thru the pinard Podcast
a conversational podcast with @Academic_Liz with midwives & other birth professionals about their studies/ research & how it's changing our practice globally - email thruthepinard@gmail.com
thru the pinard Podcast
Ep 79 Soo Downe on Midwifery Innovations and Global Insights
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Ep 79 (ibit.ly/Re5V) Soo Downe on Midwifery Innovations and Global Insights
@PhDMidwives #MidTwitter #research #midwifery @world_midwives @MidwivesRCM @UCLan
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Discover the transformative journey of Soo Down, Professor of Midwifery Studies at the University of Central Lancashire, as she shares her path from literature and linguistics to a groundbreaking career in midwifery. Sue's passion was ignited at a maternity mission station in apartheid-era South Africa, leading to a direct entry midwifery program in Derby. Our conversation delves into the historical context of midwifery training in the UK, the emergence of midwife-led care, showcasing her unwavering commitment to advancing midwifery practice.
Reflecting on the evolution of maternity care, we explore the Fernandez Institute's collaborative initiatives in India, under the visionary leadership of Dr. Evita Fernandez. We discuss balancing caesarean section rates and promoting physiological births while examining the rise of medicalisation, caesarean rates, and birth trauma awareness. This episode sheds light on the increasing fear in modern maternity care and contrasts it with the trust and confidence that once prevailed, emphasising the need for compassionate care and stress management during childbirth.
We also navigate the intricate journey from master's to PhD in midwifery, offering practical advice for aspiring researchers. Soo shares her insights on the importance of selecting research topics fuelled by genuine curiosity, the dynamics of PhD viva traditions worldwide, and the critical gaps in midwifery research, particularly in the areas of the epigenome and microbiome.
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Midwifery Evolution in UK & Australia
Speaker 1Thank you very much for joining me, as per usual. Can you introduce yourself, please?
Speaker 2Yes, of course. So my name is Sue Down and I am currently the Professor of Midwifery Studies at the University of Central Lancashire in the UK. I'm a midwife by background, trained in well, between 82 and 85, a direct entrant midwife so many many years ago, um, with about maybe 18 years of clinical practice before I moved into academia and in fact you've just been down to oz.
Speaker 2Recently you were on the east coast yeah, yeah, I came to see liz and co down there, which was really in allison, which was lovely, and and they're launching a new network on physiological labour and birth, which obviously is, you know, a topic that's very dear to my heart. So it was lovely to go and see them and beautiful down there where they were yeah, a great time.
Speaker 1So let's go back to the 1980s then. What got you into midwifery in the first place?
Speaker 2So I was actually doing a degree in literature and linguistics at the time and, um, before before going to university, I was involved in the, the scouts and the guides. I don't know if you have that in australia, but yeah, yeah, so, uh, yeah, so, and I'd been invited out to a place called our chalet, which is in, uh, in switzerland, and I'd spent some time in our chalet working there while I was at school and met a woman there who actually was living in South Africa, and she invited myself and another person that she met, that you know in um, in our chalet, to go to a jamboree in South Africa oh cool which which happened to be while I was in my second year of university, and at the time it was still a time of apartheid because it was so long ago and I became aware that I was this was a white kind of liberal middle class family, and I became aware that I wasn't really tuned into what was actually happening in South Africa. So I said you know, can, can I go and experience something else of what's going on here? So she arranged for me to go to a mission station, not that I was a missionary, but you know a mission station in Bopudiswana, which is one of the homelands, yeah, um, and it happened to be a maternity mission station and I just kind of got this kind of road to Damascus experience, basically of thinking, wow, watching these women give birth not the babies so much, but the women, if we get birth right, we get the world right was kind of mantra in my mind and that was it. That was it. That was.
Speaker 2After that I was going to be a bit off. So, um, that's my second year at university and came back and realized that, um, after I finished university, that I really I needed to find out what it was like here as opposed to over there. So, and at the time, as far as I was aware, you had to do a nursing training to become a midwife. So I thought, well, I'll go, I'll go and find out what it's like to be an auxiliary, you know, on the labor ward.
Speaker 2So I went to guys in st thomas's, which is a big hospital in london, and spent some time there I can't remember how long, but several months, I think working as an auxiliary there. And while I was there I found out that you could actually become a midwife without being a nurse, and it was at the time there were two places you could do that. One was in Edgware in London and the other one was in Derby. So I applied to Derby. My wife did Derby not not London, but anyway and got in and while I was in on the course in Derby they closed down the educare course. So at that point Derby was the only place that you could be a direct entrant midwife how long had the direct entry course been running then?
Speaker 2oh, forever. So there'd always been direct entrants. It's just that it kind of expanded and conflated and expanded and conflated over time, you know, in terms of the number of people that became midwives. So yeah, I mean, the Midwives Act in 1904 was separate from the Nurses Act, always from the very beginning.
