Slow midwifery

Article Outline

• Summary
• Time to ask new questions of old and new work…
• Past and present: a story of timekeepers and time
• A potential midwifery predicament: being with woman and with watch
• Changing times in midwifery…
• The Slow movement
• The tempo giusto of midwifery: powerful beyond the imagination…
• References
• Copyright

Summary 

Some patterns of timekeeping and counting are fraught in midwifery. In this paper we suggest our societal love affair with all things fast can cause us, as midwives, to limit women's possibilities (and our own). We suggest that timekeeping and counting potentially disrupt the midwife–woman relationship and, further, timekeeping and counting contribute to us valuing particular qualities in women and in the health system, including the idea that fast is better than slow. Pondering how this could be different, we consider a beginning global trend about time and speed – the Slow movement – and suggest a new movement, ‘Slow Midwifery’, in which midwives bear the responsibility of trying to be more connected to the women with whom we work by being less connected to our watches.

Keywords: Midwifery, Time, The Slow movement, Feminism, Midwives, Women-centredness

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Time to ask new questions of old and new work… 

Using what we know and do at work as midwives (and organise as midwife–managers and teach as midwife–educators and research as midwife–academics) we suggest in this paper that there is a pattern of timekeeping and counting which is fraught with danger in midwifery, as it is in society. We suggest that timekeeping and counting potentially disrupt the midwife–woman relationship and, further, timekeeping and counting contribute to us valuing particular qualities in women and in the health system, including the idea that fast is better than slow. Thus our societal love affair with all things fast can cause us, as midwives, to limit women's possibilities (and our own). Pondering how this could be different, we suggest that by using a different way to view our midwifery world it may be possible to re-pattern our work in ways which might be more useful to women and their babies. Re-patterning may also make our midwifery work easier and more enjoyable by rekindling strong midwifery relationships with women. Considering a global trend towards ‘slow’ may change midwifery for the better by helping midwives stay more connected to the women with whom we work and less connected to our watches. We see that our task for midwifery may be the creation of a new future in line with Elizabeth Grosz's^1(p261) call:

The task is not so much to plan for the future, organise our resources towards it, to envision it before it comes about, for this reduces the future to the present. It is to make the future, to invent it. And this space, and time, for invention, for the creation of the new, can come about only through a dislocation of and a dissociation with the present rather that simply its critique. Only if the present presents itself as fractured, cracked by the interventions of the past and the promise of the future, can the new be invented, welcomed, and affirmed.

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Past and present: a story of timekeepers and time 

Some time ago a complimentary and thankful birth notice appeared in a major Australian metropolitan newspaper. In the birth notice the parents wrote

‘After completing his first marathon’ [their baby] crossed the finish line at 9am. Besotted parents […] would like to give thanks to the judges Drs […], the timekeepers, the wonderful midwife staff […and] ‘we will love and cherish you everyday of your life…’.²

This birth notice is poignant and amazing, not only in the way it expresses the baby's long and hard road to birth, the parents’ love for their new baby and their gratitude for fine maternity care, but for its clue to two fundamental facets of ‘modern’ maternity care, judgement and timing/counting. In this paper we pick up the issues of timing and counting and its effects on midwifery work.

We know that in our society, midwifery both reflects the values of society and contributes to them. Fast has become highly valued. Our world is increasingly fast—fast cars, fast computers, fast food. We sleep less and work more.³ We work through our lunch breaks and on our days ‘off’. In the clinical areas we are called in to work overtime or they ask us to work a ‘double’. As managers and teachers our work is never complete. It oozes into our home and family time. Our children seem to grow up more quickly.⁴ Our food is pushed to grow and ripen faster than it would naturally.³ Motorists get angry if someone slows them down—road rage is often related to speed or lack of it.⁵ We use microwave ovens to heat our food up quickly and computers to dial into the Internet. Now an ordinary modem won’t do, we want Broadband, and fast Broadband at that.

