journal - new zealand college of midwives...can serve as an explanatory narrative, a blueprint for...

New Zealand College of Midwives • Journal 31 • October 2004 1j o u r n a l 3 1october 2004

J O U R N A LE v i d e n c e R e v i e w

Nuchal translucencyscreening for Down’ssyndrome: the midwife’s role

Lesley Irving

N e w Z e a l a n d R e s e a r c h

An evaluation of the midwiferyservices at a New Zealandcommunity maternity unit(birth centre)Anne Barlow, Marion Hunter,

Caroline Conroy, Michele Lennan

“Leaving your dignity at thedoor” maternity in Wellington1950 – 1970

Jane Stojanovic

Midwives’ experiences ofworking with women in labour:interpreting the meaning of pain

Stephanie Vague

New Zealand College of Midwives • Journal 31 • October 2004 3

Philosophy of the JournalPromote women’s health issues

as they relate to childbearing womenand their families.

Promote the view of childbirthas a normal life event for the majority

of women, and the midwifery profession’srole in effecting this.

Provoke discussion of midwifery issues.

SubmissionsSubmit articles and letters to the Editor:

Alison Stewart, School of Midwifery,Private Bag 1910, Dunedin.

Phone 03 479 6107.

Subscriptions and enquiresSubscriptions, NZCOM,

PO Box 21106, Edgeware, Christchurch.

AdvertisingPlease contact David Tolhurst

APN Educational MediaPhone 04 471 1600

Email [email protected] Box 200, Wellington

The New Zealand College of Midwives Journalis the official publication of the

New Zealand College of Midwives.Single copies are $6.00

ISSN.00114-7870Koru photograph by Ted Scott.

Views and opinions expressed in this Journalare not necessarily those of the

New Zealand College of Midwives.

ReviewersMaggie BanksAnne BarlowCheryl Benn

Sue BreeDiane ChandlerRea Daellenbach

Joan DonleyKathleen Fahy (Australia)

Maralyn FoureurKaren Guilliland

Jackie GunnDebbie MacGregor

Marion McLauchlanSuzanne Miller

Lesley Page (United Kingdom)Elizabeth SmytheMina Timu Timu

Sally Tracy (Australia)Nimisha WallerGillian White

Editorial BoardAlison Stewart

Rhondda DaviesDeborah DavisJean PattersonSally Pairman

Pamela Wood

Kate Alice

An evaluation of the midwiferyservices at a New Zealandcommunity maternity unit(birth centre)Anne Barlow, Marion Hunter,Caroline Conroy, Michele Lennan

“Leaving your dignity at thedoor” maternity in Wellington1950 – 1970

Jane Stojanovic

Nuchal translucency screeningfor Down’s syndrome:the midwife’s role

Lesley Irving

Midwives’ experiences ofworking with women in labour:interpreting the meaning of pain

Stephanie Vague

Jean Patterson

G u e s tE d i t o r i a l 4

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c o n t e n t sJ O U R N A L 31 October 2004

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B o o k re v i e w

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Practice Wisdom

N e w Z e a l a n dR e s e a r c h



E v i d e n c eR e v i e w

New Zealand College of Midwives • Journal 31 • October 20044

G U E S T E D I T O R I A L

This year is the centenary of midwifery registra-tion in New Zealand. The Midwives Act 1904established midwifery registration and the regu-lation of midwives’ practice. It standardised mid-wifery training and enabled the setting up of a Statematernity service through St Helens hospitals.

This centenary will no doubt be commemoratedin a number of ways throughout the year. Al-though I am not a midwife, as an historian I wasinvited to work in collaboration with midwiferycolleagues, Joan Skinner and Judy Stehr, to pro-duce an exhibition which traced the history ofNew Zealand midwifery over the last century. Theobvious place to locate an exhibition of this kindwas Archives New Zealand, the repository of allgovernmental records and therefore the site ofcentralised archival material on the regulation ofthe midwifery profession. Our project proposalwas accepted by Archives New Zealand and wesubsequently joined forces with archivists AlisonHadfield and Carly Hall. The resulting exhibi-tion, ‘A Labour of Love: 100 Years of MidwiferyRegistration in New Zealand’, was therefore a col-laborative venture between Archives New Zealandand the Graduate School of Nursing and Mid-wifery at Victoria University of Wellington.

The exhibition opened at Archives New Zealandin Mulgrave St, Wellington, on 13 May and willrun for one year. The displayed material includesitems such as letters, legislation, memoranda,booklets, photographs, film, oral history record-ings, cartoons, newspaper articles, licenses, inspec-tion reports, examinations, advertisements andeven equipment. The exhibition demonstrates thechanges in practice, in professional regulations andrelationships, and in the places where midwiveshave practised over 100 years.

Any event which commemorates the centenary isbased on the premise that there is value in castinga gaze back over midwifery’s professional past. Thisyestergazing must be done, though, with a criti-cal eye as much as an appreciative one. It shouldlead to an understanding which is free from ro-manticism. Any profession which romanticises itspast or allows myths to gain hold without chal-

lenge, runs a grave risk of losing its history in acloud of distorted ideas about the past. Nursinghas risked this from time to time. It would be apity if midwifery did as well.

Let’s focus on myth-making for a moment. Anygroup with a shared culture creates social mythswhich serve a particular role in sustaining the cul-tural fabric of that group. As I have written else-where,1 in everyday language ‘myth’ is often usedto denote untruth but in exploring the culture ofa group, ‘myth’ has another meaning. Myths aresymbolic statements about the world and our placein it. They may arise in response to difficult situ-ations, as a result of entanglement with reality, oras an effort to inspire or sustain the group. Mythscan serve as an explanatory narrative, a blueprintfor social structure, a charter for action, or a crea-tive force providing energy for the group.

While the substance of a myth may not be ‘true’in a factual sense, or may have only a kernel offact, the ‘truth’ of a social myth is gauged by howeffective it is in helping the group understand itsworld and its experiences. One role of an histo-rian is that of myth-revealer, always a risky role asno culture appreciates an outsider (or insider) ex-amining its myths too closely. I have taken on thischallenge to present some ideas about the kindsof current midwifery beliefs which might, indeed,be mythical. As with any historical enterprise,however, my interpretation of midwifery’s historyis exactly that – an interpretation – and equallyopen to challenge.

Let’s look at three beliefs I have heard expressedby current midwives which, based on my archivalresearch in the history of New Zealand midwiferyand maternity services, strike me as contempo-rary social myths. The first relates to the historicalpractice of midwives, the second to the professionalworld they worked in and the third to the widerlegislative context of that professional practice.

Myth 1That there was in the past a golden age of mid-wifery (which should be aspired to again), in whichmidwives practised with minimal intervention inthe birth process. Furthermore, it was only whenbirthing shifted to hospitals (a trend which wasclearly evident by the 1930s) and becamemedicalised, that the practice of midwives work-ing in these hospitals became equally medicalisedand interventionist.

Points to ponderTo investigate this line of argument it is not suffi-

cient to look for historical evidence that showsthat midwives practising in hospitals weremedicalised and interventionist in their practice.We need to find evidence that midwives who re-mained practising outside of the main hospitalsretained a non-interventionist mode of practice,if this had existed. Midwives practising in the verysmall hospitals, which had perhaps two to six bedsand maybe only one midwife on at a time, wouldhave had a great deal of control over their dailypractice. They would have had the choice of howto practise and could have continued to do so in anon-medicalised, non-interventionist way.

The evidence, however, shows the opposite, whentaking as one indicator their active use of painrelief medication during the birth process. Forexample, a 1948 survey of all hospitals, which in-cluded small private hospitals and maternityhomes where midwives worked, showed that al-though they were not permitted to use chloro-form without a doctor present, they were routinelyusing a range of analgesic drugs, including Pethi-dine, Chloral and Bromide, and Nembutal. Onlyone midwife, who ran a two-bed private mater-nity home in Auckland, did not give pain-reliev-ing drugs.2 It might be suggested that this wide-spread use of analgesic drugs is just evidence thatmedicalisation had spread beyond the large hos-pitals, infiltrating the small private maternityhomes. The real issue, though, is that even in theseplaces, where midwives could choose how to prac-tise, there is no evidence of a golden age of non-interventionist midwifery and clear evidence ofthe opposite.

Even earlier evidence comes from the St Helenshospitals which, from 1905, provided a Statematernity service to working-class women whichwas delivered almost exclusively by midwives. EachSt Helens hospital had a medical superintendentbut this doctor was only called in when birth com-plications were anticipated. These hospitals werechampioned by the government as places whichachieved better health outcomes (e.g. fewer for-ceps deliveries, lower puerperal sepsis rates andfewer maternal deaths) than other hospitals,whether large or small, private or public, wheredoctors were more directly involved in the birthprocess. Midwives today should be proud of theachievements of these midwives in the past. How-ever, as my research with Dr Maralyn Foureur isshowing, even in these hospitals midwives wereintervening in a range of ways to manage the birthprocess and puerperium, such as administeringlotions, sedatives, douches and a variety of treat-ments for insufficient milk supply.3

Pamela J Wood RGON BA M Ed PhD Dip Tchg (Tert)

Associate ProfessorGraduate School of Nursing and MidwiferyVictoria University of Wellington

Contact for correspondence:[email protected]


Myth 2That in the medicalisation of childbirth whichaccompanied the shift to birthing in larger hospi-tals, midwives became professionally subservientto doctors.

Points to ponderA significant part of the government’s hospital-based maternity service was sited in the St Helenshospitals. By 1920 these hospitals were establishedin Wellington, Auckland, Christchurch, Dunedin,Gisborne, Wanganui and Invercargill. As mentionedearlier, the maternity service in these hospitals wasprovided almost exclusively by midwives.

The key point here is that even in State-run StHelens hospitals, under the watchful eye of a gov-ernment department where doctors held power,for several decades midwives provided this dailymanagement and delivery of a very importantmaternity service. It would be hard to argue formidwifery subservience to medical power in theseSt Helens hospitals which were such a significantpart of the State maternity service in the first dec-ades of the twentieth century.

Midwives in private practice in these same earlydecades had times of troubled professional rela-tionships with doctors. These conflicts, however,do not show evidence of midwifery subservienceto medical domination. Quite the opposite.If midwives were not able to solve problems di-rectly, they took appropriate action by requestingsupport from the government department ableto intervene.

In 1916, for example, an Auckland midwife re-ported to Amelia Bagley, the government Inspec-tor of Midwives, that doctors told her they were‘determined to put a stop to midwives taking caseswithout medical men being engaged also’, and thatAuckland doctors were ‘going to refuse to attendif called in emergency to a midwife’s assistance’.Amelia Bagley immediately sent a memorandumto the Auckland District Health Officer. She de-scribed the situation in very clear terms and clev-erly challenged him to think about the need fordoctors to have collegial relations with trained mid-wives, compared with their current support forunqualified women, especially as this support con-nived at breaches of the Midwives Act which en-dangered the lives of women.4 Hardly subservience.

Myth 3That legislation enacted in the early years of thetwentieth century prohibited Mäori women

from breast-feeding their babies, a situation ofparticular concern to midwives today who sup-port women to breastfeed their babies and pro-mote breastfeeding as the optimum method ofinfant feeding.

Points to ponderThe legislation usually referred to in discussionsof this amongst current midwives (and others) isthe Native Health Act 1908. There is no such Act.Nor is there any Act bythat name, or any similarname, in the decades oneither side of that year. Norwas breastfeeding byMäori women suppressedthrough any other Act,such as the Tohunga Sup-pression Act 1907. Otherhistorians have alsosearched for legislation af-fecting breastfeeding inthis way, but it has neversurfaced.5 In fact, Mäoriwomen were actively encouraged to breastfeed andthis was incorporated in health policy, particu-larly by Mäori Health Officers like Maui Pomareand Peter Buck, and other members of the De-partment of Health.6 The Department also had aconsistent policy of encouraging all women tobreastfeed and reported success rates in this, in itsAnnual Reports.7

Sadly, this myth has already become embedded asfact in teaching material, academic theses, researchreports and published articles, even within thisjournal. I hope that Lis Ellison-Loschmann’s cor-respondence to this journal, challenging the his-torical errors conveyed by a participant in the re-search reported in an article,8 has been heeded byall researchers, educators and midwives. She madethe same points that I and others have continu-ally made in numerous attempts to reveal the fic-titious nature of this claim. For me, it illustratesthe endurance of myths which serve some pur-pose to a group, even in the face of repeated expo-sitions of their lack of historical basis. The ques-tions remaining are what purpose do these threemyths serve, and to whose advantage?

My reason for wanting to stimulate some discus-sion around these myths is to reinforce the im-portance of understanding the complexities inhistory and the need to delve under the easily ac-cepted ‘surface’ presentations of the past. We needto resist each sweeping generalisation about thepast. We therefore need to look for research which

offers a finely-grained analysis and reasoned in-terpretation of specific aspects of professional his-tory, at specific times and places. We need to avoidpartisan histories, those with a professional agendaas subtext, and welcome all careful, well researchedhistories which inform midwives’ understandingof their professional past. We need to be mindfulof myths and understand their place in ourprofessional cultures. I will leave it to midwivesto consider why these myths might have arisen,

the purposes they mightserve and the reasons fortheir persistence.

What else does a knowl-edge of history, based onsound research, offer us? Itcan tell of the resilience ofmidwives in the face ofprofessional struggles,their persistence and deter-mination in providing asafe, effective and accept-able maternity service for

women, and their creativity in offering backblocksfamilies a service that met their particular needsin an innovative way. It shows us the way mid-wives have provided a diverse range of services inhomes and hospitals. It identifies those areas wheremidwives played a significant part in world-lead-ing New Zealand initiatives, for example in theinvolvement of St Helens midwives in the dra-matic reduction in maternal deaths from puer-peral sepsis from the late 1920s. And, more re-cently, history can show us midwives’ strength inpolitical action, joining with women to gain choicein childbirth.

History can be used to shape current policy. Asound historical knowledge can give midwives astronger place to stand professionally, arguing forchange or advocating to retain current practiceand services. Sound knowledge, however, dependson squarely facing the possibility that currentbeliefs might be mythical. It requires a willing-ness to examine the dearly-held tenets ofmidwifery faith, an understanding of how knowl-edge is constructed, a determined critique, andcareful research.

Historical research can also be used to celebrateachievement. This year is significant for the mid-wifery profession. It marks a century of theprofessionalisation of midwifery practice. It willsee the transfer of registration and regulation tothe profession’s own, separate, statutory body. It

Any profession which romanticises its

past or allows myths to gain hold without

challenge, runs a grave risk of losing

its history in a cloud of distorted

ideas about the past. Nursing has

risked this from time to time.

It would be a pity if midwifery did as well.

continued over...


is a year to celebrate. I have enjoyed the chance tobe part of these celebrations and to contribute tothe profession’s commemoration of 100 years ofmidwifery registration in New Zealand. I look for-ward to ongoing debates about midwifery history.

Wood, P. (2004). Guest editorial. New ZealandCollege of Midwives Journal, 31, 4-6.

Guest Editorial

Rhondda Davies

Introduction

I am delighted to introduce the following contribu-

tion to the Midwifery Wisdom Column. At first read-

ing it may seem to extend beyond the original brief

the Board composed in Journal 27, October 2002.

So much of what we “know” and incorporate into

our practice is shaped by personal beliefs and values.

When these find resonance with comments and sto-

ries shared by another midwife, there is a sense of

relief and validation or vindication. At other times

comments from colleagues oblige us to review auto-

matic and habitual behaviours. These encounters

constitute the vital shaping of how we practice.

Sarah Wickham (2001,P.26) writes, “Research is only

one of the forms of evidence available to women and

midwives. Indeed, other forms or evidence may bet-

ter serve to answer questions which are outside the

boundaries of research …” She illustrated this as

a series of bubbles in a diagram. Each bubble

containing evidence sources which she labelled

“Experience, Intuition, Practice, Insight, Physiology,

Research, Women, Spirituality, History, Reflection

and Philosophy”.

The following contribution from Kate is, I believe,

aligned with the sources of “Reflection, Philosophy,

Experience, Insight, Practice and Women”. Kate feels

passionately about her topic. It is something she is

conscious of on a daily basis. How more basic to good

wise (sage [femme]) midwifery practice than using

le mot juste?

What do you think? Send any comments or your own

view of practice wisdom to [email protected].

Hey… mind your language!(Ou gardez votre mots!)“Pizzas are delivered. Strong women give birth.”A plea to make to my sister midwives and althoughyou have probably heard it before, I ask you to bepatient. I realise that you are sensitive to politi-cally correct means of talking to your colleaguemidwives and medical staff. I know that you willnever ask a woman to “hop(s) up on to the bed,after having popped into the loo to do a little wee”(Leap, 1992, p. 60). I am certain that you wouldnever speak of ‘allowing’ this or ‘permitting’ thatand ‘management’ is what the facility leaders do,isn’t it?

Ask yourself, as you read this piece (it is short)…whose language are you talking, who are you seek-ing to influence. Because words are never, ever‘only words’. They form our thoughts, make ourexperiences and, moreover, express our allegiances,so be very, very careful. In the days of radical femi-nism, there was a phrase—speaking ‘the languageof the oppressors’. In attempting to communicatewith the patriarchal hierarchy, the only wordswomen could use were those of the hierarchy it-self and in so doing we participated in our ownoppression. The validity of this radical viewpointmay be questioned but we must consider the lan-guage we use when communicating with our sis-ter midwives, our medical colleagues and the

Kate AliceKate recently left her role as Charge Midwife,Queen Mary Maternity Centre, Dunedin, tocomplete her MPhil and to refresh her homebirthskills. Prior to that she worked in a variety ofsettings both in hospital and in the community.Currently she works part time as ResearchAssistant for the “Iodine in Breast Milk” study atthe Department of Nutrition, Otago University.