Speaker 2And actually while I was there, or while I was there in the first few years after, there was quite an early group of the Association of Radical Midwives that was set up in derby, partly because but it was one of the places where the few places you could train to be a direct entrant, I think, and at that time we were campaigning for a lot more people, a lot more direct entry, basically for a re-expansion. Several years after, not long after I can't remember exactly how many, there was a sudden government about turn and it became the norm to become a direct entrant midwife. So now more people are trained in that through that route than they are through the post-nursing route. So it was a bit of a kind of pivotal moment really. You know, when I went into it it was decreasing and then a few years afterwards the whole thing just exploded back out again into the normal way of becoming a midwife well, midwives are still there.
Speaker 1They're very much integrated into community care within the uk, whereas it's still very much, unfortunately, over here it's still. They're not. They're around. Obviously we've got very high ratios, but it still goes to your gp. Gp still refers to the kind of the clinics there's not that you kind of first thought, oh oh, I go see a midwife first, whereas in the UK that is the kind of the automatic and the norm.
Speaker 2It kind of is. I mean more so now probably. I mean again, when I started training, women did actually go to their GPs very often. That is where they would go, and then there was a whole movement towards midwife-led care, so that it became much more. I think women would still go to the GP surgery, but they would be automatically referred to the midwife more than going to the GP. So I think I mean you have independent midwives in Australia.
Speaker 1We do absolutely.
Speaker 2So presumably people go to the independent midwives first. They don't go to them through their GPs, do they? If they can afford it? Yes, yeah, yeah, yeah, obviously yeah, but so do many women know that there are that they can, if they could afford it, go through that route um the women who do choose independent care and with the midwives.
Speaker 1Independent midwives are, yeah, highly educated in what their choices are and what their options are yeah, there's a lot of women who go through midwifery group practice who would like to do home birth but for assortment of reasons they're either it's not available or the midwives who are there they've already booked up and they can't. So we've got different states but overall, on average about 15 percent of women who can choose midwifery group practice in Australia and that changes from state to state, with obviously Queensland being one of the more advanced states to offer a variety of midwifery group practices. So we're slowly increasing, but the home birth rate is still kind of something like 0.3%, that we're still struggling with.
Speaker 2Yeah, I mean, it's still quite low in the UK. I can't remember what it was most recently, but again it fluctuates a bit. It went up a bit during COVID obviously. So I think that that exposed some women to the the advantages of it for them. So I think there's the and but we also have birth centers, so that that also there's a kind of chance of tranche of women, you know, who choose to go to birth centers because they see that as a kind of in in between space, although interestingly, based on the evidence, um, apart from if it's you're having a first, certainly for multigravity women, they're actually less likely to have intervention.
Speaker 2They're equally like to be safe than when they're baby home than they are in the hospital. You probably know this evidence and and actually freestanding units are safer than alongside units in terms of. Well, they're equally as safe in terms of outcomes for both multips and primates, but they're they're less women are less likely to have interventions. So basically, the further away they are from the hospital have interventions, geographically, yeah, so some women make that choice of the birth center as opposed to the home birth and then maybe the second pregnancy they may say, oh well, that went okay, so I might, I might go for the home birth next time yeah, yeah, it's the trend that we need to stop.
Speaker 1That obviously increased over. Covid is the free birthing. Yeah, absolutely, and that's definitely increasing.
Speaker 2Yeah, definitely definitely, and it's definitely increasing, still increasing in the UK and in fact, I was talking to somebody recently and she said that the rate of BBAs born before arrival babies is going up quite markedly, which suggests that women don't want to say their free birth, or don't even actually want to free birth, and they don't want to go to the hospital. So that's kind of almost even worse because they haven't prepared anything at all, you know. So, um, in both cases, they haven't got a, they haven't got a professional with them, which is obviously going to increase the risk for many women and babies, um, and birthing people. But you know where they they're just thinking, oh, hang on, I'll hang on, I'll hang on, and they've got no preparation. It's probably the worst scenario, really. So, yeah, we have to do something about that.
Speaker 1What we do, it's a that's the big question, isn't it kind of going through? So what type of areas did you work in when you finished your initial training at derby?
Reflections on Maternity Care Evolution
Speaker 2well, I mean I was on the labor the whole time so that was my kind of home, if you like, the Labour Ward. I mean, when I was training I did quite a lot of community, actually in the community, and I do remember walking through it was quite rural walking through snowy hills to get to a freestanding birth centre when it was really snowed up. I just have that very vivid memory in my mind which is kind of a bit of a call the midwife kind of scene but it would happen.
Speaker 1But yeah, otherwise labored, yeah, so you've done some. Now I may be jumping a few kind of decades, but I'm hoping not jumping too much. But you've got some ties with india. So did that come pre your research kind of moving in that when you're saying you had 18 years of clinical or was that kind of like after that time it was?
