I consider as normal. (M7) Through ‘sensitive knowledge,’ midwives could understand the woman’s needs better.
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When the natural process was hindered by obstacles within the pregnant or birthing woman, the use of this ‘sensitive knowledge’ could ‘open doors’ for her: I have to hear what she’s saying. I have to hear, I have to feel, absorb what it is she wants, what she’s afraid of, what she’s going through just now and all that. . . . I can feel it in the air, feel it in the vibrations, you can see it in her body language; hear how she breathes, speaks. (M3) More experienced midwives acted as advisers and supporters for the less experienced. Reflecting about given care together with colleagues functioned as guidance and a basis for personal growth and increased security: One needs to reflect on things with one’s colleagues. One learns new things all the time that sink in, leaving room for more learning. This is deep-rooted knowledge. (M9) Midwives also spoke about a more integrated level of embodied knowledge, which could develop as professional experience increased. It was called ‘intuition’ by several midwives and was seen as an unparalleled tool to understand and determine a woman’s condition and needs. Based on the impressions one received in the encounter with the woman it could appear when ‘an unexpected course of events’ arose. It could also be expressed as ‘sense of worry or uneasiness’ or as ‘ feeling that things were not quite right’ (M 7). Midwives stressed that they needed courage to live out this more integrated level of embodied knowledge. The decision to have the courage to act in accordance with intuition was often based on previous experience of not having had the courage to act upon intuition: It has something to do with experience and sensitivity, which I also think has something to do with intuition. It is something that only midwives have, midwife-intuition, midwifesense. . . .I do not think we should be afraid of trusting these feelings. We often feel things long before anyone else notices anything. (M6)
DISCUSSION In the present study, midwifery is explored through the descriptions of experienced midwives. ‘A struggle for the natural process’ emerged as the essence of midwifery in the care of women at high obstetric risk or with a complication. It runs all through the interviews and seems to be an ethical demand deeply embedded within midwifery in this context. However, there are limitations to the study.
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The interviewed midwives are not representative of all midwives, and the organisation of maternity care in the studied context differs. The findings do not describe deeply enough the struggle midwives make in an attempt to achieve normality when caring for women at high risk or with a manifested complication. This struggle for the natural process is probably not recognised by midwives themselves, they just live it. To go further, a methodological multiplicity including both video observations and recordings of encounters between midwives and women, might be needed in order to deepen the knowledge of how the natural process is promoted. The word ‘natural’ is central in the findings. The midwives themselves mentioned the word ‘normal’ several times. The analysis revealed a wider perspective of the phenomenon which is mirrored by ‘natural.’ It explicates the very meaning of the midwives’ descriptions. In addition ‘normal’ is something that changes over time and culture (Downe 1996). According to etymological and dictionary analysis (Collins English Dictionary and Thesaurus 1993) ‘natural’ is something which belongs to one’s nature, not acquired, not supernatural, artificial or constructed by man but lifelike, innate, genuine, usual and spontaneous. Synonymous with ‘natural’ are real, unaffected, pure, unrefined, whole, simple, common, legitimate, logical, normal, ordinary, regular, typical, essential, inborn, indigenous, inherent, innate, instinctive, intuitive, ingenuous and open. To maintain health and regard pregnancy as a natural condition is the main task for the Swedish midwives (Svenska barnmorskefo¨rbundets policyprogram 1995). This task is probably not limited only to the Swedish context but is a main, universal element in exemplary midwifery practice. This task, however, seems threatened in the present findings. The word ‘struggle’ in the findings points to this and this is not something new. History certifies that Swedish midwives’ struggle has gone on for centuries (Ho¨jeberg 1991, Romlid 1998, O¨berg 1996). The present findings describe the internal conflict midwives may perceive. The natural process seems threatened, put aside and sometimes even totally repressed by the medico-technical perspective when risks and complications are focused upon. This makes one think of Reynolds’s description (1991) of the technocratic culture where ‘natural bodies’ are replaced with man-made bodies. In a technocratic culture only technologically obtained medical knowledge is said to be authoritative (Davis-Floyd 1994). Reynolds (1991) declares that a society’s core value system is nowhere more evident than in the treatment of the human body, particularly when that body is giving birth to new social members. It is obvious that childbirth is particularly under the domain