1 Pamela J. Wood, Nursing’s ‘place in the sun’: Interpreting aNew Zealand continuing education policy as myth, inMyth, Mystery and Metaphor, Proceedings of the 4thNational Nursing Education Conference, Melbourne,November 1990, pp.57-61.

2 Memorandum from A. W. S. Thompson, Medical Officerof Health, Auckland District Health Office, to Director-General of Health, Wellington, November 1948, ‘PainRelief in Maternity Hospitals’, held at Archives NewZealand, H1 Box 64 (111).

3 See for example Pamela J. Wood and Maralyn Foureur,Exploring the maternity archive of the Wellington StHelens Hospital, New Zealand, 1907-1922: An historianand midwife collaborate, in B. Mortimer and S. McGann,eds., New Directions in the History of Nursing, RoutledgeResearch, London, forthcoming 2004; Pamela J. Woodand Maralyn Foureur, A Depleted, dirty and dangerous

terrain: Women’s bodies as fertile but foetid in the StHelens maternity hospitals, New Zealand, 1905-1930,paper presented at the Women’s History Conference,Aberdeen, September 2003.

4 Memorandum from Amelia Bagley, Inspector of Midwives,to Auckland District Health Officer, 26 August 1916, heldat Archives New Zealand, H1, 1 Midwifery/ NursingRegistration.

5 For example, Derek Dow, personal communication, July–August 2002.

6 See for example Derek Dow, Maori Health andGovernment Policy 1840-1940, Victoria University Press,Wellington, 1999, pp.197-8.

7 Wood and Foureur, 2004.

8 Lis Ellison-Loschmann, letter to the editor, New ZealandCollege of Midwives Journal, 25, October 2001, p.38.

P R A C T I C E W I S D O M

women we serve. Medical terms are regarded as asort of objective and neutral norm when in factthey are part of a language that is privileged anddefinitely not accessible to all. If Medicine is des-ignated a language as French is, for example, thenperhaps midwives are skilled bilingualists, speak-ing Medicine to their medical colleagues thentranslating it into a form that will be comprehen-sible to the woman. I am not for a moment sug-gesting that the woman cannot understand Medi-cine but like a person in a foreign land, the nu-ances of the conversation may escape her. Not onlythat, Medicine may feel itself to be universal inthe place the woman is in—the hospital—is it‘while in our country, speak our language’?

So—this is my plea. When we say to the womanthat we will insert gel into the posterior fornix ofher vagina to induce labour could we also bringourselves to say ‘I am going to put this drug in-side your fanny (or yoni or whatever the womanfamiliarly calls herself ) to terminate your preg-nancy’? No? Why? Isn’t that what we are doing?Or does induce sound nicer, friendlier and kinderand vagina more ‘professional’? If the last sentencerings too true… whose language are we speaking?

Could I also add that Academia and Politspeak areout there too. The most fascinating thing is that,like any foreign language, the longer you conversein it—Medicine, Academia or Politspeak— themore familiar it becomes. That’s fine if you wishto understand the people and the culture but thewise woman/midwife never forgets her heritage.So remember, sisters, it’s not called yourMothertongue for nothing.

ReferencesLeap, N. (1992). The power of words. Nursing Times,

88(21), 60-1.

Wickham S. (2004). MIDIRS Midwifery Digest, 11, (1),P.23-P.27.


continued over...

AbstractA comprehensive evaluation was undertakenin 2002/2003 of the midwifery services in aNew Zealand community maternity unit. Arange of stakeholder perspectives includedinterviews with midwives and women, andanalysis of birth outcomes statistics from 1203women and their infants (1999-2001 inclu-sive). The important midwifery managementand decision-making skills needed forworking autonomously and successfullyare recognised.

IntroductionThis paper outlines the key findings from a com-prehensive evaluation undertaken in 2002/2003of the midwifery services in a midwifery-led com-munity maternity unit or birthing centre (titled“Unit” in this paper). Senior district health boardmanagement requested data on which to basepolicy decisions, and midwives were keen to have

evidence that would illumine the practice and skillsof midwives working in this community context.

Background and settingMedicalisation of maternity servicesIn the 1950s a movement towards regionalisationin health service organisation led to closures ofsmall units. Between 1970-1985, 33 rural mater-nity units were closed (Papps & Olssen, 1997).Many of these were the only hospitals in their com-munity. There was a view that these small hospi-tals, where annual birth numbers were often lessthan 100, were unsafe and that larger hospitalscould provide more technologically advanced care(Donley, 1986; Rosenblatt, Reinken & Shoemack,1984). In the larger hospitals women found thatthey often did not know their caregivers and missedcontact with their local general practitioners andmidwives. Rosenblatt et al. (1985) produced a re-port that found little to suggest that small NewZealand community hospitals were, in fact, un-safe. However, this report was embargoed frompublic release as it did not sit well with the HealthDepartment’s ideology of the day (Donley, 1986).In 2004, approximately 38 community maternityunits remain in New Zealand, and many face anuncertain future.

The social and political trend that occurred in NewZealand has been prevalent in many other coun-tries. Women have not only witnessed the closureof their small local maternity units but have alsofound it increasingly difficult to obtain a homebirth (Campbell, MacFarlane, Hempsell &Hatchard, 1999). Some health professionals andconsumers have challenged this trend, and ques-tioned whether large hospitals are actually the mostappropriate place of birth for all women (Papps& Olssen, 1997). In particular, concern has beenexpressed that a ‘medical model’ of care, domi-nant in large hospitals, actually increases the riskof intervention for otherwise normal women(Papps & Olssen, 1997).

The influence of place of birth and carer onbirth outcomesResearchers internationally have considered safety,cost-efficiency and efficacy of small hospitals withvarying results and, according to Campbell (1997),with some contention. A medical research statis-tician, Tew (1990), found that over a number ofyears (1958-1970) the analysis and interpretationof published UK statistics data was deliberatelymisinterpreted to favour births in large hospitals.

There have been a number of studies examiningthe effects of place of birth on birth outcomes andmaternal satisfaction (Hodnett, 2002; Hundleyet al., 1995; Rowley, Hensley, Brinsmead &Wlodarczyk, 1995; Waldenstrom, 1998;Waldenstrom & Nilsson, 1997). Where the con-text and the caregivers support ‘normal’ birth thereis less likelihood of interventions associated withless optimal clinical outcomes (Campbell et al.,1999; Page, 2000, 2001, 2003). Page (2000)notes, for example, that women offered continu-ity of carer are more satisfied with their care, haveless likelihood of receiving epidural anaesthesia orepisiotomy and show some evidence of increasedconfidence and preparedness for the birth and careof the baby. Kirkham (2003, p.260) describes “theenabling culture” of birth centres to provide “choice,control and continuity” for women.

New Zealand studiesDonley (1986) believed that the small units, suchas the one in this study, have been a threat tomedical control of obstetrics, yet, there are lim-ited studies that have investigated the safety ofsmall community units in New Zealand (Conroy,2000). Wagner (1994) reviewed care provided insmall community hospitals and confirmed thefindings of Rosenblatt et al. (1985) that New Zea-land women are safe and better placed in ‘low tech’units. A retrospective descriptive study by Conroy(2000), comparing birth outcomes statistics forlow-risk women at two small community mater-nity units supported the safety of these units.

The implications of providing intrapartum mid-wifery care in small community hospitals wereexplored in a study of Auckland independent self-employed midwives (Hunter, 2000). Her thesisshowed that providing intrapartum care in smallmaternity units required additional midwiferyskills such as being:

• confident to provide intrapartum care in a lowtechnology setting

• comfortable using embodied midwifery skillsand knowledge to assess a woman and her babyas opposed to using technology

• able to ‘let labour be’ and not interfere unnec-essarily

• confident to avert or manage problems thatmight arise

• willing to employ other options to manage painwithout access to epidurals

• solely responsible for outcomes without accessto on-site specialist assistance and

N E W Z E A L A N D R E S E A R C H

An evaluation of the midwifery services at a New Zealandcommunity maternity unit (birth centre)

K. Anne Barlow PhD MA BA NZRM NZRGON

Anne is a Senior Lecturer in midwiferyand Director of Centre for Midwifery andWomen’s Health Research at AUT

Marion Hunter MA BA NZRM NZRGON

Marion is a Senior Lecturer in midwiferyat AUT School of Midwifery and works as anindependent midwife in South Auckland

Caroline Conroy MHSc SRM SRN

Caroline works as a midwife in South Auckland

Michele Lennan MA (Anthropology) BA

Michele has an interest in maternity issues andwomen’s health and specialises as a researchconsultant in evaluation

AffiliationCentre for Midwifery and Women’s Health,School of Midwifery, Division of Health CarePractice, Health Studies Faculty, AUT

Contact for correspondence:Anne BarlowDirector, Centre for Midwifery and Women’sHealth Research, School of MidwiferyAuckland University of TechnologyPrivate Bag 92006, [email protected] or [email protected]


continued...

• a midwife who enjoys practising what partici-pants called ‘real midwifery’.

A midwifery model or philosophy and a focus on‘keeping birth normal’ (Hunter, 2000; Page, 2000,2001, 2003) underpinned the perspectivesbrought to this evaluation.

Research aimsThe overall aim of the evaluation was to provideinformation that would support current positiveaspects and identify aspects that could be improvedor modified in the Unit’s midwifery services, inorder to contribute towards improvements inwomen’s birth outcomes and experiences.

Research designThe study used a design consistent with evalua-tion literature and a mixed-methods approach(Greene, 2002) provided a diversity of researcherperspectives.

EthicsEthics approval was gained from the AucklandEthics Committee (ref 2001/266), the AUT Eth-ics Committee and the National Plunket EthicsCommittee. There was considerable planning withkey stakeholders prior to the study. Quotationsincluded in this article are presented anonymously.

SettingThe midwifery-led Unit stands alone from otherhealth services within a large metropolitan NewZealand city, providing care for 300 births annu-ally and for women who are transferred postna-tally from the base tertiary hospital, located at adistance of twenty minutes road travelling time.Women also transfer from the community to thebase hospital for secondary services.

ParticipantsThere was purposive sampling to collect a rangeof material and viewpoints. Information was gath-ered from hospital and self-employed midwives,hospital managers, clinical educator, women whohad used the Unit within the last year, consumerorganisations and health provider representatives.In addition, ‘information-rich’ participants(Patton, 1990, 1997), such as administration staff,and a student midwife were also invited to par-ticipate. Birth outcomes from 1203 women andbabies, the total who had used the Unit between1999-2001 inclusive, were collected and analysed.

MethodsThree midwife researchers and one evaluation re-searcher collected the data. Data collection meth-ods included: literature review, development of aprogramme logic to guide the evaluation, face-to-face interviews, focus groups, site visits, document

analysis, a patient satisfaction survey (retrospec-tively analysed by a hospital survey researcher in-dependently from the researchers), and maternal/ infant birth outcomes data (collected retrospec-tively by one of the research midwives). Interviewsand focus groups were generally audio-taped (oth-erwise notes were hand written if this was pre-ferred by participants) and sessions lasted approxi-mately one hour. The Unit midwives preferredface-to-face interviews with a researcher, whereasa number of self-employed midwives and consum-ers chose focus groups. A semi-structured inter-view schedule, based on key evaluation questionsguided the interviews.

Analysis of the dataData was analysed against an evaluation frame-work (Veney & Kaluzny, 1998) using descriptivestatistics for birth outcomes, surveys, and eco-nomic data. Qualitative approaches were used fordocument analysis, interviews and focus groups.Qualitative information was analysed using con-tent analysis. Birth outcomes data and surveymaterial were analysed with SPSS software usingdescriptive statistical methods.

FindingsThis article focuses on the interviews with mid-wives and consumers and reports the main find-ings from the statistical analysis of the maternaland infant birth outcomes data. These three per-spectives illustrate the activities and relationshipsbetween midwifery practice, women’s experiencesand satisfaction with their care, and the maternaland infant birth outcomes recorded in the Unit.

Women’s perspectivesForty-three women were recruited via commu-nity organisations and Well Child providers suchas Parents Centre, Plunket, La Leche League andlocal play centres. They were interviewed by anevaluation researcher, who was not a midwife, ei-ther face-to-face or in focus groups. Approximatelyhalf of these women had given birth and the otherhalf had received postnatal care in the Unit withinthe previous year. Two-thirds had self-employedlead maternity carers (LMCs) and one-third hadhospital-employed midwives as their LMC. TwelveMäori and thirty-one Pakeha/European womenparticipated, with no responses from the smallpopulation of Pacific Island women who usedthe Unit. The comments in the text derive fromthese interviews.

The value of the UnitAll the women articulated well the value of theUnit for them. They liked that it was close to homeand easy for their family and whanau to visit. Formany, the long established Unit was part of fam-ily history, and it was good for mothers to show

their children where they were born. The atmos-phere was “homely” and food was cooked on site:

[The Unit] was more relaxed, it was morecomfortable. Being in a familiar place was acomfort. And I found the staff really good.

Place of birthWomen who chose to birth in the Unit were allsupported by their midwives, and were confidentto give birth in a “low-tech” environment. The Unitwas not associated with hospitals and sickness:

You come here to have babies, you don’t come herebecause you’re sick and that’s the difference. [Basehospital], you go there when you’re sick and not forthings like having babies.

One woman gave an unprompted comparisonwith a base hospital and recounted her past expe-riences:

At [previous base hospital] they were not focusedon people, you were part of a process, you wentupstairs, you were observed, then they induced youand then you did this and this and this, and thenyou popped out the other end with a baby sort ofthing. I was very put off by staff at [base hospital]saying “then you’ll do this, and this will take thatlong.” And I thought, “Hang on, isn’t it differentfor every woman?”

By comparison, the small Unit had an emphasison natural processes. One woman felt the verynature of the Unit would change if the focusshifted away from a midwifery-based service:

[The Unit] is small and personal and provides acosy environment. To bring machinery and stuffwould be wrong, it would be just like [basehospital].

Midwifery careAll the women who delivered in the Unit werevery satisfied with the care and support they re-ceived during labour. They felt confident in thedecisions that were made and said they felt safe atall times. One positive aspect for women was thetime for breastfeeding support and mothercraft.

I thought [the Unit] was a good intermediate pointto go and learn the mothering aspect of it, yourfirst baby and things like looking after their skinand looking after myself. I found it wonderful interms of a half-way step – that was brilliant.

I had trouble with breastfeeding and if you pushedthe button someone would come and help you, anytime of the day and night. And they’re not annoyedat all.

The difference in care is that they never judgedme. They didn’t care that he [baby] was my fourth,they never said: “Get a grip lady, it’s your fourthbaby.” But at the other place I went to [in another

An evaluation of the midwifery services at a New Zealand community maternity unit (birth centre)


continued over...

town] they said, “Get over it, lots of women haveboobs [breasts] like you.”

Some of the women had difficulties with conflict-ing advice around breastfeeding especially, andwere distressed if midwives placed their hands onbreasts without asking. Despite this, all the womenfound the midwives to be professional in theirwork, and whenever different advice was provided,they reported that it was done in such a way as toavoid criticism of their colleagues. Only onewoman, out of the forty-three interviewed, re-ported that she had given up breastfeeding becauseof the difficulties she had experienced. One rea-son given for being successful was the lack of pres-sure put on women to leave before breastfeedingwas established and most felt comfortable withtheir breastfeeding when they were discharged.

My well being when I got home was immeasur-able because of my experience there.

There was some difference in opinion whether theUnit should remain as a birthing or postnatal onlyunit, though overall, women thought that the Unitprovided a positive experience for women:

For a first experience it was very pleasurable. I’vehad good memories from it. It hasn’t put me offhaving another one. I’d definitely recommend theUnit to anyone.

Midwives’ perspectivesThe perspectives of ‘core’ midwifery staff, inde-pendent midwives and a student midwife (31 par-ticipants in total) was gained. Hunter (2003) hadindicated from previous research that midwivesperceived they had greater autonomy and moreclinical freedom in small maternity units and theresearchers were therefore interested in the day-to-day activities and practice. Important aspectsfor participant midwives included the:

• relevance of the Unit for the community

• trust in the Unit’s safety held by women andfamilies

• philosophy of birth as part of a normal life event

• partnerships held with women and families

• autonomy of practice possible within acommunity setting and

• collegiality with other midwives.