Speaker 2after that. So it was while I was at university. Yeah, I actually can't remember how we initially made the contact with I'm just thinking now who made the contact with Fernandez in the first place? Oh, yeah, I know it was. So there was an individual called Andy who's very sadly died since who worked with the Fernandes and with Becky Reed because the Fernandes wanted to grow their midwifery capacity. So this was led by Evita Fernandes, who's a consultant, a marvellous, wonderful doctor, whose family set the Fernandes Institute up, and she became exposed to midwifery, realised that midwives could make a huge difference and in fact, you know, could teach the obstetricians a lot, got in contact with Becky I don't know for what route and Andy, and Andy then came to do a PhD with us. He was in the middle of the PhD when he died very tragically, but he then made. The link was then made between Andy and the Fernandes group and we then helped. We located and trained some midwives from the UK to go and work in the Fernandes to train their trainers at master's level. So that was the kind of that was the routine.
Speaker 2And then Evita became a member of the what was called at the time the Normal Birth Research Conference steering group. I mean in the UK it's now, for various political reasons, the spontaneous labor and birth. Is that what it's changed to? Yeah, but anyway. So evita was part of that, that that group, for a number of years and so, and we had a conference shoot. She set a conference up in india, in fact during covid, so that was online.
Speaker 2So yeah, and, and we're still, you know very, we're currently doing some research, a big research project with them that's actually run out of Birmingham, the University of Birmingham that we're a part of and they're the India link for that big project, big MRC Medical Research Council study, actually interesting one on. It's looking on three aspects First of all, how to make sure that women can have access to cesareans if they need them, because in some areas of india they've only about four percent section rate or something. How they can, um, how we can make sure that if they need one they have a safe cesarean, yep, and how we can make sure they don't need a cesarean. They don't have one. So in talangana province, where the fanadas institute is, some hospitals have an 80, eight zero percent cesarean section rate.
Speaker 2Oh yeah, so the the big chunk of the project that we're we're involved in a number of bits of it, but obviously our interest is what they call seen on. So how do we support women to have physiological labor and birth, or of on two births, um, rather than cesareans if they don't need them. So it's quite an interesting project. But the philanders are in india and in tanzania as well, but, um, the philanderses, is the India bit of that which is really interesting.
Speaker 1So I'm going to jump back again now. Okay, so you spent 18 years in the clinical setting. Yeah, what's the things that you reflect on now that maybe stayed the same? Or surprise you when you look back and go well, we've come a long way, or actually we haven't. We've gone backwards, or we've stayed the same. Or surprise you when you look back and go well, we've come a long way, or actually we haven't.
Speaker 2We've gone backwards, or we're still the same yeah, that's an interesting question, um, I mean, I do think I mean it's really really easy to look back with rose-tinted glasses, isn't it? Um, it is, but I do think that we had a much better opportunity to make relationships with women then than is the case now. I'm not working clinically now, so you know I'm not directly involved, but from what I hear, from what the midwives say sadly not working technically I wish I was um, but I mean I I do. I do remember women, even though at the time there was a lot of standardization, there was a lot of medicalization, although far less than there is now. We thought there was a lot of medicalization. But you know, I think our cesarean section rate was probably something like 15 percent, whereas in some parts of the uk now it's over 40 percent, in some hospitals over 40 percent, which is a very steep. That's changed very rapidly in the last five or ten years for various reasons, but anyway, so, um, a lot more women having spontaneous, physiological, spontaneous births. Then we possibly missed birth trauma. We possibly didn't think birth trauma then as we do now. We definitely, um didn't think about inequality as much then as we do now. So I think those are. It's good that we are beginning to really understand and realize that those, those are important aspects.
Speaker 2But I do think that women were less scared then. I think there was less fear in the system. I mean, hannah hannah talks about this, doesn't she? Hannah darlin yeah, the notion of fear and trust and all that. And, um, we, we, the midwives, were less fearful.
Speaker 2I think we were. We, we had more grasp of our, of our knowledge of physiological labor, birth, and we and we trusted it more. And I think we trusted our capacity also to notice when things were not quite right and to respond to that. Whereas I think, um, and and women, as I say, would come in, they would, I mean they wouldn't, they wouldn't, they would, or everybody would come into labor. Women usually come into labor with trepidation, because people often do, because you don't, especially when it's your first baby, because you don't know what you're going to do. But I don't think they came in with that deep fear that women now have of their bodies and labor and birth. Um, and now I think midwives, definitely in the uk anyway, well, in england specifically, because of a whole range of reasons, are, I think. I think many midwives have lost their sense of um trust and faith in their midwifery skill set.
Speaker 1Not all yeah, what do you think has been the contributing factor for that?