Our expectations of women and babies are affected by the ever increasing pace of society. Much midwifery work revolves around the clock and how we time and count affects the women and babies with whom we work in immeasurable ways.⁶, ⁷ While we know that midwives have been the timekeepers around women and babies for a long time as the old midwifery adage of not letting the sun go down twice on a labour reminds us,⁸ our current love of speed makes us tend to manage our work differently. We often do not let the sun go down even once, with many a potential marathon becoming a middle distance event, or even a sprint.

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A potential midwifery predicament: being with woman and with watch 

In our society we can feel caught up in the (rat) race; increasingly stressed over a lack of time, increasingly busy, increasingly undertaking task oriented counting work and overwhelmed by a sense of futility of how to get it all done.⁵ In midwifery it is easy to feel the same pressures. So much of our work revolves around the timing and counting:

Clearly, this list is not comprehensive and there is even more timing, counting and measuring when labours become complicated. This list just serves to remind us how much of our midwifery work is about timing and counting. Estimating how long, how short, how thick, how thin, how much, how little, how often, how rarely, how high, how low, how big, how small, how full, how empty, how hot and how cold fills up our hours and days at work and fills up women's time in the health system.

Maternity practitioners are caught up in timing and counting. Yet we do not want to over simplify midwifery work here, nor reduce it to ‘just’ counting or timing. We know that much midwifery energy is, and always has been, spent ‘holding a space’ for women to be pregnant, labour and give birth, lactate and parent in their own ways and in their own time, supported by their midwife/midwives. In fact the midwifery model can be held up as a solution to the way time dominates thinking and actions in the medical model of birth.⁹

However, midwives in Australia and elsewhere have grown up in health systems which are highly regimented with medical, nursing and management models dominating our health care system, and this dominance affects women and midwives in many ways.⁹ These models affect how we view reality and what we consider to be normal or even healthy.¹⁰ A health system which values efficiency highly, for example, often values speed and, at the same time, devalues the time required to build a relationship with a woman and undervalues the skills, capacities, patience and time required to work with women during their personal complex physiological and spiritual processes.⁶

Midwifery works in and out of a complex gendered social and embodied time/space in our society¹⁰ (as in many others). Aligning with women, as midwives do, in our medicalised society during the processes of childbearing is very complex and potentially difficult and at the same time holds within it the possibility of irresistible joy. Clearly, pregnancy, labour and lactation, and therefore midwifery, are about bodies, minds and emotions. As we know the word midwife comes from the old English ‘mid’ with and ‘wyfe’ woman^11(p3) and this meaning ‘shapes midwifery's philosophy, work and relationships’.¹² ‘With woman’ means being ‘present’ for the woman both in body and in spirit^13(p13). It includes sharing parts of a midwife's self in a friendly way, believing in the woman and her abilities and working honourably so the woman sees the midwife as trustworthy.¹⁴ Midwifery, being with, means helping in a multitude of practical ways: offering information, observing, counting, timing, comforting, checking, advising, validating, mirroring, implementing treatments, documenting, second-guessing, capacity building, consulting and referring, and it includes trusting, and thus not disrupting, a healthy process.¹⁵, ¹⁶ Thus the concept of midwifery, as of being with/being useful, also holds within it the concepts of doing/not doing¹⁷, ¹⁸ and fast/slow.

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Changing times in midwifery… 

Midwifery's sense of itself as a practice-based discipline (underpinned as it is by a great deal of knowledge about childbearing and women), dominates midwifery's other concepts of/about midwifery, as it has always, from the current ways of learning midwifery at universities, back through the days of ‘hospital-based training’ to our midwifery forebears who passed along their knowledge and skills to other appropriate women. Undergraduate medical schools were still teaching a doctrine of ‘masterly inactivity’^19(p110) well into the 20th century in caring for birthing women. However, in the middle and later years of the century, the discourses of obstetric ‘doing’ and ‘managing’, for example ‘active management of labour’, became a common way of referring to accelerating women's ‘progress’ in labour.²⁰, ²¹ Interestingly, in the most well known and far reaching piece of research into managing a woman's labour by speeding it up, undertaken in Dublin in the 1970s, labouring women had a midwife with them constantly.²² As this research was quickly implemented into practice all over the Western world,²³ with varying degrees of vigour, the one midwife to one labouring woman ratio was discarded and millions of women's labours were commenced or sped up without the benefits of having a midwife with them at all times.²⁴ In the implementation of the medical findings of this research outside Ireland, the accompanying requirement for the constant presence of ‘the nurse’ [midwife] was ignored and so most countries went ‘without the most important aspect of the package’^25(p106). Today research is showing us again the value of the presence of a labour companion,²⁶ especially one with whom the woman has a continuous relationship²⁷ and the most recent meta analysis of research comparing maternity models of care goes further, telling us that ‘All women should be offered midwife-led models of care and women should be encouraged to ask for this option’^28(p1). ‘Being with’ can be shown to be scientific…perhaps ‘masterly inactivity’ may well turn out to be too.