Promotion of normal childbirthPhilosophy of birthThe overarching values held by the participantmidwives were that the Unit enabled normal child-birth and the Unit’s function was to meet the needsof the community. Midwives repeatedly linked theUnit with normal birth and noted that a highnumber of women (including Mäori women) usedthe Unit and returned for subsequent births. Oneparticipant described the maternity Unit as follows:

The Unit is community based, it allows for

women’s choice and they have a belief that this is agood place for birth, especially Mäori women andtheir whanau who have confidence in being at theUnit. Other ethnicities also tend to have thisbelief. There is a long history of positive birth outcomes, and the environment is seen as supportive,caring and restful by the community… There isan affirmation of birth as a normal life event at[the Unit]. There is good rapport with GPs,Tamariki Ora, Plunket,and local Iwi. (Midwife H)

Another midwife de-scribed it as:

I have a strong belief inwomen’s choice and somewomen don’t like the hos-pital model. This canaffect the way they birth,so it helps if the womenlike the facility they are in.If they feel comfortablebeing there, they will birthmore easily. (Focus group midwives 2)

PartnershipThe New Zealand College of Midwives(NZCOM) philosophy (1993, 2002) emphasisesthe need for midwives to work in partnership withwomen and to protect the normal process of child-birth. Participants indicated their commitmentto partnership and the provision of flexiblemidwifery care:

What is important for me is that it is the woman’sexperience. Women are given options, given theinformation they need, and supported to birth theway they should birth. I’m being invited into thiswoman’s birth experience, so this is the basis forhow I work. I believe in the process, and I believein women and I believe that we can do it. (Focusgroup midwives 4)

Autonomy of practiceAlthough secondary services consultations wereavailable by telephone, the distance from the basehospital created a need for autonomy in decision-making. The ability to practise autonomouslywas associated with being separate from tertiaryfacilities:

Autonomy of practice is fostered at [the Unit] asthere are only midwives here, so the immediatedecisions are made by midwives by the sheernature of the distance from [the base hospital].(Focus group midwives 3)

It makes a statement that no medical staff areavailable in small units which reinforces thenormality of the pregnancy and this gives a strongmessage to the public that midwives are autono-mous practitioners and have the skills. This has

been a huge change from 10 years ago, and womenexpect us to be able to cope. (Focus groupmidwives 2)

A positive aspect to being separate from a largerorganisation was an ability to operate within a dif-ferent time-frame, more attune to women’s needsand circumstances:

We are (the base hospital’s) best-kept secret out hereand we can practise the waywe want to with moreflexible timeframes and weare not rushed. (Midwife D)

Collegial relationshipsA convivial relationshipbetween midwives (regard-less of employment status)seems to be essential forthe success of a primarymaternity facility. Physicalsupport between col-leagues was seen as being

particularly helpful, for example during occasionsof transfers. One midwife stated:

The staff are there for you. For example, gettingthe IV trolley. If there is thick meconium, the staffwill assist you to get the woman out and get hertransferred as quickly as possible. (Focus groupmidwives 1)

Participants also commented on the willingnessof core staff to engage in discussion with an inde-pendent midwife concerning the progress ofwomen in labour:

It is safer practice to use consultation, as no oneknows everything... There is goodwill on both sides.(Focus group midwives 1)

There is a two way process where independent andhospital midwives help each other out and answerphones etc. You are able to discuss with colleagueswhat is going on and this stops that feeling ofisolation. (Focus group midwives 2)

Best practiceParticipants acknowledged that best practice wasachieved through the high number of womenbirthing normally in the Unit. Waterbirth was alsoan option for women and many women had aphysiological third stage. Participants believed thatbreastfeeding rates were better than in secondaryand tertiary units and midwives were willing tospend time with women to ensure thatbreastfeeding was successful.

Maternal and infant birth outcomesA retrospective analysis of birth outcomes at thesmall community maternity Unit was undertaken

I have a strong belief in women’s

choice and some women don’t like the

hospital model. This can affect the

way they birth, so it helps if the

women like the facility they are in.

If they feel comfortable being there,

they will birth more easily.

(Focus group midwives 2)


continued...

for the years 1999 to 2001 inclusive. Data onwomen who presented in premature labour or forreasons other than labour care were excluded.

DemographicsThe number of women included for each year of

ing a continued decline in the number of generalpractitioners providing lead maternity carer(LMC) services (Ministry of Health, 2001, 2003).The results also revealed the positive impact thatthe introduction of a ‘Know your midwife’ (KYM)scheme during the latter part of 1999 had on birth

Decision making in third stage of labourAlthough it did not reach statistical significance(p=0.198), the only other variable to show achanging trend over the three years of the studywas ‘third stage management’. There appeared tobe an increase in the use of ‘physiological man-agement’ and a corresponding decline in the useof ecbolics, though the administration ofsyntometrine still remained the most frequentlyused method of managing the third stage (Figure2), whilst blood loss rates remained unchanged.

Neonatal outcomesNeonatal outcomes were good with over 99% ofbabies born at the Maternity Unit recording Apgarscores of eight or above at five minutes. Seventyfive percent of babies required no resuscitation andof those that did, most only required suction.

TransfersThe overall transfer rate including third stage andneonatal problems immediately following birthwas 12.1%. The most frequently occurring rea-son for transfer was ‘failure to progress in the firststage of labour’. Transfer rates can be influencedeasily by the restrictions or otherwise placed onwomen who are eligible to use maternity unitsand for this reason it is difficult to compare ratesbetween one maternity unit and another. The trans-fer rates appear, however, to compare favourablywith similar units and birthing centres overseas.

Fetal monitoringThe use of electronic fetal monitoring was alsolow with 91.8% of women birthing at the Unitreceiving no electronic fetal monitoring (CTG).The usual practice was for the fetal heart to belistened to intermittently with a hand-held Dop-pler or pinards stethoscope.

BreastfeedingEighty-nine per cent of women breast fed theirbaby at the first feed, 6.7% artificially fed, and amissing count of 4.2% was not recorded.

Summary of birth outcomesThe Unit was particularly well supported byyounger women and Mäori, and appeared to be aviable birthing option for first-time mothers.Though the study did not identify many chang-ing trends within the three year period, the con-sistency of results achieved does give some assur-ance that the good results achieved can be main-tained over several years. There were very few ad-verse events recorded such as post-partum haem-orrhage or the need for extensive neonatal resus-citation, so this should allay the fears of someLMC’s and women who worry about ‘what ifthings go wrong?’ This appears to demonstrate thatmidwives are successful in identifying risk factors

continued...

An evaluation of the midwifery services at a New Zealand community maternity unit (birth centre)

the study, as well as transfers to the local base hos-pital during labour, are shown in Table 1. Datawas analysed to identify if there were any chang-ing trends in maternity care between the threeyears of the study, differences between ethnicgroups or differences in birth outcome forthose who birthed at the Unit compared to thosewho needed to transfer to the base hospitalduring labour.

The most frequently occurring age group at theUnit for the period was 21-24 years of age(23.2%), followed by the 25-28 year age bracket(22.9%). Women identifying as Mäori (47.2%)and Pakeha (40.6%) were the two main ethnicgroups using the Unit, with 9.3% of women iden-tifying as Pacific Island. There was a significantrelationship (p<0.0001 ) betweenage and ethnicity, with Mäori tend-ing to have their children at ayounger age, as reflected in nationalfigures (Ministry of Health, 2001).The Unit’s rate of 28.4% for first-time mothers is remarkably close tonational rates of 29% (Ministry ofHealth, 2001).

Maternity provider (LMC)The only variable to show a statis-tically significant (p<0.000)1 changeover the three years of the study wasthe professional status of the ma-ternity provider. The results ob-tained reflect national figures show-

numbers. It appeared from the results that theKYM scheme’s objective to increase birth num-bers at the Unit was achieved in 2000. This wasfurther supported by the 2001 figures where therewas a reduction in overall birth numbers notedwhen some of the midwives left the KYM scheme(Figure 1).

Method of deliveryThe overall normal delivery rate for those birthingat the Unit, as well as those requiring transfer was94.7% with a corresponding instrumental deliv-ery rate of 2.5%, caesarean section of 2.4% andbreech delivery of 0.4%. Instrumental andcaesarean deliveries only occurred at the base hos-pital (Table 2).

Table 1: Number of women per year and place of birth

Place of birth 1999 2000 2001 Total

Community Maternity Unit Count (n) 338 403 326 1067% within 89.2% 89.6% 87.2% 88.7%year of birth

Transfers to base hospital Count (n) 41 47 48 136% within 10.8% 10.4% 12.8% 11.3%year of birth

Total Count (n) 379 450 374 1203% within 100% 100% 100% 100%year of birth

Maternity provider

KYM schemeGP/ hospitalmidwife

Hospitalmidwife

Independentmidwife

Perc

ent

50

40

30

20

10

0

Figure 1: Maternity provider by year

1 P value reported as this because calculatedby a statistical programme which reports togreater than 3 decimal places


continued over...

in the antenatal and intrapartum period thus mini-mising the potential for adverse events to occur.Collaboration with secondary services and goodtransfer outcomes reflect teamwork and medicalsupport when necessary.

NZCOM provides guidelines for evaluating mid-wifery outcomes statistical data (NZCOM, 2000)and the Report on Maternity 1999, 2000, 2001(Ministry of Health, 2001, 2003) provide recordsof outcomes, availability and utilisation of NewZealand maternity services in 1999–2001. Thereare a number of limitations with the national datasets, nonetheless at face value the birth outcomesat the Unit compare favourably. By contrast, theconsequences from poor birth outcomes can placeburdens on non-maternity budgets such as men-tal health, paediatrics, child development, educa-tion, as well as personal and public social resources.

DiscussionThe findings reported in this paper represent mid-wives’ and women’s perspectives and birth out-comes from a community maternity unit in NewZealand. The study has provided a valuable in-sight into the midwifery practice in the Unit andshown that such units can offer low risk womenan alternate birthing option to large base hospi-tals, whilst still ensuring good outcomes for moth-ers and babies. The Unit achieved an extraordi-nary number of normal births, had appropriatereferral and transfers and demonstrated highbreastfeeding rates. It indicates midwives’ abilityto ‘keep birth normal’ for the women who gavebirth there and provide pain relief such as watertherapy and water births as alternatives to epidur-als. These birth rates have remained relatively sta-ble over the three year period, that is, they havebeen resistant to global caesarean section rate trends.

The beliefs of midwives in this study that the en-vironment has a positive influence on birth out-comes was also suggested by Stojanovic (2003) ina report on Otaki Birthing Centre. Page (2001)writes of the oases of good practice found inbirthing centres and stand-alone units where con-tinuity is more likely to be practised. Kirkham(2003) records also that the whole ethos of birthcentres is one of normality and the philosophyfocuses on the concept of mid-wifery being at the heart of a so-cial, rather than a medical modelof care. Women in this study re-ported that midwifery care in theUnit gave them and their fami-lies strength and supportednormal birth, and they couldclearly differentiate between careprovided in the Unit and inlarger hospital contexts. They saidthey were given good opportuni-ties to birth naturally and exer-cise choice.

Midwives in this study demon-strated ‘real midwifery’ (Hunter,2000, 2003) meaning that themidwives utilise all of their mid-wifery skills when they practisewithin primary maternity units.Participants believed that the Unit met the needsof women, especially Mäori, as shown by the highpercentage of Mäori women choosing to give birththere. The larger evaluation report contained someminor suggestions for practice and management.

Implications for midwifery practiceMany women and midwives stated that threats ofclosure were unsettling to all of the communityand emphasised the need for a better utilisationof primary maternity units. Hendry (2003) stud-

ied rural maternity services in the South Islandand encouraged LMC midwives to support smallunits in order that these services could be sustainedand fulfil community needs. Women in this studywere more likely to choose the Unit if they andtheir midwives were confident in a ‘low tech’ en-vironment. It has been recognised that studentsand new graduate midwives especially need op-portunities to learn the skills practiced in smallunits. It is becoming increasingly difficult to findsatisfactory clinical placements for students andmeet Nursing Council of New Zealand registra-tion requirements and competencies with the cur-rent static birth trend (Jackie Gunn, personal com-munication, 2001; Nursing Council of New Zea-land, 1998). It is critical, therefore, that midwiveshave confidence to inspire women to give birthnaturally and safely in these environments andcontribute to positive experiences for women andtheir families.

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Campbell, R., MacFarlane, A., Hempsall, V., Hatchard, K.(1999). Evaluation of midwifery-led care provided at theRoyal Bournemouth Hospital. Midwifery, 15, 183-193.

Place of birth TotalMaternity BaseUnit Hospital

Transfers

Normal vaginal Count (n) 1065 74 1139delivery % within place of birth 99.8% 54.4% 94.7%

Forceps/ventouse Count (n) 30 30% within place of birth 22.1% 2.5%

Breech Count (n) 2 3 5% within place of birth 0.2% 2.2% 0.4%

Lower section Count (n) 29 29caesarean section % within place of birth 21.3% 2.4%

Total Count (n) 1067 136 1203% within place of birth 100.0% 100.0% 100.0%

Table 2: Method of delivery by place of birth

3rd stage

syntometrine& synto

physiologicalsyntocinonsyntometrine

Perc

ent

50

40

30

20

10

0

Figure 2: Third stage management by year

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Wagner, M. (1994). Pursuing the birth machine. The search forappropriate birth technology. Camperdown, Australia. ACEGraphics.

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Waldenstrom, U. (1998). Continuity of carer and satisfaction.Midwifery, 14, 207-213.

AcknowledgementAn AUT Faculty of Health Studies Research Grantsupported this research.

Copyright statementWhilst published in the NZCOM journal thecontent of the article is part of a larger report atthe Centre for Midwifery and Women’sHealth, Auckland University of Technology. Forthose interested please contact authors [email protected]

Accepted for publication: January 2004

Barlow, K.A., Hunter, M., Conroy, C., & Lennan, M.(2004). An evaluation of the midwifery services ata New Zealand community maternity unit (birthcentre). New Zealand College of MidwivesJournal, 31, 7-12.

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Hunter, M. (2003). Autonomy, clinical freedom andresponsibility. In, M. Kirkham (Ed.). Birth centres: A socialmodel for maternity care, 239-249. UK: BFM, ElsevierScience Ltd.

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AbstractThis descriptive historical research traces thesociopolitical changes in New Zealand mater-nity from 1900 to 1970 to create a backdropagainst which the place of women in society,the hospitals, the workforce, maternity prac-tices and the childbearing process are illumi-nated using the insights of women and mid-wives who experienced them.

IntroductionThe intent of the research was to illustrate thematernity experience of the time and to examinethe historical, environmental, sociopolitical andcultural factors which created and maintained thematernity environment in which these womenlaboured and these midwives worked. For centu-ries birthing in most cultures had happened in atraditional, women centred environment withbirth attendants who had usually experienced birththemselves.1 The period in this study was charac-terised by a medicalised public maternity systemwith a workforce dominated by single women whoworked as nurses, rather than as midwives. A wom-an’s comment took me back to my student dayswhen a common saying was “You leave your dig-nity at the door when you go in to have a baby”.These comments suggested the title for the thesisand gave my research direction.

Noeleen: That’s what this lady who had had herbaby, said to me, she said, You lose your dignity whenyou have your baby.

Personal impetusWhen I was a child, as children do, I enjoyed lis-tening to my mother tell stories of my birth andbabyhood. It was a way of validating who I amand made me feel secure and wanted. We laughedat my father’s anxious behaviour and I was alwayspleased that I was a breastfed baby and that mymother had none of the problems caring for me,a second child, that she had caring for my olderbrother. My mother always attributed this to thecare she had received in the homelike environ-ment of a small private maternity home inJohnsonville, Wellington. I was born in 1945 in asmall four-bed private maternity home, ‘Ranui’,in Fraser Avenue.

When I reached adulthood and bore my childrenin the mid 1960s and early 1970s there were lim-ited choices of where to have a baby. Homebirthwas not available and it appeared that most of thesmall private maternity homes had disappeared.Later, as a trained midwife I realized that many ofmy colleagues were unaware that these facilities hadexisted at all, yet they had been quite numerous in

“Leaving your dignity at the door” maternity in Wellington 1950 – 1970

Jane Stojanovic MA (Applied) RM RGON ADN

After thirty years in various midwifery roles inhospital and self-employed midwifery Jane iscurrently teaching in the Massey UniversityBachelor of Midwifery Programme atPalmerston North. This article reports researchundertaken as a thesis for the Master of Arts(Applied) Midwifery degree atVictoria University of Wellington, which shecompleted in 2003.



the greater Wellington area. This piqued my curi-osity. I wondered why such places had disappeared.

I was ‘trained’ as a nurse in the early 1960s thenlater as a midwife at a time when midwifery edu-cation was strongly influenced by nursing andmedicine. I had a perception, fostered by my edu-cators, of childbirth prior to medical control andhospitalisation as a wilderness where ‘SaireyGamp’2 type midwives harmed women with theirlack of knowledge, negligence and lack of cleanli-ness. The view that many women had died be-cause they were not in hospital and did not haveaccess to hospital was common among the mid-wives and nurses at that time. The medical menwho were our educators constantly reinforced tous the importance of medicine and hospitalisa-tion as methods of saving women and babies. Thechanging social conditions and the advent of an-tibiotics were not mentioned as possible contribu-tors to the lowering of the maternal mortality rate.

Exploring the history of midwifery during mymidwifery training in the mid 1970s made merealise that I was forming my conclusions aboutthe past on misinformation and, therefore, it waslikely that so were many other midwives and ma-ternity consumers. Researching for my Master’sdegree gave me an opportunity to find some an-swers to questions raised during my experiencesof the maternity system.

I decided that I would like to document the per-ceptions of the consumers and the midwives whoexperienced the environment of the apparentlyhighly regimented maternity hospitals of the1950s and 1960s and to attempt to illuminatesome of factors which had created that environ-ment. I hoped to demonstrate the effect that thesehad on the birthing experience of women and onmidwives’ practice.

Background to the studyPrior to the 1950s small, private maternity homeswere common, many having just one maternitybed so that they could avoid the regulation fromthe Health Department that came with havingmore than one inpatient.3 In Wellington, the capi-tal city of New Zealand, as in most urban areas,there were also larger private maternity hospitalsincluding charitable institutions,4 epitomized inWellington by Bethany and Alexandra hospitals.There were several private maternity hospitals inupper Willis St., one of the main city streets, in-cluding Harris Hospital and the Willis St. Ob-stetric Hospital pictured in Figure 1.