Speaker 2oh, I mean the, the, the maternity reviews that have come out. You know what, very, very often, very regularly, the kind of general accusation that midwives are, um, when anything goes wrong, it's the midwife's fault, effectively, that's what's, that's what tends to be in the media, um, and the sense that that you can always, that every baby and every birth can always be perfect and and should be perfect. And I think to an extent we've, we and I mean we then now as a, you know, maternity, maternity, um, kind of system, have let women down a bit with that, because I think there's a kind of when anything doesn't go quite the way that women thought it might do, it becomes a sense of failure for everybody. And sometimes it's not, you know, sometimes, sometimes things go the way they go because they go the way they go and actually there can be learning from trauma, there can be positive learning from trauma. You know, we can sometimes experience that sense of growth through trauma that I think has been lost, in this sense that anything that goes wrong is always traumatic and isn't, it isn't a space for development and growth.
Speaker 2And of course, you know, obviously, if women lose babies, that is terrible and nobody would ever want wish that on anybody and under any circumstances. But I mean, I've got a daughter who's profoundly disabled and it's kind of one of those things in I, the way I look at it, the way I see it, it's one of those things and actually I know it couldn't have been prevented, it's, it was just one of those. It was a, you know, a kind of mosaicism that just kind of arose, wasn't there wasn't any family history or anything. And you know, life gives you things that you have to accommodate to and adapt to and change. And I do remember talking to a couple of women who had lost babies and they were, they had become filmmakers as a consequence. And they said to me you know we cannot say this out loud, we can't, we can't say this anywhere public because we were completely ostracized for it and castigated for it. But although we wish we'd never lost our babies, we have gained something in our lives that we would never have had in better circumstances, which is this capacity to be filmmakers, which otherwise we never would have done. Which is this capacity to be filmmakers which otherwise we never would have done.
Navigating Suffering and Compassionate Care
Speaker 2So both of them said, you know, it's kind of unsayable, but sometimes in that, but in their case, that traumatic event generated something that was really positive as well as also being terribly tragic, and I think we've kind of lost that sense of things are one-dimensional, lost that sense that there, there, that there are shades in this, that you know, that every you know human lives don't always go on smooth tracks from beginning to end and are not predictable, and sometimes that unpredictability generates hope. Yeah, and actually I think at the moment, people have lost a lot of, as well as being fearful, and as well as losing trust, they've also lost hope as well, and that's a very dark place for us to be in. I think and I'm not just talking about maternity care here, you know, I'm talking about beyond that, um, you know, in the public sector as a whole and society as a whole as well.
Speaker 1And I think it kind of you can relate that to us as a society not appreciation the variations of normal that it can still be normal, but a variation of it.
Speaker 1And then it's seen. If it's not that perfect image, it's got to be wrong. And I was watching and I cannot remember. I can picture them and I used it in. I can picture them and I used it in class and they were talking about compassionate care. But I was Diane Minaj and they were talking about how we don't talk about suffering in midwifery, that it's not talked about. In fact we don't talk about suffering in life because we don't want to have that, even though everyone suffers at different levels at different stages. But we want to and social media has enhanced this that you only see the curated good side of people. You don't get to see the reality of it, which increases so much pressure on other people and, from a lot of the readings and the research, increases the risk or the fear factor for women having babies and pregnancies, because they kind of read the kind of rabbit holes that you can get into that end up being just far too bad for your mental health.
Speaker 2Exactly, and I think it's actually both sides of the coin, isn't it? It's partly that things are curated. So you see these perfect mothers, perfect babies, all that kind of thing, perfect births, perfect all that which is deeply very, very hard for women and birthing people who don't have those kinds of experiences, who really want them, and I can see why people would become kind of quite passionately antagonistic to what they see, is the midwifery visual, the midwifery, the midwifery idealism, you know, if you like, because I think that becomes. It becomes extended from what they see online to what they think midwives are there for, which is obviously not. We're there for both sides of it, but on the other, on the other side of it, there's a lot of stuff online, as you say, about how things have gone wrong and how traumatic things are and how terrible things are. So I think there's these two complete extremes, and maybe what you're saying is that the notion of suffering as a kind of human condition, but not something that's deeply, it doesn't have to be profoundly traumatic forever and ever, and it doesn't have to be, you know, obviously it's not on the other end of everything's perfect. It's just something that we're evolved to cope with. To an extent it's like we, we talk.
Speaker 2So hannah, um and our cell and other people have talked about this notion of a stress, distress and eustress. So, um, a stress is no stress and that's not a great place to be. You know, in both physiologically in the body the body isn't built to have no stress at all doesn't actually function in a gap where there's no stress and distress is where it's taken to too far. You know where all doesn't actually function in a gap where there's no stress and distress is where it's taken to too far. You know where it doesn't function because it's because it's actually, um, you know it's in a state where it can't actually function because it's too too stressed. But eustress is that space in the middle where a degree of stress is, is physiological and promotes well-being. And I think to an extent that's where midway, where midwifery, the kind of notion of midwifery with with women, woman notion, sits in that.