of technocracy when risks or complications are more frequent. Mercantile forces behind the technicalisation often strengthen its power. Technical developments offer opportunities to improve maternity care. But they also entail new risks. With advanced technology, the woman’s body risks being placed outside her self, impossible to understand even for herself (Ho¨jeberg 2000). This is typical for modern science, which aims at being master of nature in order to control it (von Wright 2000). This does not contradict the fact that it is intended to be good for human life. One meaning of the midwives’ struggle was their effort to obtain a balance between the natural and medical perspective. According to Bla˚ka Sandvik (1997) two different discourses exist in modern maternity care, ‘the medical science of birth’ which emphasises that all births have a pathological potential, and ‘the traditionally based knowledge’ which includes a natural perspective. Midwifery is practised at the point of intersection between these two discourses. The fact that several times the midwives used the word ‘patient’ in this study could signify that maternity care is still governed by medical science. Bla˚ka Sandvik (1997) emphasises that the midwives must be allowed to give care based on their own standpoint and proposes that they have to take into account both discourses when creating a new self-image in modern maternity care. The findings show that a ‘mutual relationship’ between midwife and woman was defined as the basis for the care of these women. Mutuality, or reciprocity, is according to Dahlberg (1996), crucial in a confirming, caring relationship as it bestows the patient a place ‘to be’. The constituent ‘enduring presence’ illuminates another feature of the relationship. ‘Enduring’ means continuing, durable, lasting and persisting and points to the nature of the ‘presence’ of the midwives. ‘Presence’ is found to be a universal element of interpersonal phenomena and a central concept in caring (Gilje 1992). Presence is ‘being here and not elsewhere’. It is being with, which means closeness in a physically, psychological, emotional and spiritual sense. It is nearness in time, space, amount or resemblance (Paterson & Zderad 1988). The midwives want to be constantly present, an enduring presence, if not physically so at least mentally. Together, as colleagues, the team of midwives contributed to this but at the same time the interviewed midwives stressed the need for there to be as few people as possible around the woman, to reach a higher degree of continuity. It is important as Thomson (1980) stated as early as 1979 that the specialisation of obstetric care has led to a fragmentation of care for the women treated by many different midwives and doctors.
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Continuity of midwifery care, on the other hand, is associated with lower intervention rates than standard maternity care (Waldenstro¨m 1998). ‘Presence’ is also the influencing act of intervention including active and passive strategies intending to control situations (Gilje 1992). This is also obvious in the present study. The midwives expressed their advocating action for the woman cared for. According to Hildingsson and Ha¨ggstro¨m (1999), advocacy of the woman is essential in supportive midwifery during pregnancy. ‘Embodied knowledge’ was another constituent in the findings. It consisted of practical, theoretical and sensitive knowledge. This kind of knowledge is described as important in an applied discipline (Benner et al. 1999). Practical knowledge is ‘know-how’ - knowledge, theoretical knowledge is ‘know-that’ knowledge and the sensitive knowledge described in the findings is the same as ‘perceptual knowledge’. The more integrated level of embodied knowledge described by the midwives is similar to what Benner (1984) defines as expert nurses’ ‘intuitive grasp’ (p295). It relies on perceptual capacity and is defined as a ‘direct apprehension of a situation based upon a background of similar and dissimilar situations and embodied intelligence or skill’ (p295). Vague hunches, such as ‘a sense of uneasiness’ or ‘a feeling that things are not quite right,’ expressed by the midwives, are similar to common characteristics of an ‘expert nurse.’ The intuitive grasp is a useful tool and ‘may lead to early identification of problems and the search for confirming evidence’ (Benner 1984, pxix). The midwives told how their personal decision to dare to use and act according to their inner feelings was often based on a specific caring experience when they had been lacking in this courage. This responds to what Benner et al. (1999) call a ‘paradigm-case’ (p568), a clinical episode that alters one’s way of understanding and perceiving future clinical situations. Guidance by colleagues was described as a necessary ingredient in the developing of embodied knowledge. This is concordant with one of the constitutions (SOSFS 1995:15) for Swedish midwife’s work which states that the nurse/ midwife needs time for reflection and analysis of different problems together with colleagues and other professionals in order to deepen their experiences from daily work. This reflection and discussion of the art itself is probably really important as it contributes to a uniform professional identity, which fortified the midwives to promote the natural process. However, over the last few years a wide range of organisational changes in Sweden has led to a diminishing work force with a subsequent loss of time for reflection. Due to this situation there is less time for
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informal discussions with colleagues, a fact that probably increases midwives’ difficulties in promoting the natural process.