There was also the state owned St. Helens Hospi-tal and Training School for Midwives in

Newtown, an old in-ner city area. Wel-lington Public Hos-pital catered only forabnormal maternitycases such as womenwith breast abscesses,or other medical andobstetric complica-tions, until 1947,when the WellingtonMaternity Annexewas opened.5

The 1950s were atime when the postwar baby boom wasat its height, birthwas almost totallyhospitalised andthere was a shortageof nurses and mid-wives.6 It was also atime that small pri-vate maternity homes were giving way to larger hos-pitals provided by Hospital Boards.7 The increas-ing medical control of childbirth culminated in thepassing of the Nurses Act in 1971, when midwiferylost the legal right to be an autonomous professionfor twenty years. The period of this study includesthe years 1962 – 1965 when I worked in Welling-ton Hospital as a student nurse and my experienceas a consumer of maternity services in St HelensHospital in 1966, 1967 and 1970.The study was planned to describe the maternityscene in Wellington during an era when midwiferyhad been subsumed by nursing, was controlled bymedicine and nursing, and was practised in hospitalsmanaged by those disciplines. The medicalisation ofchildbirth and the ‘nursification’ of midwiferychanged the way maternity care was delivered andaffected women’s maternity experience.8

It is my belief that midwifery is a profession whichdesperately needs to understand its history becauseits knowledge and practice have been clouded byinfluences from the disciplines of medicine andnursing over generations. This has happened to suchan extent that it takes major effort on the part ofeach individual midwife to identify what is in truth‘midwifery’ as distinct from what are actually medi-cal and nursing ideas of what should be midwiferypractice and knowledge. Researching historythrough the eyes of midwives and women helps usto sift out what has actually happened in maternityand trace the introduction of changes that occurredin midwifery practice so that we can assess the rea-sons for and the appropriateness of some practiceswhich may be problematic in the changed mater-nity environment.

MethodologyHistoriography is the name of the process usedby historians in carrying out historical inquiry.9

It is the methodology of historical research, in-corporating theories, techniques and ideas whichneed consideration in any historical research.10

These include theories and principles whichinfluence the choice of topic, finding and ac-cessing the sources of data, and analysing, in-terpreting and reporting the data. The theoryof historiography has evolved from the peculiarintricacies and interpretive requirements inher-ent in researching past events.11 In historical in-quiry it is preferable for participants to be iden-tified so that the reader can assess their situa-tion in relation to their testimony. The fourwomen, Babs Le Page, Ivanka Marta, Helen vanKampen and Noeleen Ruston and the two mid-wives, Kathleen Brosnahan and Ruth Beltonwho participated in this research were happy tobe identified and I would like to thank themfor their generosity and acknowledge their con-tribution to this work.

The research reported in this article is a descrip-tive historical study of Wellington’s maternityenvironment based on the testimonies of womenand midwives as the main primary source. Itdescribes how they perceived their maternityexperience. Institutions, people, social issues andhospital routines that shaped the women’s ex-periences were included, where necessary, ascontextual information and to illustrate morefully what was happening in maternity in the1950s and 1960s.

Figure 1. Exterior view of the Willis St. Obstetric Hospital, Wellington, 1949.(With permission from the Dominion Post Collection, Alexander Turnbull Library, Wellington, NZ Ref F-905677- 1/2.)

continued over...


I used oral history as the pivotal primary sourceto give life and direction to the study and increaseits authenticity, and research into other primaryand secondary sources to substantiate and explainthe findings from the oral histories. The more al-ternative primary and secondary sources that re-inforce the story, the more credible is the research.

The goal of the traditional historian is todetermine what actually happened and why it wassignificant and to find the underlying causes ofthe events. Historians recognise that their evidenceis incomplete and that we are viewing a pastthrough 20th century eyes and with 20th centuryvalues whereas many values and beliefs of theperiod under study were quite different.12

In relation to this study we, the readers, are view-ing the past through twenty-first century eyes at atime when midwives are able again to practice au-tonomously. The study was not intended as a criti-cism of past midwives or their practice, but as away to examine the influences that pro-duced the environment in which they practised,and to record the way thatthey practised.

The four women consum-ers who experienced ma-ternity in Wellington andtwo midwives who workedin Wellington’s maternityhospitals during this pe-riod provided their oral tes-timonies as the main pri-mary sources for this study.My recollections of beinga student nurse and a con-sumer in Wellington andother primary and secondary sources were usedto substantiate, explore and explain the topic.

Ethical approval for this study was granted by theVictoria University of Wellington’s Ethics Com-mittee. The audio-taped interviews were con-ducted in the homes of the participants exceptfor one woman, Ivanka, who chose to be inter-viewed at my home.

The studyThe women who were interviewed experiencedmaternity in a variety of Wellington’s maternityhospitals over a number of years, 1953-1970. Be-tween them they had thirteen maternity episodesin the study time period and experienced eightmaternity facilities. The women were all of Euro-pean descent.

The interviews were transcribed and then analysedwith each woman’s story being summarised andwritten from the information given. Informationconcerning topics such as breastfeeding, hospitalsand staff, labour care and others was then extractedfrom the transcriptions and compared with theother women’s comments, contemporary text-books and the midwives’ testimonies.

Although my research is specific to Wellingtonthe findings could reasonably be used as an exam-ple when describing what was happening in ma-ternity throughout New Zealand as the social,political and economic influences on maternityin other regions were closely aligned to the Wel-lington experience.13 The study therefore, shouldadd to our knowledge and understanding of thehistory of maternity in New Zealand. The oraltestimonies of the six participants described bothpositive and negative aspects of their maternity ex-periences, but the three strong themes that arosefrom the women’s accounts included ‘being alone’,‘lack of autonomy’ and ‘uncaring attitudes’.

The historicalbackgroundThe professionalisationand ‘nursification’ of themidwifery service beganwith the passing of theMidwives Act 1904 andthe formation of the StHelens Hospitals andTraining Schools for Mid-wives. The Act placedmidwives under medicalcontrol and by introduc-ing a new type of midwife,the ‘nurse-midwife’, began

the process of the ‘nursification’ of midwifery.14

Despite homebirth and midwifery being sup-ported by the Health Department, technologicalprogress, especially the developments in asepsisand anaesthesia, aided the medical profession inmaking hospital and medically controlled birthattractive to women.15

The restrictive practices introduced by the HealthDepartment to combat the rise in maternal mor-tality due to puerperal sepsis had a highly signifi-cant influence on the manner in which maternityservices developed and on the women’s experienceof birth. The Obstetrical and Gynaecological So-ciety was formed to resist control from the HealthDepartment, and once formed became a stronglobby group, achieving its aims which were thesetting up of a Chair of Obstetrics at Otago Uni-versity and the reformation of the maternity serv-ice. The Social Security Act 1938 granted free

medical, midwifery and hospital care to womenthus accelerating the hospitalisation of birth andestablishing doctors as the gatekeepers to the ma-ternity service. Midwives became skilled in theirspecialised areas of hospital nursing, but lost theknowledge and confidence to care for birthingwomen outside the hospital system. 16

The examination of women’s role in society dur-ing the 1950s and 1960s showed that marriageand family life were idealised as proper fulfilmentfor women but that women were often deprivedof the ability to make choices, particularly in re-gard to fertility and childbirth, because of the lackof information available to them. Married womenwere expected to be full-time mothers and home-makers and only a small percentage of womenworked outside the home, thus creating a situa-tion where the maternity service was providedmainly by a hierarchy of single women who staffedthe hospitals.17 From 1950 to 1970 with the ad-vent of reliable contraception and some changesin attitude, there was a slow increase in the num-bers of married women joining the workforce butnot until the end of the period of the study werethere any significant changes to its composition.

At the start of the twentieth century homebirthwas still the norm but gradually disappeared as anoption because of the growing medicalisation ofbirth and the establishment of doctors as ‘gate-keepers’ to the maternity service. From 1925 on-ward the small private hospitals slowly closed be-cause of political and financial pressures and werereplaced by state provided maternity beds. Thesewere usually in facilities administered by the Wel-lington Hospital Board in response to the gov-ernment’s requirement that Hospital Boards pro-vide sufficient beds for maternity in their areas.This was occurring at a time when there was in-creasing demand for hospital childbirth, due tothe Obstetrical and Gynaecological Society’s suc-cessful selling of hospital birth as safer and lesspainful, combined with the postwar upsurge inthe birth-rate. The Hospital Board’s situation wasalso exacerbated because of the postwar shortageof nursing and midwifery staff. 18

The two most important maternity hospitals inWellington during the study period were the Wel-lington Public Hospital, a teaching hospital formedical and nursing students, and St HelensHospital which was a teaching hospital for stu-dent midwives and maternity nurses. St Helenswas under the auspices of the Health Departmentuntil the Wellington Hospital Board took over in1966. The two charitable institutions, Bethanyand Alexandra (also a maternity nurse teachinghospital), were still available until the end of the


continued...

Researching history through the eyes of

midwives and women helps us to sift out

what has actually happened in maternity

and trace the introduction of changes

that occurred in midwifery practice so

that we can assess the reasons for

and the appropriateness of some

practices which may be problematic in

the changed maternity environment.


study period. Karitane Hospital was an impor-tant complementary facility and ‘backup’ to thematernity hospitals, providing care for small, weakbabies or mothers who needed help caring for theirbabies, particularly prior to the development ofneonatal units in the early 1970s.19

Not only the ‘bricks and mortar’ of some of thematernity facilities were important to the mater-nity experience of women, but also the workingconditions for staff, with particular emphasis onnursing and midwifery students and midwives.Using the testimonies of the two interviewed mid-wives, my own memories, and other primary andsecondary sources the hospital culture whichframed the environment in which the women la-boured and birthed was explored. Long hours,heavy workloads and a culture of control and dis-cipline in the workforce were identified as possi-ble contributing factors to the reported lack ofempathy among some nurses and midwives to-ward the women. The workforce of the time wasalmost exclusively made up of unmarried women.This was a monumental change from the centu-ries of midwifery care by women with experienceof birth. Obviously, there are many excellent mid-wives who are childless, but it can be speculatedthat a workforce consisting almost entirely of sin-gle women, combined with other factors such asthe hierarchal, oppressive nature of the system inwhich these women were employed couldpossibly have changed the ‘culture’ of the mater-nity service.20

Women and maternityThe women interviewed displayed pragmatic at-titudes toward pregnancy and childbirth. It wasthe expected outcome of marriage. They expectedto have children and work in the home. This wasillustrated by Mab’s answer to my question regard-ing contraception “If the children came quicker,it didn’t worry you?” She replied, “It didn’t matterbecause that was our aim in life.” Adding, “the wifestayed home and the man went to work and thatwas it”.

Society fostered the idea that marriage and theconsequent bearing and nurturing of children wasthe most desirable and fulfilling role a womancould attain. The acceptance of this role is shownby the comments of the women and is representedin the photograph of the “ideal family” (Figure2). However, although most tolerated their child-bearing experience with the attitude that the doc-tors and nursing/midwifery staff were the experts,discontent with the system was demonstrated inthe wider maternity area with the formation ofthe Parent’s Centre movement. The Parent’s Cen-tre achieved some improvement, introducing an-

tenatal classes and encouraging natural birth, butthe system had become so entrenched that changewas slow in coming. Rooming-in, for instance, al-though first mooted in the early 1950s did notarrive in Wellington until the new Kenepuru andSt Helens Hospitals were opened in the mid tolate 1960s.21

The acceptance of thehealth professional as‘the expert’ had be-came part of New Zea-land’s culture in linewith the wider accept-ance of technology asthe modern miraclethat would solve allproblems. The adop-tion of Truby King’steachings on infantcare also reinforced theidea of the experthealth professional.Women’s belief in theirown instinctual knowl-edge was downgradedand minimized. Exper-tise in childbirth had been lost to mothers andmidwives with the promotion of medical knowl-edge and technology. This not only supplantedwomen’s ways but treated women in a manner thatwas detrimental to their emotional and culturalwell-being. The women were isolated from theirsupport systems and required to adapt to alien in-stitutions and routines at a time when they wereat their most vulnerable, adapting to their newroles as women. 22

The childbearing process over the two decadesbecame increasingly technical and intrusive andwomen’s psycho-social and emotional needs wereonly just beginning to be recognised by the end ofthe 1960s with increased participation by fathersand the introduction of rooming in. While treat-ment of women was often kindly some maternitystaff displayed little understanding or empathy to-ward the women. There was little or no opportu-nity to gather information upon which to makechoices and little, if any, opportunity to refusetreatment or to choose care other than that laiddown by medical protocols based on the prescrip-tive practices which had been introduced by theHealth Department in 1923. 23

Lack of autonomyA major issue which emerged from the study wasthe lack of autonomy for the women who wereobliged to become ‘patients’ and conform to therequirements of the institutional environment and

the maternity hospital staff. They had no abilityto control their birth including positions for birth,interventions or even basic privacy.

Mabs: …they took me down to theatre andthey strapped my legs, of course. Terrible thing

to do to anyone. Theyhad me up there and incame, about, ten studentdoctors and all thesenurses I’d never seen. Itwas quite traumatic.

They received instruc-tion from health pro-fessionals on all aspectsof maternity includingthe physical act ofbirthing, breastfeedingand care of the infant.The women generallyaccepted the routinesand the regimentationbecause they believedin the expertise of thehealth professionalsand that acceptance

would make themselves and their babies safer. Thiswas partly in response to the excellent propagandacampaign which had been mounted by the doc-tors in the 1920s and 1930s and had kept up adegree of momentum throughout. Their belief inthe safety of hospital birth waxed steady evenin the face their awareness of dangers such as the‘H bug’ (Staphylococcus aureus) epidemic ofthe 1950s. 24

Mabs: I forgot to mention to you that when I wasin Wellington Hospital, it was almost the start ofthe H bug. That was a terrible thing. They didn’tknow how it was all happening. Mind you, I’vebeen back to Wellington Hospital in this day andage and there’s still cockroaches.Jane: So, you just remember being worried aboutthe H bug?Mabs: Yes, everybody was.Jane: And had you known that some babies haddied because of it?Mabs: Yes.

A lack of autonomy could also have been felt bymidwives. Their role was directed by doctors andnurses leading to their special status as ‘midwives’being hidden. This was an era in which the in-creased birthrate and the shortage of midwives andnurses were putting severe pressure on the hospi-tals and their workforce.25 Within that workforcemidwives were quite ‘invisible’ to the women par-ticipants. My mother had often described the

continued over...

Figure 2: The 1950s or 1960s family entitled ‘Of such isthe kingdom of Heaven’ from the Old Otaki MaternityHome. (Used with permission from the Otaki Birthing Centre Ltd).


kindness and skill of the midwife who had caredfor her in the 1940s, but, nevertheless, I had been‘delivered’ by a doctor and my mother never men-tioned the word ‘midwife’, always talking of heras ‘the Matron’. Noeline speaks of the ‘head nurse’and the matron and only speaks of midwives whenshe discusses ‘Sister Ritchie’ who had a NursingHome, and the elderly lady ‘Mrs. Sullivan’ ofTawa, who cared for her mother during her birthsat home and was ‘probably a midwife’. Ivankamentions a midwife once and otherwise talks ofnurses. Mabs who was more aware of midwiferybecause her great-grandmother had been a mid-wife was definite that the word ‘midwife’ was notused in the hospital.

The lack of recognition of the hospital staff asmidwives reflected their invisibility and is indica-tive of the ‘nursification’ of midwifery and possi-bly also reflective, at least in Wellington Hospi-tal, of the use of nursing students to deliver muchof the direct care.

Being aloneAnother major issue to emerge from this studywas that of “being alone”. The maternity systemand the culture of the study period isolated womenfrom their families, their support systems and theirbabies. The change from the 1900 system of awoman birthing at home usually with family andother women supporting her had changed to onewhere the woman was removed from society andplaced in an institution, alone. Her husband wassent home and it was not until later in the studyperiod that he was able to stay for part of the la-bour. Visiting hours were controlled quite strictlyand children were usually not allowed to visit orwere allowed only at certain times. Even at homeafter the birth and the postnatal period womenwere often expected to sit alone in their rooms tobreastfeed as the prudish culture of the day meantthat many women felt uncomfortablebreastfeeding in company, particularly in front ofmen, even within the family circle.26

The other sense of “being alone” the women ex-perienced was that of being isolated from theirbabies. Sharing a bed and cuddling baby were alsoforbidden by the strictures of the day which dic-tated that this was ‘spoiling’ the baby. Beforerooming-in became accepted practice, babies weretaken to the nursery and mothers and fatherscould only view them through the window. Somedid not see their baby for days.

Noeline: But just after she was born – ‘cause theytook her out, straight away, in those days and puther straight into the nursery – so I never saw her.… in those days I never saw her. I didn’t see herfor seven or eight days.

Separation from babies was even more acute forwomen who became ill and were transferred toWellington Public Hospital, as babies were notadmitted to the hospital with their mothers. InHelen’s case her first baby was transferred to theKaritane Hospital while she was admitted to Wel-lington hospital with medical complications anddid not see her baby for eight weeks. Even whenrooming-in began to be adopted, it was usualfor babies to be held in the nursery for the firstfew days with limited visits to their mothersfor feeding.27

The sense of aloneness while hospitalised was ex-acerbated because of shift work and task orientednursing practices. The people who were caring forthe woman changed constantly because midwivesand nurses work in shifts. In hospitals where tasknursing was practised there would be no particu-lar nurse or midwife assigned, which increasedshort-term contact with a large number of staff.Even if, over time, a woman began to recogniseand become familiar and at ease with individuals,there was no guarantee that they would be avail-able at the birth of her baby or at any crisis point.28

Women expressed that they felt alone.

Helen: I was so scared, I really was, I wasterrified. One of the nurses came and checked meand she said to me, “Don’t you know what’s goingon?” and I said, no. She said, “We’re going toprepare you, we shave you and then we test to seehow high the baby is.” Then they left me all night.I was on my own all night.