Speaker 2Yes, labor, if we're talking about labor here, not, you know, pregnancy and everything else is obviously relevant too, but labor hurts and it is hard work. That's why it's called labor, yeah, but actually that's not going to kill you most of it. Hopefully, hopefully it's never going to kill you. But you know, except in very extreme circumstances, um, it will. It will. Actually, you know if, if you're prepared, if you're helped to prepare for it and if you have good support, and if you choose to have a cesarean, that's fine, and if you choose to have a in an epidural, that's absolutely fine.
Speaker 2You, like, you say your version of normal.
Speaker 2Whatever your version of normal is, if you're able to, um, you know, if you're able to experience eustress in that version of normal, that's normal for you and your baby, then you're probably going to come out of this feeling feeling really good, you know, feeling great and being able to mother and doing all the things that actually having those kinds of experiences prepares you for.
Pathways to Midwifery Research Success
Speaker 2On the other hand, obviously what you don't want is to be in the distress position where you, where you do feel that it's traumatic or where something does go wrong for you. And, on the other hand, obviously what you don't want is to be in the distress position, yes, where you do feel that it's traumatic or where something does go wrong for you or your baby, and you don't want to be in a position where, as I say, you might want to be in a position where there's no stress at all, no-transcript um, and it's so much linked to that distress, to bonding and attachment, which then goes on to generational kind of like yeah, consequences as well, that kind of leads on yeah, absolutely, absolutely I think you're seeing.
Speaker 2I know there's some stuff on aces. There's a lot of stuff on aces in australia, particularly because of the indigenous perspective of it all. So is there is, there is work growing in that area in australia it's.
Speaker 1It's really interesting to see because of course, we've got the edinburgh postnatal scale, but then we've actually got one of the life quality scales and in that they've actually asked a question about ace. So adverse childhood experiences. For those that don't know what ace, yes, yes, yes, and it's really interesting when you look at that as, like relationships, it's looking at kind of that trauma and that that is now recognized as having a consequence to your own parenting style, your own bonding and attachment style. So it is increasing, absolutely increasing usage, um, and I think it will be increasing even more with. We're kind of looking at a lot of it.
Speaker 1I know it's being picked up a lot more in the court system as well when they're doing a lot of it. I know it's being picked up a lot more in the court system as well when they're doing a lot of their histories on perpetrators, that they're kind of looking at backgrounds and kind of going well, this is where they came up from, so they've lost these kind of characteristics or they never developed right and wrong type things. So I think it's going to be something more and more. I want to take you back to how did you get into university? So was that because you started doing postgrad studies, or did you go into that before your postgrad studies?
Speaker 2Well, I mean, I think the first thing to do is go back a step, because actually the direct entry training I did was not even a diploma level. Oh, okay, wow, it was taught. So I had a degree. I came into it with a degree because I got a linguistics degree, but you didn't have to have that.
Speaker 1So it's a hospital certificate.
Speaker 2Yeah, it was that kind of level, oh cool, yeah, yeah, yeah. So, and I have to say I felt I mean I loved doing my first degree, my English, which was, yeah, my first degree. I felt it was, I really, really loved it. Yeah, my first degree, uh, felt it was, I really really loved it. But, but doing the midwifery was so much more consequential because I felt this is, you know, this is to be dramatic, this is life and death. You've got to get this right. I mean, if I didn't write a good essay for my my english exam, well, it didn't really matter, I didn't get such a good result, but there you go. But if you don't understand what's going on in labor and birth and you can't pick up when, when you know, things are maybe deviating from the norm, that is critical in terms of an individual's life and also in terms of their well-being as well. If you don't get the kind of relationship right in you know in, yeah, absolutely in my case, during labor and birth, if you're doing continuity even better through the whole thing. So, yeah, so, so that was the diploma.
Speaker 2So then, um, then I, when I was working at Derby, I thought, oh, I better, I began to get interested in some of the things that were happening. So I had some questions, I had lots of questions questions are good. Yeah, loads of questions about practice and I thought the only way I'm gonna well, at that time there was no such thing as a research midwife, yeah. So I thought the only way I'm going to be able to find out about this is to do a master's. So I did a master's while I was working full-time and actually had a baby at the time new baby, but okay, um, and and then, having done the master's, I thought, well, maybe we should do a PhD, I should do a PhD.
Speaker 2So the PhD kind of grew out of the master's. It was actually the master's the first step on the PhD, really. Um, and then in between all of that um, I remember going for a job interview for a sister post, a kind of a G grade post or senior post, more senior, not very senior, but more senior post and in the interview I said what I really want to be is a research midwife. And they said ha ha ha, no such thing. So, um, so we create over the next year or two. We made sure there was such a thing, but yeah, and then obviously going into university. Then I went to university with the PhD and at that time there were very few. I think there were 10 midwives of PhDs in the UK.