Our concepts of doing and what needs to be done change over time however. Today we find ourselves doing, doing, doing, counting, counting, counting, timing, timing, timing and charting, charting, charting. In our time, fast is generally more valued than slow and doing generally more valued that not doing and together, these two trends compromise our potential to be with woman.

In the Birth Notice mentioned above the new parents finished with a message for their baby ‘we will love and cherish you everyday of your life…’.² Amid the pressure of getting everything done and counted and timed and recorded in the dailyness of midwifery, we often do not have time to relationship-build with women. We do not have time to value and love the relationships we have built with women. We are often too tired to remember to love and value our work and ourselves. Rushing and being forever involved in detail means we have less time to think, read or just ‘be with’. We are constantly doing, checking, surveilling. We often do not wait on the ebb and flow of women's bodily processes. We frequently are locked into processes, policies and procedures which rely on inexact, inaccurate, useless and potentially harmful technologies.²⁹ These issues make our midwifery lives complex. They also potentially undermine a woman's belief in her own body³⁰ and constrain her in a myriad of other ways.⁷

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The Slow movement 

Obviously, there are times when speed and timing and counting are of the essence in midwifery but as the world continues to speed up and sweep midwifery and women along with it, the risk is that the joy and the ‘with woman-ness’ will also disappear. Extending the calls we³¹ and others³² have made, in this paper we make an appeal for considering another way.

In 1986, McDonalds opened a restaurant beside the famous Spanish Steps in Rome. Honore^5(p59) wrote that ‘To many locals, this was one restaurant too far: the barbarians were inside the gates and something had to be done’. An Italian food journalist, Carlo Petrini, launched the Slow Food Movement,³³ in reaction to eating on the run, eating pre-prepared meals, eating standing up, walking around or more often, in front of the television. A busy life requires fast food. Fast food means more can be done in a day which in turn means less time for preparation and enjoyment of meals. The Slow Food Movement has a clear message—eat well and still save the planet.

[It] stands for everything that McDonald's does not: fresh, local, seasonal produce; recipes handed down through generations; sustainable farming; artisanal production; leisurely dining with family and friends. Slow food also preaches “eco-gastronomy” – the notion that eating well can, and should, go hand in hand with protecting the environment. At its heart though, the movement is about pleasure.^5(p59)

The Slow movement has evolved from a movement about food into one about quality not quantity in all aspects of life, including schooling,³³ Slow Cities, work and relationships.³⁴ The Slow movement is not about doing everything slowly, nor is it about going back to the Dark Ages before technology affected our lives so incredibly. The Slow movement is made up of people who want to live better in our fast-paced modern world. It is about balance: that is, ‘Be fast when is makes sense to be fast, and be slow when slowness is called for. Seek to live at what musicians call the tempo giusto—the right speed’^5(p15)

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The tempo giusto of midwifery: powerful beyond the imagination… 

We are not suggesting here that we throw the baby out with the bath water. Obviously many things in our modern scientific world are valuable and important. As well, we know Slow is not a new concept. We only need to look towards Australia's Aboriginal cultures for a traditionally different view of time from the frantic timing and counting way of life in post-industrial cultures.³⁵ Gibson³⁵ wrote recently that while slow may be a ‘new’ concept in Western society, it is a concept integral to many Indigenous cultures, including and especially Australian Aboriginal cultures: ‘Slowness is a great idea, as good as Time itself. But let's not pretend we invented it’.³⁵