The birth of the baby was another time when manywomen experienced feelings of aloneness with nofamily support allowed, and the sense of aliena-tion made more intense by the masks and gownswhich hid the attendant’s facial expressions. Theposition of the woman and the sterile drapes puther in the situation of ‘being delivered’ which inmany ways divorced her from full involvement inthe birth of her baby often with a resulting senseof disempowerment. 29

Uncaring attitudesThe women indicated that the lack of autonomyand feelings of aloneness were mitigated somewhatbecause the staff treated them well. They describedcare and kindness from nursing and midwiferystaff. However, although there were many instancesof kindness from staff, this was not always the case,and perhaps negative incidents remain longer inmemory because a number of incidents were de-scribed by the women that demonstrated an un-caring attitude.

Mabs: …anyway we had this particular Sister, whoused to delight somehow, in leaving us all in tears

in the night. Everyone would be crying because ofthis wretched woman. She never helped you…. Allthese women around trying to feed these babies,with not a great success rate because it was said tous that, if we couldn’t manage, they went on tothe bottle.

Ivanka also felt a lack of empathy from the staffcaring for her and was subjected to a severe ‘tell-ing off ’.

I don’t remember who it was, a short lady, andwow, she laid into me. Oh, she gave me such ahard time. “Get back on the bed! What do youthink you’re doing? You’re killing your baby … andda da da da … Y’know, she was probably justbeing sensible. I thought okay. So I get back onthat bed and I … That’s when I felt, oh, I’m attheir mercy.

Annette Stevenson discussed the authoritariancontrol and discipline of nurses in her thesis30 andKathleen gave an account of the unkindness ofsome of the midwives in the old St Helens to themidwifery students, It would seem that the au-thoritarian control and discipline that nurses andmidwives were subject to was passed on to womenby some staff.

It is interesting to consider the idea that the un-married workforce may have been less empatheticto the women because they had never experiencedmarriage and childbearing themselves. This, ofcourse, is a huge generalization, and there are manyexcellent midwives who have never had children.However, when I asked Ruth Belton whethershe thought that having a large number ofsingle women in the workforce made a differenceshe replied:

Yes, I think it did. I think once we had moremarried Sisters too, at St Helens, I felt that it wasever so much easier for the patients, as theregistered nursing staff, the married women seemedto understand the patients much better. Actually,getting married when I did in the 1970’s, I thoughtI would have been a much better midwife, of muchmore help to people, had I had known more aboutwhat it was like to be married, beforehand.

I have been the recipient of comments from mid-wives who have had babies that the experience haschanged their midwifery practice but Ruth’s com-ment stands alone in this research and must betaken only as one opinion.

It is however possible that the combination of theauthoritarian discipline, the busyness and the largenumber of single women created a culture inwhich some nurses and midwives were able to ig-

continued...



nore the feelings and wishes of other women, staffor ‘patients’. The emergence from the interviewsfrom the study participants of experiences of un-caring attitudes and even unkindness by some staffcannot be lightly dismissed. Certainly the busynessand unavailability of staff was mentioned by sev-eral of the women and Kathleen revealed theamount of work that needed to be done by themidwives.

We had very long hours. We had to do all our ownpacking; we brought our own equipment, makingswabs and things like that, which we stayed until2 or 3 in the morning to do. We were on call fordays and days and days. Our conditions were verypoor indeed and we worked extremely hard.

Annette Stevenson also identified workforce is-sues concerning unpaid overtime at WellingtonHospital.31

ConclusionThe findings of the research suggest that child-bearing women of the 1950s and 1960s passedthrough a medicalised and interventionist ordealin order to give birth in what they understood tobe a less painful and safer manner. They copedwith it because they believed in the health profes-sionals’ expertise and good intentions and theybelieved that the process was necessary for theirown and their babies’ well-being. Because otherwomen were managing and everyone wentthrough the same process they realized that theycould also cope.

Noeline: I thought, Oh heck. It was a bit fright-ening but however, I soon got over all that, andrealised that there were other women in thesame position.

Women were role models for each other. The proc-ess could be seen as a rite of initiation into moth-erhood. Body exposure and invasive proceduresand pain although, of course, disliked by mostwomen do not appear to have been the factorsthat engendered lack of faith in the system orcaused the most stress.

While I had envisaged the loss of modesty andthe indignities visited upon childbearing womenduring their preparation for birth, from such ritualprocedures as shaves and enemas, as epitomisingthe saying “leaving your dignity at the door”, com-ments were made by women that these procedureswere endured and thought of as a necessary evilbut nevertheless were not of great concern to them.

Helen: I just thought it was part and parcel of thething. I just did everything I was told to do. To getit over with, you know.

The issues which were elicited from this study asbeing difficult for women to cope with were thoseof “lack of autonomy”, as they were forced intoa situation where they lost control over decisionmaking for themselves and for their babies, “be-ing alone”, which in-cluded separation from so-cial support systems suchas family, separation fromtheir babies and alienationbecause of certain hospitalpractices such as task nurs-ing and the wearing ofgowns and masks in thebirthing room, and “un-caring attitudes” partic-ularly when the women’sphysical and emotionalneeds were not met or ig-nored and minimized bybusy or unsympathetic at-tendants. These issues wereengendered by the hospital culture which had de-veloped from a hierarchal regimented nursingworkforce, the busyness caused by the high birthrate and the nursing shortage, the task orientednature of practice and the stringent medical re-quirements demanded by the Health Department32 which were time-consuming for staff as well asdepersonalizing for the women.

I set out to describe the 1950s and 1960s mater-nity ‘scene’ in Wellington. I explored the historyto discover what had produced the ‘scene’. Thatcreated an important framework for the structureof the study. I needed to study women’s role insociety in the 1950s and 1960s to understand whywomen, including the hospital staff, behaved asthey did. The women’s stories and the midwives’accounts posed more questions than they answerednecessitating more exploration into the physicaland cultural aspects of the maternity system inWellington. The women’s stories told some of thestory but I found that I needed to expand this byincluding a description of the management of thebirth process to complete the picture.

Within a mainly state-provided hospital system,maternity care in Wellington during the 1950s and1960s was provided by a very busy workforce com-posed of mainly single nurses and midwives whohad been socialised into medicalised midwifery andhad lost the knowledge of women-centred mid-wifery and the confidence and ability to workoutside the hospital.33 Homebirth was almost non-existent, hospitals were becoming fewer, larger,increasingly medicalised, interventionist and regi-mented.34 Women suffered the loss of autonomy,feelings of aloneness and the uncaring attitudes ofsome health professionals because they had been

socialised into the belief, promulgated by doctors,that they were safer in hospital. The mitigatingfactors that arose from the participant’s stories werethe enjoyment of a hospital ‘rest’ for some womenwho had several children and the kindness and

caring attitudes of many ofthe nurses and midwives.

The study incorporatedthe stories of four womenand two midwives in rela-tion to maternity in Wel-lington, 1950 – 1970. Italso contains contextualinformation from docu-mentary primary and sec-ondary sources as well asfrom my own experiencesas a student nurse andconsumer of maternityservices in Wellington atthis time, and from my

later experience as a midwife. I did not set out toprove any particular theories although having ex-perienced the maternity system of the 1960s I sus-pected that the regimentation and rigidity of thesystem might come to the fore, but did not knowin what form. The participants were recruited asa convenience sample but the commonalities intheir stories were inescapable and evolved quitespontaneously. Through the loss of autonomy, lossof social support systems, enforced isolation, andsometimes not being treated with respect, each ofthe women “left their dignity at the door”.

1 M. Cooper, Towards the Professionalisation of New ZealandMidwifery 1840 - 1921, Unpublished Masters Thesis,Massey University, Palmerston North, 1998, p. 67.

2 P. Mein Smith, Maternity in Dispute: New Zealand, 1920-39, Historical Publications Branch, Department ofInternal Affairs, Wellington, 1986, p. 1.

3 J. Neill, Grace Neill, The Story of a Noble Woman, N.M.Peryer Ltd., Christchurch, 1961, p. 50.

4 L. Barber & R. Towers, Wellington Hospital 1847 - 1976,Wellington Hospital Board, Wellington, 1976, App. 8.

5 L. Barber & R. Towers, Wellington Hospital, p. 103.

6 E. Papps and M. Olssen, Doctoring Childbirth andRegulating Midwifery in New Zealand, Dunmore Press,Palmerston North, 1997, p. 104.

7 J. Stojanovic, Leaving your dignity at the door, Maternityin Wellington 1950 - 1970, unpublished Masters Thesis,Victoria University of Wellington, 2002. pp. 50 - 54.

8 R.L. Russell, Historiography: a methodology for nurseresearchers, .Australian Journal of Advanced Nursing, Vol16, No. 1, Sept-Nov., 1998, p.141.

9 B. Lusk, Historical Methodology, for Nursing Research,Image: Journal of Nursing Scholarship, Vol.29, No. 4,Fourth Quarter, 1997, p. 85.

10 See for example: O. Church, Using Historical Sources, InWoods, N. F. and Cantanzaro, M. Nursing Research:Theory and Practice. C.V.Mosby, St Louis, 1988; C.Helmstadter, Deconstructing and Reconstructing History,Journal of Professional Nursing, Vol. 14, No. 3, May-June,1998, p. 136.; A. Stevenson, Realities and rhetoric:general hospital nursing in New Zealand 1945 to 1960,

continued over...

The findings of the research suggest that

childbearing women of the 1950s and

1960s passed through a medicalised

and interventionist ordeal in order to

give birth in what they understood to be

a less painful and safer manner. They

coped with it because they believed in

the health professionals’ expertise and

good intentions and they believed that

the process was necessary for their own

and their babies’ well-being.


continued...

Unpublished Masters Thesis, Victoria University ofWellington, Wellington, 1997. pp. 101-102.

11 C. Helmstadter, Deconstructing and ReconstructingHistory, Journal of Professional Nursing, Vol. 14, No. 3,May-June,1998, p. 136.

12 J. Stojanovic, Leaving your dignity at the door, p.25.

13 J. Stojanovic, Leaving your dignity, pp. 50 - 54.

14 J. Stojanovic, Leaving your dignity, p. 43

15 J. Stojanovic, Leaving your dignity, p. 53.

16 A. Stevenson, Realities and rhetoric, p. 103.

17 L. Barber and R. Towers, Wellington Hospital, p.3.



20 J. Stojanovic, Leaving your dignity, pp. 159.

“Leaving your dignity at the door” maternity in Wellington 1950 – 197021 J. Stojanovic, Leaving your dignity, pp. 161.



24 L. Barber & R. Towers, Wellington Hospital, p. 103.


26 J. Stojanovic, Personal experience.



29 A. Stevenson, Realities and Rhetoric, p.102.

30 A. Stevenson, Realities and Rhetoricc, p. 101.

31 A. Stevenson, Realities and Rhetoricc, p. 101.

32P. Mein Smith, Maternity in Dispute: New Zealand, 1920-39, Historical Publication Branch, Department of InternalAffairs, Wellington, 1986. p. 29.

33 J. Donley, Save the Midwife, New Women’s Press Ltd,1986, p.99,


AcknowledgementsTo Alexander Turnbull Library, Wellington and OtakiBirthing Centre Ltd for kind permission to includephotographic images.

Accepted for publication: August 2004

Stojanovic, J. (2004). “Leaving your dignity at thedoor” maternity in Wellington 1950-1970. NewZealand of College Midwives Journal, 31, 12-18.

E V I D E N C E R E V I E W

AbstractNuchal translucency screening (NTS) forDown’s syndrome is carried out in New Zea-land despite the absence of a national screen-ing policy, information, guidelines or training.This article explores NTS in relation to itseffectiveness, the issues generated for womenand society, the midwife’s role and responsi-bilities and makes recommendations formidwifery practice.

IntroductionTen years of independent midwifery practice inNew Zealand have seen many changes in mater-nity care but the introduction of the nuchaltranslucency screening (NTS) test for Down’ssyndrome has caused a major dilemma withinthat practice.

There are implications related to the effectivenessof the test and consequences for the parents andsociety which impact on the role of the midwife.

Knowledge concerning availability and effective-ness of NTS varies amongst health professionalsand consumers alike. One woman at her first an-

tenatal visit in my practice produced an ultrasoundreport which gave the nuchal translucency (NT)measurement of her baby. She asked what thismeant as the general practitioner, who ordered thescan, had requested a dating assessment. On fur-ther questioning of the ultrasound department itseems that they were “just practising”. Some knowl-edge of the test has brought women to their firstantenatal visit with requests such as “please may Ihave that new scan to see if the baby is alright?” or“my friend had a scan to see if the baby has Down’ssyndrome”. The inference is that performance ofthe test will provide an immediate indication asto whether or not the baby is affected. Nothingcould be further from the truth. Discussionsamongst colleagues have indicated that there arehuge variations in practice. Some practitioners areunaware of the test while others, who are aware,do not offer the test. Within my own practicethe test is offered but this usually results in alarge part of the first antenatal visit focusing onfetal abnormality.

The dilemma that midwives now face is that theyare obliged to provide women with clear, accu-rate, objective information regarding the impli-cations of NTS despite the fact that there has neverbeen any information, training or guidelines pro-vided by the Ministry of Health. The risk of falsepositive or false negative results further compli-cates matters and women may be faced with inva-sive testing such as chorionic villus sampling (CVS)or amniocentesis which carry a risk of fetal loss inthe range of 1:100 (Enkin et al., 2000) in orderto confirm a definitive chromosomal diagnosis.

There is also the dilemma for the parents ofwhether or not to continue the pregnancy ifDown’s syndrome is identified or indeed if a less

Nuchal translucency screening for Down’s syndrome: the midwife’s role

Lesley Irving RM ADM

Lesley has been working as a midwife for 21years and is currently employed as a ClinicalEducator for Auckland University of Technol-ogy. She previously spent 10 years working asan independent midwife in South Auckland.Prior to that she was employed as a midwiferymanager in the UK.


severe abnormality is identified when terminationof pregnancy would not usually be an option.Recently a colleague was caring for a 33 year oldwoman who was delighted at being pregnant withher second child. NTS was performed after coun-selling and the result showed that the risk forDown’s syndrome was increased. Subsequent am-niocentesis identified a fetus with Turner’s (XO)syndrome which does not always cause major dis-ability. The pregnancy was terminated at 17 weeksgestation at the woman’s request.

This article explores the literature in relation tothe effectiveness of NTS and the issues the testgenerates for women and society. The role andresponsibilities of the midwife working in part-nership with the woman are discussed in relationto NTS and recommendations are made for mid-wifery practice. A glossary of terms is provided atthe end of the article.

Effectiveness of NTSEvidence based clinical practice involves use of thebest evidence available to arrive at the best deci-sion for practice. In order to use evidence in prac-tice it is important to assess the needs and valuesof the woman. The evidence needs to be inter-preted and used wisely with discussion and re-flection on outcomes, feelings and consequencestaking place (Page, 2000). NTS is currently prac-tised in New Zealand without any clear evidenceof its effectiveness or consideration of the conse-quences. The test is funded by the Health De-partment whilst maternal serum screening is not.There is no evidence however to support the useof NTS without the associated use of maternalserum markers (Wald et al., 2003).

Ultrasound measurement of nuchal translucency(NT) was developed in the early 1990s and stud-


continued over...

ies which have examined its implementation inroutine practice have demonstrated varying de-tection and false positive rates. Using NTS aloneBewley, Roberts, Mackinson and Rodeck (1995)found detection rates of only 33% with a falsepositive rate of 6.0%. Hafner, Schuchter, Liebartand Phillip (1998) demonstrated higher detectionrates of 57% but also a much higher false positiverate of 17%.

The rates of detection improved when NT meas-urements were adjusted in accordance with ma-ternal age. Nicolaides, Sebire and Snijders (1999)identified 75% of affected fetuses with a false posi-tive rate of about 5%. The Fetal Medicine Foun-dation Multicentre Prospective Intervention Study(Snijders, Noble, Sebire, Souka & Nicolaides,1998) of almost 100 000 women found that as-sessment of risk by a combination of maternal ageand NTS gave a detection rate of almost 73%.

Schuchter, Hafnet, Stangl, Ogris and Phillip(2001) argue that the combination of NTS at 10-13 weeks gestation and the triple test at 16 weeksgestation results in a higher detection rate. Theyconducted a retrospective study over a 5 year pe-riod of 9342 women and found that the com-bined approach had detection rates of 95%. Therate of invasive testing was 7.2% which was lowerthan a rate of 10.7% which resulted from screen-ing by maternal age alone. False positive rateshowever were not given.

Wald et al. (2003) conducted a large prospectivestudy of 47 053 women with singleton pregnan-cies to identify the most effective method of ante-natal screening for Down’s syndrome; the SerumUrine Ultrasound Screening Study. Varying com-binations of NT, maternal serum and urine mark-ers and maternal age were assessed in women whobooked at 8-14 weeks gestation with a singletonpregnancy. NT measurements were included ifobtained between 9-13 weeks gestation. Efficacywas assessed by measuring the false-positive ratefor a detection rate of 85%. NTS used alone hadthe highest false positive rate of 20%. When per-formed at 10 weeks gestation as part of the inte-grated test, the false positive rate was reduced to1.3%. NTS performed at 10 weeks gestation aspart of the combined test had a false positive rateof 6% which was significantly lower than NTSalone, but the serum integrated test without NTShad a false positive rate of only 2.7%. The resultsshowed that NTS used alone was the least effec-tive whilst the integrated test was the most effec-tive. Indeed, the serum-integrated test was moreeffective than the combined test which includedNTS. The authors also suggest that the integratedtest is safe and cost effective as the low false posi-

tive rates reduce the numbers of invasive diagnos-tic procedures required.