Speaker 2If that, not many in the world actually. So, yeah, so that again, that was just serendipitous in that there happened to be it was a professor, I can't remember, think it was a professor's, but I can't remember if it was a professor's post or senior. I think it was a senior principal lecturer. That's right, it was a principal lecturer's post, um, which we had to move up the country with with all the kids, and it happened that my partner also got a job in a similar kind of area on the same day. Oh, wow, which is amazing. And um, yeah, and, and the, the head of the school at the time was really open to actually that being a research post. So there was hardly any teaching. In fact, there was no teaching. I don't think it was actually a research post. Oh, so it was, it was and it has been ever since, so it's never actually had a.
Speaker 2I mean, there is teaching, I teach a module we do, yeah, but it's never been a teaching post, so, um, that was just luck, sheer luck, the right place at the right time.
Speaker 1So what did you do, masters on?
Speaker 2my masters, yeah, so it was a talk masters. So so there was lots of, obviously, which was great. That was really really helpful in terms of learning a lot about research methods. So it's a research methods talk masters, but, um, the dissertation was um and the eventual phd was a randomized trial. I can't remember which bit of it I did, for the dissertation must have been some preliminary work, um.
Speaker 2But then the phd was a randomized trial of women in different positions, well, sidelined or upright, with an epidural in situ, because in the passive second stage of labor. Because I'd noticed that, you know, obviously we all know that you know women with epidurals at that point, particularly where it was quite a dense block, tended to have much higher rates of instrumental birth. And the rationale was that, you know, because the pelvic floor is is a bit soggy when you have an epidural, it's lax, the head comes down. If it comes down, it doesn't rotate properly because it doesn't get actually get their right resistance. So the idea was if women were in the lateral position, which midwives always used to use the lateral position for a long time I'm not sure if they still use it in australia or not, but anyway it would help rotation yep and in fact it did so.
Speaker 2So there were less forceps and there was more rotation um of the fetal head. So it was great. And the reason I did it is because I was scared of randomized trials. Okay, because, you know, because I kind of I had done more, I had done quantitative research but also qualitative research and I thought, right, I'm gonna have to do this randomized trial thing because otherwise I'm always going to be scared of it. So it was a, it was a bit of a challenge. But mary renfrew was my supervisor Ah, beautiful, not really External supervisor. So that was kind of like having royalty.
Speaker 1Oh, yes, I'm trying to speak to a lot of people with this podcast and also I've done 75 episodes and I think about 70 or 69 of them have been with people who have completed PhDs.
Speaker 2Really Wow.
Speaker 1And I'm trying to reach the grand dames of midwifery.
Speaker 2So I'm trying to reach the grand arms of middle school.
Speaker 1So I'm trying to reach all of the ones, because it's like looking at the journey and it's our history, it's our academic history and looking at what they went through and then going to now it's.
Speaker 2It's a more recognized pathway, so that changing guard, but also what we can learn and the commonalities, which is the really big thing of serendipity, as you said, that the doors open in the right direction and all the Swiss holes kind of line up, and it's just kind of like you're doing this well, no, well, yeah, you are, and we're going to help you do it yeah, yeah, definitely, and I also think I mean you know we say this and I said it as well but you know, complexity theory would say that you create the conditions in which, if you like, luck happens. So I think very often and I think it is a bit different now actually, because I think there's a lot more support certainly in England there's a huge amount of support for people doing PhDs. The pipeline is phenomenal. We've just actually had a grant awarded to one of the of the, the nurse um leaders in our organization, um, for something called an insight grant. They're all they've been awarded all around the country and basically what it does is it.
Speaker 2It looks at what they call under not underserved, it's something underrepresented populations. So nurses, midwives, professions allied to medicine, social care, and it's for them, us and um it it from the third year undergraduate onwards. So there's an internship at the third year undergraduate level. Then there's support to do masters. There's a series of master's programs and funding for master's programs. Then there's something called a pcaf, which is a bridging award that takes you then where you can design your phd. Then there's funding to support people to do their ph and then that then taps into a kind of National Institute of Health Research NIHR pipeline that can take you to the postdoc period and up until senior professorships.
Speaker 2So it's really a whole pipeline from third year undergraduate all the way to senior professorships, which you know in my day. Yeah, it didn't exist. The reason it does is because people have worked on these things, created the initial, which you know in my day. Yeah, it didn't exist. The reason it does is because people have worked on these things, created the initial conditions for the last 20, well, how long? 30, 40 years probably, and I guess it's similar in Australia, I don't know.
Speaker 1We haven't got that exact pipeline, but we've got people who are really fighting for it and fighting for that recognition, and I think globally. From my literature searching, there is this misunderstood about what clinical staff can offer who've got a PhD. Yeah, so nursing and midwifery especially is these and kind of some of the documents talk about advanced practice, but then you can be advanced practice without having a phd. But there's also the difference between the phd, the prof, doc and the dnp. And now they introduced the dmp so they're quite known. The doctor of nursing practice and doctor of midwifery Practice are quite known for their professional kind of clinical focus and they're not quite CPI. But all of them are Level 10 qualifications. So for us we've got 10 levels. So basically they're the terminal qualifications. You can't get anything higher, right?