However, whether Slow is a new or an old concept, many of us are working harder, longer, and doing more with less. Every year sees an increase to our workload³ which leads in midwifery to a decrease in the time available to just be ‘with woman’, in part caused by technology. Our ability to test, measure, count, see and hear increases ours and women's dependency on technology but does it actually make their lives or ours better? Often we have counted and measured because we can, not because it was useful (for example, see many cases of maternity care considered not useful³⁶, ³⁷). However, many midwifery interventions are useful and so while we are suggesting a different way may be possible and even helpful, we take account of Albert Einstein (quoted in ^5(p126)) on technology and humans: ‘Computers are incredibly fast, accurate, and stupid. Human beings are incredibly slow, inaccurate, and brilliant. Together they are powerful beyond the imagination’.

We wonder about the justice of women being hurried and hassled at a most precious time in their lives. Mindful of Denis Walsh's^32(p416) advice about what midwives can learn from the slow food movement and his suggestion of a ‘slow birth’ movement, we conclude this paper by reiterating our suggestion³¹ for a movement in which, and for which, midwives bear particular responsibility: Slow Midwifery. Over many years now, midwives and midwifery educators and managers have watched the speeding up of pregnancy, labour, birth and lactation. We watch and we contribute. Because we count, measure and time we know how long and how high and how fast things are. Because we know (or because we think we know) and because we can, the temptation is to do. Our societal patterns are very hard to resist. The pace of society is getting faster and in reaction, so is midwifery. We push women in pregnancy, labour and even after. We push, accelerate, hasten, speed up, get her going, make it go quicker, push harder, higher and faster, discharge earlier. Midwives, ourselves on a treadmill, often put women on one too. We believe that trying to move off the societal treadmill of speed is a midwifery responsibility as we try not to ‘…place the blame elsewhere, outside our own daily activities…[but to] examine our own complicity in the maintenance of social injustice’^38(p484).

Honore describes fast and slow as ways of being, or philosophies of life:

Fast is busy, controlling, aggressive, hurried, analytical, stressed, superficial, impatient, active quality over quantity. Slow is the opposite: calm, receptive, still, intuitive, unhurried, patient, reflective, quality-over quantity. It is about making real and meaningful connections – with people, culture, work, food, everything.^5(p14)

Clearly while a midwifery philosophy is closely aligned with the qualities of Slow, we appreciate that to think differently about counting and timing may be difficult. Because we live in a society where fast is ‘beautiful’, to un-change our patterns of behaviour, to re-view our work using another lens may prove a major task. However, we believe like those who are suggesting a slowing of eating, preparing, living and schooling that something which is being lost in our maternity world may be re-gained by slowing down. Elizabeth Grosz^39(p97) writes ‘[t]he kinds of world we inhabit, and our understanding of our places in these worlds are to some extent an effect of the ways in which we understand space and time’. Further, Grosz believes, as we do, that unless we question our understandings of space and time that ‘[w]omen, once again, may be granted no space or time of their own’^39(p101).

Women take their cues from midwives. If we think it is OK, they will mostly believe us. If we rush, hustle and hassle women, if we emphasise time, numbers and counting, if we value arriving more than the journey, we risk losing the joy of waiting, of savouring every moment, of learning in a deep and useful way and at the same time, we risk losing what makes us midwives—the desire and ability to ‘be with’. More importantly, in our continual ‘rush to nowhere’^3(p4) we risk reducing our possibilities as both women and midwives.

Slowing down may buy us some time to consider other possibilities, to do and be differently, or even to decide to stay as we are. We have little evidence to suggest that in all baby-having, fast is beautiful. So if we as midwives begin to look at what we are doing now –timekeeping and counting—and seek new ways to help women and their babies stay safe we may be surprised. We may open up what currently seems normal and natural to other possibilities. Getting our timing right – our midwifery tempo giusto – may indeed be powerful beyond imagination.

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