The only maternal serum screening test currentlyavailable in New Zealand is the triple test. Higherdetection rates when usingcombined NTS and tripletest have been demon-strated (Schuchter et al.,2001) but the rate of inva-sive testing is still signifi-cant. Reduced rates of fe-tal loss or damage as a re-sult of invasive diagnosticprocedures can only beachieved by using screen-ing tests which signifi-cantly reduce the false positive rate. These testsare not currently available in New Zealand.

Issues for women and societyNew Zealand currently lacks a national screeningpolicy for Down’s syndrome yet NTS has beenintroduced and funded by the Maternity BenefitsDepartment under the Notice Pursuant to Sec-tion 88 of the New Zealand Public Health andDisability Act 2000 (Ministry of Health, 2002).Before a screening test is introduced into societyconsideration should be given to balancing thecost of not screening against the prevalence of thedisease. Also, the test should be simple, sensitive,cost effective and reliable (Beaglehole, Bonita &Kjellstrom, 1993). There should be an effective,acceptable, safe treatment should the test provepositive. NTS has never been evaluated to see if itmeets the required criteria and the only treatmentis termination of the fetus.

Down’s syndrome is the most common cause ofsevere mental retardation in the developed worldwith a birth incidence of 1-3:1000 (Mulvey &Wallace, 2000) with obvious financial implica-tions. In the United Kingdom, Gilbert et al.(2001) found that there are long term financialbenefits to the country if a fetus, detected by an-tenatal screening as having Down’s syndrome isaborted. This view ignores the contribution a disa-bled person can make to their family and society.Indeed, many parents of Down’s syndrome chil-dren express the joy the child brings to the family.The emphasis on identification also needs to con-sider assisting those affected families to avail them-selves of all of their options and help those whochoose to continue with the pregnancy to preparefor the event.

The affordability of NTS requires consideration.Although the test is funded by the government,most ultrasound scanning departments or busi-

nesses charge the woman a ‘co-payment’ whichmeans that it is not readily available to all women.The triple test which is the only available serumscreening test for Down’s syndrome currently avail-able in New Zealand, is not funded in the same

way and the woman is re-quired to pay the full cost.This occurs despite evi-dence that detection ratesare increased when NTS isused in conjunction withtriple test (Schuchter et al.,2001). These factors sup-port the view that technol-ogy and subsequent inter-vention occurs amongstthose who can afford to

pay. The cost of counselling, further tests such asCVS or amniocentesis and the rate of fetal losshave not been taken into account. No pregnancyis replaceable and the cost of screening in humanterms has not been evaluated.

A reliable test provides consistent results and cor-rectly categorizes people into groups (with or with-out disease) (Beaglehole et al., 1993). Wald et al.(2003) have demonstrated that NTS alone is notreliable and should be used in conjunction withmaternal serum markers. Furthermore, the testestimates the woman’s ‘risk factor’ and does notprovide a definitive diagnosis. It has also beendemonstrated that the accuracy of NTS dependson the availability of well trained and certifiedultrasonographers (Snijders et al., 2002). Only thelarger centres in New Zealand have the staff andequipment to undertake this type of programmewhich makes screening available only to womenwho have access to those centres.

The social implications of NTS include the risksof anxiety and possible effects on bonding andparenting. The mere implication of ‘increased risk’can cause anxiety in the mother (Cheffins et al.,2000) and prenatal screening tests that indicate arisk of fetal abnormality can induce clinically sig-nificant anxiety and distress in women (Santalahti,Lattika, Ryynanen & Hemminki, 1996). Mater-nal anxiety has been associated with behaviouralproblems in early childhood (O’Connor, Heron,Golding, Beveridge & Glover, 2002). Somewomen view ultrasound as a rewarding experiencewith expectations of reassurance but Filly (2000)has found that women experience overwhelmingconfusion and worry when those expectations arenot fulfilled. Ultrasound may strengthen mater-nal and fetal bonding which then poses a prob-lem for those who have an abnormality diagnosedand find that they are faced with the decision

There is also the dilemma for the

parents of whether or not to continue

the pregnancy if Down’s syndrome

is identified or indeed if a less severe

abnormality is identified when

termination of pregnancy would

not usually be an option.


whether or not to terminate the pregnancy (Garciaet al., 2002). Alternatively the use of technologycan affect the bonding attachment and womenmay “suspend” their attachment until results areknown (Wolf, 2001, p. 31). Midwives need to beaware of the risks related to anxiety so that appro-priate reassurance can be provided.

False positive and falsenegative results result infurther problems. Falsepositive results can exposethe pregnancy to invasivetesting such as CVS or am-niocentesis, both of whichhave significant risks of in-fection, haemorrhage, fetaldamage or loss (Alfirevic,Sundberg & Brigham,2003). False negative re-sults whereby the parentsare falsely reassured canhave psychological consequences. Hall, Bobrowand Marteau (2000) found that a false negativeresult can have a small but adverse effect on pa-rental adjustment for between 2 to 6 years afterthe birth of an affected child.

The variety of options and possibilities forhealth care often conflict with the values and re-alities in the lives of women, their families andsociety. It would seem that NTS could give rise tothose conflicts.

The midwifery partnership and NTSThe midwifery partnership refers to the relation-ship between the woman and the midwife as onewhere trust, control and responsibility are sharedbetween the two (Guilliland & Pairman, 1995).The main principles include individual negotia-tion, continuity of care, informed choice and con-sent (ibid, 1995). The underlying premise is thatindividual negotiation acknowledges the expertisethat both partners bring to the relationship. Thewoman brings self knowledge and experienceto the partnership whilst the midwife bringsscientific knowledge, midwifery experienceand intuition.

Midwifery practice has become more complex asa result of new and advanced technology. Thedecision to undergo NTS should only be madeafter the woman has received clear, accurate un-biased information so that she is able to make adecision based on the information presented. Thescientific knowledge and experience of NTSbrought to the relationship by the midwife maybe very limited as formal training programmes forNTS are not available in New Zealand for health

professionals. New Zealand does not offer a na-tional screening policy for antenatal detection ofDown’s syndrome and the screening currently of-fered varies depending on the individual centre,individual woman or lead maternity carer. Womenneed accurate information in order to make an in-formed choice which in this case may prove a sig-nificant challenge for the midwife.

Continuity of care allowstime for the woman andthe midwife to get toknow each other, clarifyexpectations and developtrust. NTS is problematicin that it is carried outbetween 11-13 weeks ges-tation so the giving of in-formation and counsellingoften needs to take placeat the first antenatal visitwhen the relationship has

not yet established. Women may attend that firstvisit with no thought of fetal abnormality and leavewith that as their only concern. The challenge forthe midwife is to initiate the relationship, bringvalid knowledge and provide information in a waythat does not influence the woman’s decision butallows her to make a truly informed choice. Con-tinuity of care and effective communication al-lows that relationship to continue to develop re-gardless of the woman’s decision.

Recommendations formidwifery practiceWhen counselling with regard to NTS, midwivesworking in partnership need to ensure women areaware of the following points.

• NTS is a screening test only, it will not providea definitive answer.

• When used alone NTS is not the best screeningtest for Down’s syndrome and predictive out-comes only improve when the test is used inconjunction with maternal serum screening.

• There are risks of false positive and falsenegative results with NTS. False positive resultscan lead to invasive testing such as CVS oramniocentesis, whilst false negative results giveinappropriate reassurance.

• Invasive testing carries a risk of fetal loss ordamage.

• Testing may result in identification of lesssevere abnormalities for which termination ofpregnancy is more contentious.

• NTS is carried out in order to offer termina-tion of affected fetuses.

Any screening service is available for people to useas they choose. Choice is based amongst otherthings, on the provision of appropriate informa-tion and technical advances in screening can onlylead to improved outcomes if those offered thescreening are fully informed of the process.

ConclusionTechnological advances should be implementedinto health care only after clear evaluation andconsideration of the implications, side effects, ac-curacy and cost. The implementation of screen-ing tests should make a positive difference to thewoman and her baby and should occur only afterclear evaluation and judicious use of the evidence.The way in which NTS is currently employed inNew Zealand does not demonstrate either.

The evidence does not support retaining the useof NTS alone as low detection and high false posi-tive rates have been demonstrated (Bewley et al.,1995; Hafner et al., 1998). NTS used in conjunc-tion with maternal age improves detection rates(Nicolaides et al., 1999) and those rates are sig-nificantly improved when NTS is used in con-junction with the triple test (Schuchter et al.,2001). The most effective method of screeningfor Down’s syndrome however is the integratedtest (Wald et al., 2003) but this is not currentlyavailable in New Zealand.

Midwives are obliged to provide quality care byensuring they are fully informed of the servicesavailable. It is important that the information theyconvey to women includes the nature and birthprevalence of Down’s syndrome. Detection rates,false positive and false negative rates of NTS aloneand when used in combination with maternal se-rum markers should be identified. The womanneeds to be made aware of the invasive diagnostictests that would be offered if the test result is ‘highrisk’ and the risks of fetal damage or loss than canresult from those tests. She should understand theimplications of increased anxiety while waiting forresults and the choices to be made in the event ofa positive result. The possible outcome of termi-nation of pregnancy should be made very clear towomen as those who would continue with thepregnancy regardless of abnormality may choosenot to be screened.

Counselling women with regard to NTS forDown’s syndrome requires great care and consid-eration of the consequences.

Nuchal translucency screening for down’s syndrome: the midwife’s role

continued...

New Zealand currently lacks a national

screening policy for Down’s syndrome

yet NTS has been

introduced and funded by the

Maternity Benefits Department under

the Notice Pursuant to Section 88 of

the New Zealand Public Health and

Disability Act 2000 (Ministry of Health, 2002).


Glossary of Terms

Combined test. First trimester test based oncombining nuchal translucency measurement withfree beta-human chorionic gonadotrophin (beta-hCG), pregnancy- associated plasma protein A (PAPP-A) and maternal age.

Double test. Second trimester test based on themeasurement of alpha-fetoprotein (AFP) and hCG(either free beta-hCG or total hCG) together withmaternal age.

Integrated test. The integration of nuchal translu-cency and PAPP-A measurements in the first trimesterwith the quadruple test markers in the secondtrimester.

Nuchal translucency (NT) measurement. The widthof an area of translucency at the back of the fetal neck,usually measured at about 10-13 weeks gestation usingultrasound.

Quadruple test. Second trimester test based on themeasurement of AFP unconjugated oestriol (uE3),free beta-hCG (or total hCG) and inhibin-A togetherwith maternal age.

Serum integrated test. A variant of the integrated testusing serum markers only (PAPP-A in the firsttrimester and the quadruple markers in the secondtrimester).

Triple test. Second trimester test based on themeasurement of AFP, uE3 and hCG (either total hCGor free beta-hCG) together with maternal age.

ReferencesAlfirevic, Z., Sundberg, K., & Brigham, S. (2003).

Amniocentesis and chorionic villus sampling for prenataldiagnosis (Cochrane Review). In: The Cochrane Library,Issue 3. Chichester, UK: John Wiley and Sons Ltd.

Beaglehole, R., Bonita, R., & Kjellstrom, T. (1993). Basicepidemiology. Geneva: World Health Organisation.

Bewley, S., Roberts, L.J., Mackinson, M., & Rodeck, C.(1995). First trimester fetal nuchal translucency: problemswith screening the general population. British Journal ofObstetrics & Gynaecology, 102, 386-388.

Cheffins, T., Chan, A., Haan, E., Ranieri, E., Ryall, R.G.,Keane, R.J., et al. (2000). The impact of maternal serumscreening on the birth prevalence of Down’s syndrome andthe use of amniocentesis and chorionic villus sampling inSouth Australia. British Journal of Obstetrics & Gynaecology,107, 1453-1459.

Enkin, M., Keirse, M.J.N.C., Neilson, J., Crowther, C.,Duley, L., Hodnett, E., et al. (2000). A guide to effectivecare in pregnancy and childbirth (3rd ed.). New York:Oxford University Press.

Filly, R.A. (2000). Obstetric sonography: The best way toterrify a pregnant woman. Journal of Ultrasound inMedicine, 19, 1-5.

Garcia, J., Bricker, L., Henderson, J., Martin, M.A., Mugford,M., Nielson, M.D., et al. (2002). Women’s views ofpregnancy ultrasound: A systematic review. Birth, 29 (4),225-250.

Gilbert, R.E., Augood, C., Gupta, R., Ades, A.E., Logan, S.,Sculpher, M., et al. (2001). Screening for Down’ssyndrome: effects, safety and cost effectiveness of first andsecond trimester strategies. British Medical Journal, 323,423-425.

Guilliland, K., & Pairman, S. (1995). The MidwiferyPartnership: A model for practice. Wellington, NZ:Department of Nursing & Midwifery, Victoria Universityof Wellington.

Hafner, E., Schuchter, K., Liebart, E., & Phillip, K. (1998).Results of routine fetal translucency measurement at 10-13

weeks in 4233 unselected pregnant women. PrenatalDiagnosis, 18, 29-34.

Hall, S., Bobrow, M., & Marteau, T.M. (2000). Psychologicalconsequences for parents of false negative results onprenatal screening for Down’s syndrome: retrospectiveinterview study. British Medical Journal, 320, 420-422.

Ministry of Health. (2002). Maternity Services Notice Pursuantto Section 88 of the Health and Disability Act 2000. NewZealand: Author.

Mulvey, S., & Wallace, E.M. (2000). Women’s knowledge ofand attitudes to first and second trimester screening forDown’s syndrome. British Journal of Obstetrics &Gynaecology, 107, 1302-1305.

Nicolaides, K.H., Sebire, N.J., & Snijders, R.J.M. (1999).The 11-14 week scan. The diagnosis of fetal abnormalities.London: Parthenon Publishing Group.

O’Connor, T., Heron, J., Golding, J., Beveridge, M., &Glover V. (2002). Maternal antenatal anxiety andchildren’s behavioural/emotional problems at 4 years.British Journal of Psychiatry, 180, 502-508.

Page, L. A. (Ed.) (2000). The new midwifery science andsensitivity in practice. London: Harcourt Publishers Ltd.

Santalahti, P., Lattika, A.M., Ryynanen, M., & Hemminki, E.(1996). Women’s experiences of prenatal serum testing.Birth, 23, 101-107.

Schuchter, K., Hafnet, G., Stangl, G., Ogris, E., & Philipp,K. (2001). Sequential screening for trisomy 21 by nuchaltranslucency measurement in the first trimester andmaternal serum biochemistry in the second trimester in alow risk population. Ultrasound in Obstetrics &Gynaecology, 18 (1), 23-25.

Snijders, R.J.M., Noble, P., Sebire, N., Souka, A., &Nicolaides, K.H. (1998). UK multicentre project onassessment of risk of trisomy 21 by maternal age and fetaltranslucency thickness at 10-14 weeks of gestation. Lancet,351, 343-346.

Snijders, R.J.M., Thom, E.A., Zachzry, J.M., Platt, L.D.,Greene, N., Jackson, L.G., et al. (2002). First-trimestertrisomy screening: nuchal translucency measurementtraining and quality assurance to correct and unifytechnique. Ultrasound in Obstetrics & Gynaecology, 19(4), 353-359.

Wald, N.J., Rodeck, C., Hackshaw, A.K., Walters, J., Chitty,L., & Mackinson, A.M. (2003). First and second trimesterantenatal screening for Down’s syndrome: the results of theSerum, Urine and Ultrasound Screening Study (SURUSS).(Electronic version). Health Technology Assessment, 7 (11).

Wolf, N. (2001). Misconceptions. Truth, Lies and theUnexpected on the Journey to Motherhood. London: Chatto& Windus.

AcknowledgementThis article was written as part of an assignment forthe Knowledge Paper, in the post graduate Certificatein Health Science (Midwifery); led by Marion Hunterat Auckland University of Technology.


Irving, L. (2004). Nuchal translucency screening forDown’s syndrome: The midwife’s role. NewZealand College of Midwives Journal, 31, 18-21.

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AbstractWhat is it like to stand by and watch a womango through the pain of labour? How do mid-wives show that they care? How do they goabout helping? These questions underpinnedmy study which explored the meaning of theexperience of midwives working with womenand their pain during labour. A qualitativestudy, using hermeneutic phenomenology, al-lowed me to talk with seven midwives abouttheir experiences of providing intrapartum care.This article offers an interpretation of theirnarratives and, in presenting the findings, re-veals aspects of practice frequently taken forgranted in their everydayness.

IntroductionFor most women labour involves pain. Often thepain of contractions is the most severe pain that awoman ever has to face and she can approach la-bour with considerable trepidation about what liesin store. She may have endeavoured to prepareherself by attending childbirth education classesand talking with friends, family and health pro-fessionals. In the end, though, a woman’s labouris a unique experience. It is a private and totallysubjective experience because it is her labour andonly she can feel her contractions. In working witha woman in pain, the midwife occupies a privi-leged position. She is sharing a momentous occa-sion in the life of this woman and her family. Thenature of the relationship which forms with themidwife can influence the woman’s confidence inher own ability to cope with labour. Most mid-wives understand the importance of the rapportwhich needs to be established with a woman inorder to foster in her a sense of security and trust.Communication is of vital importance in form-ing a relationship (Ralston, 1998). Depending onthe woman’s choice of lead maternity carer, the

midwife could be someone she has become ac-quainted with throughout her antenatal period,or she could be a total stranger whom she is meet-ing for the first time. Midwives also know howimportant their very presence is to a woman inlabour. Continuous midwifery support has beenshown to have a positive effect on a range of out-comes including the need for pharmacologicalpain relief, duration of labour and a more posi-tive birth experience for the woman (Berg,Lundgren, Hermansson, & Wahlberg, 1996;Hodnett, Gates, Hofmeyr, & Sakala, 2003; Lav-ender, Walkinshaw, & Walkin, 1999). Women inlabour also value the chance to be involved inmaking decisions regarding their care(Halldorsdottir & Karlsdottir, 1996).