Speaker 1And yet they're all deemed as, on a hierarchy within themselves, that the PhD is the highest and then the Prof, doc and then the DMP are actually seen as lesser, when traditionally that's come to do with snobbery and hierarchy and all that kind of stuff. But why? Why have we got this kind of misunderstanding, and how do we work about having a straight pathway into looking at the future so these students do and can see a pathway going through that?
Speaker 2so many people I've spoken to said I don't want to be a phd because I don't want to go into academia right, right, yeah, yeah, and I have to say we do have a bit of that in that we've been trying there again, there is a push at national level to create clinical academic posts.
Speaker 2Yeah, um, we've certainly been trying to do that locally for the last couple of years and the problem is partly the mismatch in the funding levels.
Speaker 2Yeah, so, because I mean, maybe, maybe, actually that would be a less so now we've got, as you, as you say, same thing here. We've got more junior people, um, coming into into research than they did before, because obviously previously, if you've got people who've gone, you know, up through the ranks of the clinical practice and they're now senior practitioners, they can't come in to a university funding level because that would be a level of an expert researcher, which they're not. So that mismatch has been really problematic. But I think the NIHR is beginning to work on that. In fact, as it happens, I'm just I'm seeing a conference tomorrow, so seeing a group of people this evening that we might be able to discuss how we make that function really. But it has been a problem, but there is a definite move towards resolving it, if possible, and some places, some universities and hospitals, have done it. They have managed to have joint posts. They obviously do it with doctors.
PhD Journey and Future Perspectives
Speaker 1Yes, exactly Exactly like the priesthood has done it, finding an equivalent pathway, isn't it really? Yeah, and I know that I think it was last week um annette briley was telling me that all of the midwifery clinical chairs were getting together to kind of, because we're getting increasing number of clinical chairs now that, whereas previously it's been nursing and midwifery and a nurse has been overtaken and hasn't done anything, but these are all midwifery kind of clinical chairs, and so the pathways are there. It's taken a long time and I think within 10 years, especially when we look at the changes it's going to happen in midwifery in australia, which I think are going to be fantastic with increasing our scope of practice or getting people to recognize what our scope of practice is not increasing, but being able to work towards it in the hospitals and especially with the endorsement and prescribing rights that I think this is where the future is. It's going to be that nice, clearer pathway that people can go.
Speaker 1No, I can still do studies, but I can still work clinically and I'm supported for it. And if I take my three years out to do it full time, I'm not going to struggle when I come back because they're going to go. Well, you've been out for three years and you're not clinical anymore. So all of those issues and struggles as well, which has been quite common when people have been talking about whether they've done it full time or part time yeah, no, that's really good.
Speaker 2I mean really good. I mean I don't know how it works for you, but certainly for us, even if people are. So we have a couple of people doing their phds full-time. We're also doing, I mean I don't either bank work or agency work, or actually have like a contract with their, their hospital, where they can do half a day or a day of night or something like that. Presumably. They have that kind of potential. Yeah, yeah, yeah, yeah, which is really important, obviously, because things do change in three years. You know, if you keep up with it, then that's really good. Or have a, have a transition period when you go back, where you've got like a, you know a month or so where you're just being shadowed, you're shadowing somebody for a bit.
Speaker 2So you've got, you've got your head back into what's happening and you know now, having that would be nice the other thing I think, though, is, you know, I think it's also about getting, about working with people to see that, working with people to enable them to see that getting the PhD is not just a piece of paper, that actually what it does is.
Speaker 2It allows you to look in depth at something that you're really curious about. Yes, and PhD is almost kind of a consequence of that as opposed to a purpose of that, it seems to me, and I think, the more that people are coming, I certainly found, with our students, that those who come to it with a burning question they really want to answer, they're the ones who finish because they really want to answer, whereas those who come because it's like the next step in their academic career are far less, particularly if they come for somebody else's. You know, if you've got a project that you advertise and people come along and they're just doing it because it gives them a piece of paper at the end, that does seem to be far less beneficial, I think. So maybe part of this is about encouraging that, really encouraging that curiosity early on, so that it's an obvious next step to, you know, tie that to some kind of academic qualification, but to do it because you really want to do it.
Speaker 1We do that with our students. We support them to choose their own topic, not do something that we've kind of like we've got lots of work that they could do, but to really kind of go what are you interested in? And then kind of obviously they want to change the world and it's got to narrow it down to this tiny little slice. That is, yeah, you see, in honours, but is, yeah, you see them getting excited about it and then kind of like they'll come up and expand again.
Speaker 2No, let's bring it back. Go to do that, just bring it back, but that energy, that excitement kind of keeps them going.