Conclusion and practical implications The present study focuses upon midwifery in Sweden but there are probably many common points of reference with midwifery in other western, technocratic countries. The division of maternity care into normality and abnormality may contribute to a reductionistic view of the woman in need of care. It may also lead to a marginalisation of the midwife’s role. The findings show that the midwives providing care for women at high obstetric risk or who have obstetric complications, have undoubtedly a special responsibility as promoters of women’s natural life processes during pregnancy and childbirth. The struggle to preserve childbirth as a natural process is an essential part of human existence. Through the midwives’ sensitivity for the spontaneous, the mutual relationship with the woman cared for, an enduring presence and the constant struggle to achieve a balance between the medical and natural perspectives, this is possible. Crucial for midwifery and the care of at risk women or those with complications, is ‘embodied knowledge.’ Using this, midwives may recognise an early development of complications and thus be more prepared for these events. They may also feel secure in supporting the natural process even if a woman is at high risk or has a complication. REFERENCES Benner P 1984 From novice to expert. Addison-Wesley Publishing Company, Menly Park Benner P, Kyriakidis PH, Stannard D 1999 Clinical wisdom and interventions in critical care. W.B. Saunders Company, Philadelphia Bla˚ka Sandvik G 1997 Moderskap och fo¨dselarbeid (Motherhood and labour) Fagbokforlaget, BergenSandviken Collins English Dictionary and Thesaurus 1993 HarperCollins, Glasgow Dahlberg K 1996 Intersubjective meeting in holistic caring: a Swedish perspective. Nursing Science Quartely 9(4): 147–151 Dahlberg K, Drew N 1997 A lifeworld paradigm for nursing research. Journal of Holistic Nursing 15(3): 303–317 Dahlberg K, Drew N, Nystro¨m M 2001 Reflective lifeworld research. Lund, Studentlitteratur Davis-Floyd RE 1994 The technocratic body: American childbirth as cultural expression. Social Science Medicine 38(8): 1125–1140 Downe S 1996 Concepts of normality in maternity services: applications and consequences. In: Frith L (ed) 1996. Ethics and midwifery. Butterworth-Heinemann, Oxford Gilje F 1992 Being there: an analysis of the concept of presence. In: Gant D.A. (ed) The presence of caring in nursing. National League for Nursing, New York
266 Midwifery Giorgi A 1997 The theory, practice, and evaluation of the phenomenological method as a qualitative research procedure. Journal of Phenomenological Psychology 28(2): 235–260 Hildingsson I, Ha¨ggstro¨m T 1999 Midwives’ lived experiences of being supportive to prospective mothers/parents during pregnancy. Mifwifery 15: 82–91 Ho¨jeberg P 1991 Jordemor (Midwife). Carlssons, Stockholm Ho¨jeberg P 2000 Tro¨skelkvinnor (Women on the threshold). Carlssons, Oskarshamn O¨berg L 1996. Barnmorskan och la¨karen (The midwife and the physician). Ordfronts fo¨rlag, Stockholm Paterson J, Zderad L 1988 Humanistic nursing. National league for Nursing, New York Reynolds P 1991 Stealing fire: the mythology of the technocrazy. Iconic Anthropology Press, Palo Alto Romlid C 1998 Makt, motsta˚nd och fo¨ra¨ndring (Power, resistance and change). Bromma-Tryck AB, Stockholm Socialstyrelsen 1996 Kompetensbeskrivning fo¨r sjuksko¨terskor och barnmorskor (National Board of Health and Welfare; Guidlines for nurses and midwives). Grafotext, Stockholm
Socialstyrelsen 1996 Ha¨lsova˚rd fo¨re, under och efter graviditet (National Board of Health and Welfare; Health care before, during and after pregnancy). SoSrapport 1996:7. Socialstyrelsen, Stockholm. Socialstyrelsen 2001 Handla¨ggning av normal fo¨rlossning. (National Board of Health and Welfare; Normal birth - state of the art). Socialstyrelsen, Stockholm SOSFS 1995 Kompetenskrav fo¨r tja¨nstgo¨ring som sjuksko¨terska och barnmorska (National Board of Health and Welfare; Qualifications for nurses and midwives). 1995:15. Socialstyrelsen, Stockholm Svenska barnmorskefo¨rbundets policyprogram 1995 I livets tja¨nst ( Serving life). Svenska barnmorskefo¨rbundet och Va˚rdfo¨rbundet, AB Realtryck, Stockholm Thomson A 1980 Planned or unplanned? Are midwives ready for the 1980s. Midwives Chronicle 93(1106): 68–71 Waldenstro¨m U 1998 A systematic review comparing continuity of midwifery care with standard maternity services. British Journal of Obstetrics and Gynaecology 105: 1160–1170 von Wright G H 2000 Myten om framsteget (The myth of the future). Bonnier, Stockholm WHO 1996 Care in normal birth: a practical guide. Report of the Technical Working Group. WHO, Geneva