This article examines some of the midwifery lit-erature pertinent to the way in which midwiveswork with women during labour. It briefly dis-cusses the methodology employed and give anoverview of the way in which the study was con-ducted. The three major themes to emerge aredescribed and illustrated by verbatim excerptsfrom the study’s participants. The central find-ing, the essence of the phenomenon, seems to bethat midwives interpret the meaning of women’spain. This finding is seen in context as it emergesfrom the participants’ stories and the themes inwhich they are contained. Finally this article sug-gests ways that these findings can have relevanceto the practice of all midwives.

Literature reviewAn examination of the literature surrounding thepain of labour found much written from the wom-an’s perspective about the pain of childbirth. Lessapparent is information about the midwife’s ap-proach to pain in labouring women. Three stud-ies were located which add to our knowledge aboutthe way that midwives provide care to women inlabour with regard to their pain. First, Leap’s re-search (1996) which adopted a modified versionof the grounded theory approach to interview tenmidwives with extensive homebirth experience.Leap found that these midwives viewed the painassociated with normal labour as pain which canbe borne by most women because it represents anormal physiological process. Leap characterisedthis approach as “working with pain”, contrastingthis philosophy of care with the more traditionalemphasis on “pain relief ” (p.47).

The second study was conducted in a NorthernIreland hospital (McCrea, Wright & Murphy-Black, 1998). Eleven midwives were observed in-teracting with fifteen women during labour andthree types of approach to pain relief were identi-fied. These ranged from an emotionally aloof carerwho may have met the physical needs of a woman,but not the psychosocial needs – a “cold profes-sional”; to a “disorganised carer” who exhibited lit-tle professional competence or good communica-tion skills; to a “warm professional” – a midwifewho provided care in a holistic way and treatedthe woman as “special” (p.179). Furthermore, the‘warm professional’ promoted an attitude of part-nership and a positive portrayal of labour painthrough her presence and support, but also byencouraging the woman to voice her fears and seekclarification about aspects of pain relief.

The third study, by Lundgren and Dahlberg(2002), described nine midwives’ experiences oftheir encounters with women and their pain dur-ing childbirth in Sweden. The study used aphenomenological approach, collecting data viatape-recorded interviews. The authors concludethat the midwife should strive to be an “anchoredcompanion” (p.162). This definition encompassednotions of a physical, psychological and emotionalpresence and a relationship built on mutual trustand confidence.

Although the pain of childbirth has been exten-sively researched from the woman’s perspective,the literature I examined in the course of this studyrevealed a relative lack of information about themidwife’s approach, particularly to pain in labour.Only the three studies discussed in this sectionappear to address this gap in knowledge, citingqualities such as warmth, trust, physical and emo-tional presence as desirable traits in a midwife.

A brief discussion of the philosophical underpin-nings that have informed my approach to thisphenomenological study follows. I will explainhow my research question and the method usedare congruent with Heideggerian hermeneuticphenomenology and highlight some aspects of themethod including recruitment of participants, datagathering and data analysis.

Methodology and methodPhenomenology is a philosophical methodologythat allows for the chance to explore the natureand meaning of human experience (van Manen,

Midwives’ experiences of working with women in labour:interpreting the meaning of pain

Stephanie Vague RM RGON MHSc(Midwifery)

Stephanie has worked as an employed midwifefor many years. She taught on the midwiferyundergraduate programme at AucklandUniversity of Technology (AUT) while she wasengaged in postgraduate study. Uponcompletion of her Master’s thesis, late in 2003,she has returned to independent practice.



1990). The research question for my study asked“What is the experience of midwives working withwomen and their pain in labour?” Posing the ques-tion in this way allowed me to interview midwivesto obtain their description of working with painfrom their own personal context as well as thecontext of the environment and the women withwhom they interacted. I sought the opportunityto better understand everyday lived events throughthe words of the participants. Phenomenologychallenges us to look beyond the taken-for-grantednature of our lived world, to see afresh phenom-ena that are frequently hidden from view or partlyobscured by their everydayness (Heidegger, 1962).

The Auckland University of Technology EthicsCommittee granted ethical approval for my study.I tape-recorded interviews with seven midwivesand sought to encourage them to provide detailedaccounts of their experiences. The participantswere drawn from a range of practice backgroundsand levels of experience and were both hospital-employed and independent practitioners. I usedpurposive sampling to approach midwives whomI determined would have sufficient clinical expe-rience and be sufficiently articulate and reflectivepractitioners to enhance the opportunity for anaccount of the lived experience to be expressed asfully as possible.

A question I frequently asked to begin an inter-view, because many of the participants had expe-rience of caring for women in labour in a homesetting and in a hospital, was “Is there a differencein the way you work with women depending onwhere they choose to birth?” Sometimes I prompteda participant with something like “Tell me abouta time when you wrestled with a decision aboutpain relief ”.

An important ingredient in the interpretation ofdata in a phenomenological study informed byHeidegger is the process of the researcher openlyengaging with her pre-assumptions. Prejudices andpre-conceived opinions are held by all of us andare inextricably linked to the way in which weview the world and interact with it. Heidegger(1962) argues that we bring these pre-assumptionsto our analysis and we are unable to lay them toone side as it colours our very being in the world.

It is necessary, therefore, to keep these pre-assump-tions to the forefront during the questioning andreflecting which is so much a part of the quest formeaning that embodies data analysis. Participants’stories are interpreted and re-interpreted duringthe process of writing and rewriting which is es-sential in phenomenological work. Data analysis

is a gradual process. It began with several readingsof each participant’s transcript in order to pull outpassages which directly related to my researchquestion. These passages contained metaphors orphrases which resonated for me by their relevanceto my topic area. I played with the possible mean-ings contained withinwords and phrases as Isought to take my level ofunderstanding deeper.Gradually I accumulatedgroups of stories expressingsimilar ideas, and somewith contrasting data,from the transcripts. I wasencouraged to look at the‘bigger picture’ concerningeach story in an effort to capture a tentative ‘han-dle’ or theme. After engaging with the writing ofHeidegger and van Manen I came to see the sto-ries, with their interpretations, as parts of a largerwhole again. As I continued to reflect and re-writedeeper interpretation of the individual stories, theyfell into a number of sub-themes and graduallythe themes became apparent to me. The storiescome to be seen as parts of a larger whole, whilstat the same time being whole in themselves. Thereare stories about:

• “before the pain” – the antenatal period and thepre-assumptions that the midwife and thewoman bring to labour

• “working with the pain” – the ‘how’ of the midwife’s work

• “after the pain” – the period when the birth isover, but the pain may not be.

ThemesInterwoven throughout all of the stories are threecentral themes which each contain elements ofthe central finding of this study – the essence ofthe phenomenon of midwives’ experiences ofworking with women and their pain.

“Leaping ahead/leaping in”The first theme is “leaping ahead/leaping in”.These are terms coined by Heidegger (1962) todescribe the way a person can show concern foranother. They represent the two extremes along aspectrum of “showing concern for” that Heideggercalls solicitude.

“Leaping ahead”“Leaping ahead” of a woman may be one way amidwife seeks to prepare her for the pain of la-bour. By helping to show the woman what thefuture might contain in the course of antenataldiscussions, the midwife hopes to make such acourse of events recognizable for her so that she is

better prepared for them and more likely to en-gage in decisions about her pain management ifthey arise.

Another example of ‘leaping ahead’ can beglimpsed in the concern Amanda expresses about

men providing support forwomen without their ownback-up:

I often get quite anxiouswhen women are justgoing to have their partnersfor support… Sometimes Ithink men have their needsand they override what theirrole is in terms of being there

for that woman. Sometimes you’re giving the epi-dural for the partner who’s really unhappy and un-comfortable and feels very anxious about their lovedone. I think men often do need to have support andthat helps them put things in perspective a bit be-cause the responsibility is not 100% theirs. I thinkthat’s where they crumble often and they see whatthe women are doing in labour as a reflection onthem as opposed to it just being a normal process.

Amanda talks of men who ‘crumble’ at the sightof their partner in pain. She knows that a ‘crum-bly’ man may result in a ‘crumbly’ woman who isunsettled by the loss of a reassuring presence. Byhighlighting the need for adequate support to thewoman, she may ensure an effective support teamis in place before labour begins. “Leaping ahead”also carries connotations of preceding women intothe future in order to empower them in the pro-vision of their care.

“Leaping ahead” is also apparent in accounts bymidwives during labour when they try to antici-pate what a woman might be feeling and explainit to her.

As the labour goes on further and further, and getsmore intense, I creep closer and closer. But all thetime I’m listening to what’s happening… If I feelthat she’s losing it, I’ll say to her “What’s happeningfor you?” so that I can connect with where she’s atand… when I get the feedback from her, then I’llinterpret what’s going on for her. So there’s that tun-ing in to her all the time and as soon as I sense anypanic in her, I’m in there immediately and re-an-choring her back in the process and reassuring herthat it’s alright. [Catherine]

Catherine’s focus is totally on the woman as la-bour progresses. Gradually, but inexorably, her

Phenomenology challenges us to look

beyond the taken-for-granted nature of

our lived world, to see afresh phenomena

that are frequently hidden from view or

partly obscured by their everydayness

(Heidegger, 1962).

continued over...


presence is more and more necessary. By givingher full attention to the woman, Catherine in-vites her to describe the feelings and sensationsthat she is experiencing. She tunes in to the wom-an’s words and to her body’s voice as she seeks tounderstand what might be happening. The mid-wife is poised, not to “leap in” and take over, butrather to discern what is happening so she may“leap ahead” to prepare the way. By suchforesightedness, panic may be kept at bay. Withthis information, Catherine is able to interpretwhat is happening for the woman and put it intothe context of her labour.

“Leaping in”“Leaping in”, by contrast is a way of executingcare which is much more directive. It conveys asense of taking over, doing things for the ‘other’in a situation of more urgency. Midwives in thisstudy related times when it was necessary to “leapin” during labour. Gemma describes such a time:

I recall a primip [sic]. She was in established labourand she was doing good, then all of a sudden, ex-ploded. She didn’t ask for pain relief. She couldn’t.She was just completely screaming and wanting tojump off the bed with contractions… I stepped infinally and said “I think you need Pethidine.”

Gemma has taken over the decision making inthe presence of a woman who has lost controldue to pain. Such an action may be totally justi-fied under the circumstances as the woman isunable to converse, let alone discuss options forpain management.

Midwives also talked oftimes when “leaping in”seems to involve using theirpresence to work with awoman in pain. Diane’swords illustrate how “leap-ing in” with “self ’ can be apowerful intervention for awoman in pain:

She had been sexually abused by her father, a reallybad history… she was absolutely terrified… andshe needed quite a lot of calming. I put a lot of hotwater on her back, a lot of pressure, a lot of rocking,a lot of holding, a lot of coaxing, a lot of stroking,my voice in her ear. Later, she said that’s all she heard,was me saying “You’re alright, just calm down, it’sOK, don’t be frightened”… So you as a person, us-ing yourself, are very instrumental in what happens.

This midwife is physically and emotionally presentin this woman’s pain. She describes all the practi-cal measures she employed and also the constantexplanations and reassurance for the woman.

Diane reminds the woman to relax, to submit tothe pain, to trust her confidence in the process.She is like an interpreter, deciphering the foreignlanguage that is labour into plain English. Themeaning behind the words is what the womanrecalls because this was more important that thecontent. Diane has conveyed a sense of deepunderstanding of the woman’s pain by her wordsand her instinctive “leaping in” to enfold herwith support.

Paradoxically, there may be times when not “leap-ing in” is required. The midwife may make a con-scious decision to hold back, to bide her time.Evelyn describes her conflicting thoughts as shewatches a woman in distress:

Most of the time it’s OK, but there are times when Ifeel that the woman does need something. But I’vegot to hold back and not say anything because I don’twant her to distrust what she’s going through anddistrust herself. Obviously her not saying that sheneeds something means that she’s trusting her bodyand I’ve just got to allow myself to be quiet. And it’samazing, they do do it. So if she cries, she cries andshe’ll let me know.

Evelyn talks of the effort sometimes to “hold back”and not try to save a woman who is crying withpain. It seems that giving oneself permission tobide one’s time and wait can be hard when one’sinstinct may be to “leap in”. One way of workingwith a woman in pain seems to be making roomfor her to be-in-labour by maintaining a watchfulpresence and trusting her to determine when she

needs more midwiferyinput.

Working with timeThe second theme whichthreads its way throughmany of the narratives inthis study is the notion oflived time. Time is alwayspresent in the way that

midwives help women to interpret their labourpain, although it is more apparent on some occa-sions than others.

For instance, there is a sense that time is some-how different for the midwife who practises in ahome setting compared to a hospital environment,as this midwife describes:

There’s less time pressure. People are not watchingthe clock… so I guess it makes you feel more relaxedas a midwife. It’s a two-way thing isn’t it, if you’refeeling confident and relaxed, then you work betterwith the woman and are more able to help her feelconfident and relaxed. [Frances]

Time as measured by the clock seems to have lessmeaning in the home. Labour takes its course andthe woman, and all those who are sharing the jour-ney with her, adapt to its pace. Frances does nothave the jarring reminders of time that she en-counters in a hospital. Consequently there are notthe whispers of doubt about adequate progress todeal with constantly. The result is a more relaxedmidwife who can celebrate the progress of a nor-mal experience and project that confidence ontothose around her.

Midwives in this study understand how a wom-an’s experience of lived time alters when she is inpain. Amanda breaks time down into small seg-ments when she is faced with a woman who isbeginning to doubt her ability to continue with-out pain relief:

They want to know “how much longer am I goingto be at this point?” and I don’t know and they don’tknow, so I think you have to contract with them andsay “well, let’s do a,b,c and d and then review thesituation in …forty minutes time.

Amanda knows that lived time slows for thewoman as labour becomes more intense. She sug-gests a focus on small chunks of time rather thantrying to look too far ahead. Amanda tries to movethe woman’s gaze from the distant horizon of her“future”, an unknowable number of hours stretch-ing ahead of her, to a finite section of “future” inthe forty minute segment. In this way, Amandaworks with the woman in the “now”.

By contrast, other midwives in this study invitewomen to see their pain in terms of small units oftime while, at the same time, helping themto take a larger overview of their labour. Barbaradescribes the way she works with a womanduring labour:

Just really jolly her through, one at a time, one con-traction at a time, not looking too far ahead. I tellher not to be overwhelmed by it because very soon it’sgoing to be over and in the past.

Barbara endeavours to limit the potentiallydestabilising effect of looking too far ahead bysupporting the woman through each contraction.She also invites her to look towards her futurewhen the labour has finished and the pain will bea memory, relegated to her past.

Time as friendLived time can work in the midwife’s favour attimes. On occasion, a woman will request painrelief at an advanced stage of labour. The midwifecan be placed in a difficult position when facedwith such a request, as Barbara recalls:

continued...

Midwives’ experiences of working with women in labour: interpreting the meaning of pain

The midwife is poised, not to “leap in”

and take over, but rather to discern what is

happening so she may “leap ahead”

to prepare the way. By such

foresightedness, panic may be kept at bay.


She said right from the beginning that she didn’t wantanything for pain relief… She was 9cm dilated andshe began to lose it a bit and was determined shewanted an epidural at that stage. The head, when Iexamined her was really well down, the cervix hadalmost gone and she was demanding an epidural. Iintimated that the anaesthetist wasn’t far away. Shewent on and had the baby within 20 minutes. Afterit was all over, she thanked me for not arranging anepidural promptly, but even if I had done, it wouldn’thave been prompt enough.

Barbara used her clinical expertise to assess thatthe woman did not need an epidural anaesthetic.She was faced with a dilemma and chose to givethe impression that the epidural was being ar-ranged, which probably helped the woman to takeheart amidst her growing panic. Then Barbarastepped in closer to the woman with encourage-ment and support. Once safely on the other sideof birth, the woman is delighted with the strategyof procrastination. The woman can now see thatthere was insufficient time to organise an epiduraland Barbara’s gamble in not seeking an epiduralas requested paid off. On this occasion her inter-pretation of the woman’s pain was congruent withher own.

Time as enemyThere can be times when a midwife is castigatedby a woman because she complies with her re-quest for pain relief. Amanda describes a difficultsituation:

She was very far advanced in labour with her secondbaby and she …wanted an epidural. As the epiduralwas going in she had a strong urge to push and thebaby was born. She then asked me why I didn’t ex-amine her, because if I had, then she wouldn’t havehad an epidural. But it wasn’t actually possible toexamine her because she was so agitated and intenton the epidural that I felt that if I had even offeredher an examination, she would have felt it was tan-tamount to an assault or another delaying strategy.She was really upset about that and … couldn’t let itgo afterwards.

Here is an example of the way that time can bethe enemy of a midwife. This woman seems tohave been unable to look beyond her pain ‘now’and recognize that labour is nearly over. Amandafeels compelled to acquiesce to her request forepidural and this was the right decision in thewoman’s eyes at the time. Now that she has timeon her hands, it seems that the correct decisionhas become a wrong one. Over time, the wisdomof a course of management can be judged andfound wanting. There is a disparity in the inter-pretations of both the woman and the midwife.

BelievingThe third theme to emerge from this study is thesense of belief that midwives employ when work-ing with women and their pain. There seems tobe an inner conviction within some midwiveswhich communicates itself to women and incitesthem to call upon something inside themselveswhen they are at their mostvulnerable. The followingstory is a telling exampleof the power of the mid-wife’s belief propelling awoman through labour:

I remember a woman whowanted a homebirth becauseshe’d had an epidural [andinstrumental birth previ-ously]. She said to me ‘ Idon’t think I can cope. Ithink I need to go to hospital to have an epidural.’ Isaid ‘No, you are only saying that because you’re rightat the place where you had the epidural last timeand you haven’t got any experience of what happensfrom here on in without an epidural, but this is whatyou wanted. You wanted a normal birth, youwanted a home birth and that’s what you’re hav-ing. So, I want you to say this, ‘I’m having a normaldelivery and I can do this.’ So she just went roundand round the couch saying that… She kept walk-ing and saying it and then she started (involuntarypushing noise) and I said ‘There you go. Come on.’…She was just fantastic, she was totally rapt. Thewoman just changes instantly from being this fright-ened person to being this ‘Oh, I can do it!’ [Diane]

Diane empowers the woman to take a huge leapof faith. When she begins to doubt her ability tocope without an epidural like last time, Dianedoesn’t hesitate. By asking the woman to verbal-ise a positive and helpful message which can beheard by all present, Diane encourages her to dis-pel any doubt and await the birth. The darknessthat is the future holds unknown experiences, butDiane is prepared to accept that she cannot see,or yet understand, what lies ahead. Her messageto the woman is that together they will face thedarkness and look for signs of light which mightallow for more understanding. The birth provokeselation and self-congratulation in the woman whohas truly worked to realise this goal. In Diane’swords we can also hear her admiration for thathard work. Behind it all though, is Diane’s un-swerving belief in the woman which never waversand which conveys confidence and certainty tothe woman. The result was an exciting and satis-fying birth experience.

Sometimes midwives impart their belief inthe woman in the apparent absence of anyneed. Catherine talks of a seemingly self-contained woman:

In labour she was completely composed and didn’tseem to need much input, but I was doing my usual

talking her through andwhen I sensed she was get-ting stretched, just anchor-ing her again and talkingher through. But after shehad the baby she was a dif-ferent woman. She was justthis effervescent, outgoing,bubbly person that I hadn’tseen through the whole preg-nancy. She started it off. Shesaid ‘I wanted to say to youthat when you were saying

the things you were saying to me in labour, eventhough I wasn’t responding to you because I couldn’t– it was too intense, that was really important tome. You kept me going and if I had had midwiveswho had said the same things to me with my firstlabour, I think I would have got through withoutneeding all those other things that I had.’

Catherine describes how she ‘senses’ when thewoman is ‘getting stretched’. Small cues withinthe woman’s body language are sufficient forCatherine to respond with more intense praise andencouragement. This serves to ‘anchor’ the womanagain, to provide a steadying and dependable mes-sage that helps to maintain her sense of control.Although the woman gives little sign of needing, orheeding the midwife’s words, she recounts later thatthey were extremely necessary to keep her going.

The meaning of painAn important part of working with women andtheir pain is the meaning which is attributed tolabour pain. Although not a theme in this study,this was an area I explored during my analysis aselements of the notion appeared to be part of manyof the stories.

Pain has negative connotations for most people.They associate pain with trauma or illness. Somemidwives in this study seek to redefine pain as it isexperienced in labour in order to help women workwith it more effectively. Frances tells her clients:

The pain of labour is a good thing. It’s functional.There’s nothing bad about it. Occasionally I’ve usedwords that I’ve heard Sheila Kitzinger use like ‘wel-coming the pain’ because it’s bringing your baby. So Itry and always use positive words without making itsound like it’s easy.

continued over...

Amanda tries to move the woman’s

gaze from the distant horizon of her

“future”, an unknowable number of

hours stretching ahead of her, to a

finite section of “future” in the forty

minute segment. In this way, Amanda

works with the woman in the “now”.


Diane is even more eloquent in her description:

Pain – it’s part of the birth, isn’t it? It’s normal. It’spain with a purpose… It’s there because it’s doing afunction and it’s not something that’s to be feared.You relax into it, you go with it, all those sort ofwords. Just go down to meet the pain, don’t run fromthe pain, go to it, accept it.

The words these midwives use to describe the painof labour underlines their understanding of themeaning of labour pain. By giving voice to thepositive imagery about yielding their bodies to thepain, the midwives are attempting to permit a newunderstanding or interpretation of labour and itspain to women.

The essence –interpretingthe meaning of painA phenomenological studyseeks to answer the researchquestion by distilling thecentral themes into an es-sence. The essence of a phe-nomenon is that whichconstitutes the true beingof a thing. So, in answer to this study’s researchquestion “What is the experience of midwives work-ing with women and their pain in labour?”, the find-ings seem to indicate that midwives do this byinterpreting the meaning of their pain. Interpre-tation always occurs in the context of the world aswe are in it. It occurs in the way that midwives arewith a woman and how they can ‘be’ with her –what Heidegger (1962) called “Dasein”. Before thepain begins, they “leap ahead” to encourage themto anticipate what the pain will be like and howthey will confront it. Midwives give pain mean-ing for women by naming it and defining its pur-pose in bringing a baby. When labour begins,midwives help women to translate their embod-ied pain in its context. They “leap in” when re-quired, sometimes using self as an intervention.When midwives interpret women’s pain, they riskmisjudging a physical pain they can’t feel, therebycausing mental pain they can’t always salve. Onmany occasions though, midwives can conveybelief to women with such conviction that theywill trust in their pain to keep them safe. Mid-wives help to unlock the mystery of labour painand accompany women on the profoundly mov-ing and humbling journey that is the miracle ofchildbirth.

Implications for practiceMuch of the practice described by participants inthis study is familiar to midwives working withwomen in labour. Nevertheless, the ways in whichtime is manipulated by midwives to help women

with their pain is important to acknowledge, andto celebrate. The concept of breaking time downinto smaller chunks to help women concentrateon the “now” is recognized by many midwives butmay not be acknowledged by them as a valuablestrategy. Similarly, the way that time as measuredby the clock can prove to be a tyranny for somemidwives working in a hospital setting who wishto avoid the constraints of an institution’s time-keeping practices. Midwives know that womenlabour in different ways and blanket adoption ofpolicies for assessing progress can have a detrimen-tal effect on the way that midwives work withwomen and their pain. Perhaps the views expressedin this study lend weight to the opportunity for re-view of hospital policies in this regard to consider

less rigid expectations ofnormal labour situations.

Much of the midwife’swork with women andtheir pain in labour passesunseen by other midwives.This may be because thewoman is labouring athome and will only re-quire the presence of an-

other midwife at the time of delivery. If the womanis in the hospital setting, the door to her roommay be closed for privacy and peace. Only thesupport people gathered with her will witness theway in which the midwife works with a woman’spain. So, the opportunity to learn aspects of ex-pert midwifery practice, such as the way somemidwives inspire women through the strength oftheir belief, is limited. It is imperative, therefore,that avenues be created to ‘show’ this importantaspect of practice. This could be achieved by es-tablishing a forum for the sharing of stories frompractice in places of work and at professional gath-erings such as seminars, conferences or New Zea-land College of Midwives’ meetings. In this way,practice wisdom can be acknowledged and dis-seminated to other midwives.

Finally, the findings from this study suggest thatmidwives need to understand the subjective na-ture of their decision-making in the area of painmanagement. They rely on their interpretation ofthe woman’s perception of pain to formulate theirmidwifery care. The data in this study suggest thatthe closer the congruence between the midwife’sand the woman’s interpretation of her pain, themore likely there is to be satisfaction about themanagement of her pain once labour is finished.This has significance for all midwives working withwomen and their pain in labour. A dissatisfied, orworse, angry woman is likely to harbour ongoinghurt which may have ramifications for her transi-tion to motherhood or even delay decisions about

future pregnancy. The decisions a midwife arrivesat with women in regard to their pain have thepotential to cause lingering anguish, but it is dif-ficult to predict which situations have the mostrisk. In the end, the midwife makes a judgementbased on the context of the moment and hopesthe relationship has a strong enough platform oftrust to guide her to an action with which thewoman will concur.

ReferencesBerg, M., Lundgren, I., Hermansson, E., & Wahlberg, V.

(1996). Women’s experience of the encounter withthe midwife during childbirth. Midwifery, 12, 11-15.

Halldorsdottir, S., & Karlsdottir, S.I. (1996). Journeyingthrough labour and delivery: perceptions ofwomen who have given birth. Midwifery, 12, 48-61.

Heidegger, M. (1962). Being and time (E. Robinson, Trans.).Oxford: Basil Blackwell.

Hodnett, E.D., Gates, S., Hofmeyr, G.J., & Sakala, C.(2003). Continuous support for women during childbirth(Cochrane Review). Retrieved May 9, 2003, from http://80–cochrane.hcn.net.au.ezproxy.aut.ac.nz/

Katz Rothman, B. (1996). Women, providers and control.JOGNN, 25(3), 253-256.

Lavender, T., Walkinshaw, S.A., & Walton, I. (1999). Aprospective study of women’s views of factors contributingto a positive birth experience. Midwifery, 15, 40-46.

Leap, N. (1996). A midwifery perspective on pain in labour.Unpublished masters Thesis. South Bank University,London.

Lundgren, I., & Dahlberg, K. (2002). Midwives’ experienceof the encounter with women and their pain in childbirth.Midwifery, 18, 155-164.

McCrea, B.H., Wright, M.E., & Murphy-Black, T. (1998).Differences in midwives’ approaches to pain relief inlabour. Midwifery, 14, 174-180.

Ralston, R. (1998). Communication: Create barriers ordevelop therapeutic relationships? British Journal ofMidwifery, 6(1), 8-11.

van Manen, M. (1990). Researching lived experience: HumanScience for an action sensitive pedagogy. London, Ontario:State University of New York Press.

AcknowledgementsWith grateful thanks to my supervisors Dr Liz Smythe

and Jackie Gunn, AUT School of Midwifery, during my

Masters study, and to Liz for assistance with this article.


Vague, S. (2004). Midwives’ experiences of workingwith women in labour: Interpreting the meaningof pain. New Zealand College of MidwivesJournal, 31, 22-26.

continued...

Midwives’ experiences of working with women in labour: interpreting the meaning of pain

Diane reminds the woman to relax,

to submit to the pain, to trust her

confidence in the process.

She is like an interpreter,

deciphering the foreign language

that is labour into plain English.


Author: Ina May Gaskin, 2003New York: Bantam BooksISBN 0-553-38115-6Price: approximately $40 NZAvailable from local bookshops by ordering.

Reviewed by Jean Patterson, Midwifery Lecturer

Who can forget the impact of Ina May’s ‘Spir-itual Midwifery’ published in 1975? Everymidwife I knew had at least heard of it, read itor owned it. Many well thumbed and teastained copies remain on bookshelves as testa-ment to its popularity and appeal. Ina May,from the Farm Midwifery Centre in Tennes-see which she founded with her husband andcommunity in 1970, has now published hernew book Ina May’s Guide to Childbirth.

This publication falls neatly into two parts. Thefirst, fittingly, captures the voices of womentelling their stories of triumphant birth. Thesecond part is a mix of practical advice forwomen and practitioners alike, plus stories andanecdotes from practice. The 348 pages alsoinclude an index and several appendices.

Women are offered a wealth of advice on strate-gies to employ for optimising their chances ofexperiencing a normal birth in a hospital setting.Acknowledged and welcomed is the work of theCochrane Collaboration especially their recom-mendations as to the effectiveness of continuousemotional and psychological care for the labour-ing woman. In relation to this aspect of birth, InaMay introduces the power dichotomies of themind – body and pain – pleasure. She encourageswomen to “let the monkey in them do it” (p. 243);thus allowing the primate to emerge in the birthingprocess. Another central concept is Ina May’s ver-sion of “sphincter law” which suggests that oursphincters close when we are startled or fright-ened and that we function best in private withouttime constraints. Thus the environment for birthneeds to be familiar and filled with laughter if weare to be primal and allow our sphincters to relax.

The strength of Ina May and her partners’ ‘sci-ence’ is that it is grounded in practice. It emergesfrom the respectful and curious observation ofbirthing women and the births of 2200 babies (in-cluding 15 sets of twins at home or at the Farm)over a period of twenty years. Some labour stories

may alarm even seasoned midwives - for ex-ample the woman who stalled at 7cm dilatedfor over a day despite continuing good con-tractions, though finally going on to birth nor-mally after the resolution of an emotional is-sue. However for the sceptics Ina May lets herstatistics do the talking. She cites a caesareansection rate for the year 2000 of 1.4%. Therewere no maternal deaths and the neonatalmortality was 0.69%, which included babiesborn with “lethal anomalies”. Further the Farm,though functioning like a birth centre, has in-cluded the outcome statistics for all of thewomen who booked with them, regardless oftheir final birthplace.

I am sure this book will be welcomed and en-joyed by women, midwives and students alike.One of the highlights for me was the inclu-sion of a chapter on benchmarks for midwiferyexcellence of the past which celebrated theimpressive outcomes achieved by CatharinaSchrader who practised in the Netherlandsbetween 1693 and 1745. Ina’s book is a mix ofstories, anecdote, wisdom, advice and history.It is what it is. A bit like birth I guess.

B O O K R E V I E W

Ina May’s Guide to childbirth


J O U R N A L g u i d e l i n e s f o r c o n t r i b u t o r s

The NZCOM journal is published in April andOctober each year. It focuses on midwifery issuesand has a readership of midwives and other peopleinvolved in pregnancy and childbearing, both inNew Zealand and overseas. The journal welcomesoriginal articles which have not previously beenpublished in any form. In general, articles shouldbe between 500-4000 words.

FormatPlease ensure that the following requirements arefollowed.

• Four copies of article supplied – typed on A4paper with doublespacing OR

• Article supplied as WORD document or RTF file• Word count included• Abstract of 100 words maximum included• Diagrams, tables or photographs supplied in com-

puter generated form• Separate sheet containing biographical details of

all authors (name, occupation, current area of ex-pertise/practice, qualifications, contact addressincluding phone and / or email details).

• Letter signed by all authors stating that theysubmit the article for publication

• All referencing in American Psychological Asso-ciation (APA) 5th edition format.

EthicsAny article which reports a piece of research needsto note the processes undertaken for ethical approval.

ReferencesAuthors are responsible for providing accurate andcomplete references. The journal uses the AmericanPsychological Association (APA) format. Some de-tails of this format are available on the APA websiteat www.apastyle.org. The 5th edition of the APA Pub-lication Manual was published in 2001. In the text,

authors’ names are followed by the date of publicationsuch as “Bain (1999) noted …..” or “this was an issue inIrish midwifery practice (Mary, 2000)”. Where there arethree or more authors, all the names should appear inthe first citation such as “(Stoddart, Mews, Neill and Finn,2001)” and then the abbreviation “(Stoddart et al., 2000)”can be used. Where there are more than 6 authors then“et al.” can be used throughout.

The reference list at the end of the article should con-tain a complete alphabetical list of all citations in thearticle. It is the responsibility of the author to ensurethat the reference list is complete. A comprehensive rangeof examples are provided on the APA website. Two ex-amples are included here.Journal articlePairman, S. (1999). Partnership revisited: Towards a

midwifery theory. New Zealand College of MidwivesJournal, 21 (4), 6-12.

BookPage, L. (Ed.). (2000). The new midwifery. London:

Churchill Livingstone.

CopyrightIt is the responsibility of authors to ensure that any nec-essary permission is sought for copyright material. Thisrelates to articles which include substantial quotations,diagrams, artwork and other items which are owned byother authors. Further details and examples are includedin the APA Publication Manual. Written evidence ofcopyright permission must be sent to the journal if thearticle is accepted for publication. Please contact theEditorial Board if you wish to have clarification of copy-right material.

Review processExternal review is undertaken by two reviewers who haveexpertise relevant to the article content. In addition, twomembers of the Editorial Board act as reviewers and col-late feedback from the two external reviewers. The proc-ess of review is outlined in the October 2001 issue.

Other items for publicationItems other than articles are welcomed for publica-tion. These include:• Exemplars/ stories of practice• Book reviews• Abstracts of Masters or doctoral theses• Letters to the editorhhThe expectation regarding publication of any of theseitems is that they preserve confidentiality where nec-essary (e.g. in exemplars) and seek any necessary copy-right permission of quoted materials (see earlier sec-tion on copyright). Items other than articles are notgenerally sent out for a review. Instead the EditorialBoard reserve the right to make a final decision re-garding inclusion in a journal issue. Such decisionstake into account the length of the journal and thenature of other articles.

AcceptanceOn acceptance of an article or other item for publi-cation authors will be requested to submit the mate-rial with any necessary amendments by a specifieddate as either a Word document or a RTF file for aPC. Articles which are accepted and published be-come the copyright of the journal. In the future thismay include placing articles as part of an on-linepublication of the journal. As part of the electronicprocess of printing the journal, the Editorial boardreserves the right to modify any article which is ac-cepted with regard to formatting and layout.

Contacts for the Editorial Board:• Alison Stewart, Convenor of the Editorial Board,

[email protected]• Deb Davis, Receiving Member of the Editorial

Board c/o School of Midwifery, Otago Polytech-nic, Private Bag 1910, Dunedin.

ReferenceAmerican Pyschological Association. (2001). Publication

manual of the American Psychological Association(5th ed.). Washington, DC: American PsychologicalAssociation.

Last updated October 2003

journal - new zealand college of midwives...can serve as an explanatory narrative, a blueprint for...

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