Speaker 2It's fabulous to see yeah, I think that's really good and also just saying, you know, saying okay, what you you're never going to have as much time to look at a particular project again as you will for your PhD. So you know, if, what would you want to be doing in 10 years time? What do you want to be? What do you want to be working on in 10 years time or 20 years time? What can you what? What will this PhD time give you as a jumping off point for the rest of your career? Really, yeah, and I think that's another thing sometimes that they you know, obviously a PhD is a big thing so if you don't look beyond it, but I think sometimes, um, helping them to look beyond it gives them a sense of pacing as well.
PhD Journey and Supervisor Selection
Speaker 1It's, and this is just. I've just realised this. It's almost like the women who and pregnant people who look only up until the birth yeah, they take no planning for that postnatal period whatsoever and then suddenly they're like, oh my, I've got this thing that is reliant on me. How do I, what do I do? How do I feed my change nappy? Because I've been so focused on the birth? Yeah, they haven't. Kind of I need to remember that. Um, very good thinking back to your masters or to your PhD, because you expanded it on what is something that still stays in you, in your memory or in your emotions, that surprised you.
Speaker 2I mean, I suppose it's always surprising how exhausting it is. So you know, I mean that's a down start. A down start, I suppose, but I still think it's worth. I don't know, I don't know how you feel about this, but for me, I think what happens is you do like a, you know, you do your, whatever you do your here it's gcses, wherever your first exams are and then you do your degree, and that's a step change. And then you do your master's, and that's a step change.
Speaker 2And I think people think the step change to the, the PhD, is the same as all those other step changes, but actually it's massively different. So I think, and I think I always remember that and I always say that to students don't think you're going to be able to do this in the interstitial spaces of your day. Oh yeah, as you will, you know, so I that has always stayed with me, that it's, it's a, it's a kind of it's an, it's a leap across a chasm, you know, as opposed to jumping over a stream or whatever the others might have been, whatever the metaphor might have been. So I think that definitely did. I think it was a long time ago, so I'm just trying to remember back now and certainly in the talk masters and I think it was worth doing the talk masters I did learn that you can't just put numbers into SPSS willy-nilly and run a test and think that that's a good thing to do. It's actually might have violated all the principles.
Speaker 1I do know the chi-squared and the five and the empty numbers and all that, yeah, exactly that I did.
Speaker 2I did that was quite a shock when I spent ages doing all this analysis and writing it up and then my, my, my um tutor said nope, you violated all the initial conditions for this.
Speaker 2So, yeah, that that was. That was a learning thing and I just remember also, yeah, I suppose, the excitement of finding new things. I mean the thing with the trial is that it's kind of the other way around to qualitative research. So with qualitative research you have all these lovely interviews and you're totally engaged in that, or whatever you're doing observations, the trial you don't have any data until you get to the very end and then suddenly you get this lovely chunk of data. You know that's really exciting because now you can mess about with it. I mean, obviously, hopefully you've set some parameters as to how you're going to mess about with it, so you're not just fishing in it. But that was really exciting. And then I suppose also the other thing is is the I'm? I'm a not a completer finisher, and I think I had to learn to be a completer finisher with that, particularly with the phd, because you know there's a there's a lot of data. I mean any phd, there's a lot of data to do with.
Speaker 2I also did a whole series of. I did a survey, I did some interviews, I think I certainly did a survey. So I did a whole load of things alongside the, the um, trial, um, and I realized that I have to get to the end of it. Mary ran through something in email once towards the end of my phd. She said in capitals, nothing is more important than your phd. And then, in brackets, not capitals except your family. Yep. So the sense of being lost in the data, whichever it gets a massive amount of data. Thinking, why can't I do that? Having a sense of um, I've got to finish this and then, and then, as they phrase it, you know, you've got to kill your darlings. So this sense that I've got to I've got too much here. I've got to chop out half of what I love here. Yeah, just really focus on the thing that I'm going to have to deliver to get this PhD. Then I can write all the rest up afterwards. That's not a problem. Maybe those things.
Speaker 1Yeah, I very much understand that. So how did you? I'm kind of in that exact position. How did you balance your PhD with your work and with your family to survive and maintain mental health.
Speaker 2Yeah, well, I was working. I did have a research midwife job at that point, so I wasn't working shifts, which did make a big difference. And although I had no family, we had no family where we were living at the time. When I say no family, we were 200 miles away, so nobody local we were able to because we were both working. We were able to afford good childcare, so that really helped. And then obviously I had friends that could rally around where required and I had a partner. So I still have the same partner. I had a partner who was working away from home.
Speaker 2I do remember on one occasion thinking in four days' time I might actually get some sleep. Oh no, because he was away. The kids are three times the time, they're all young, and so on. So that, yeah, yeah. So the support network was there, but sometimes it wasn't there. It wasn't the easiest and and then I suppose just um, I mean using sometimes. So I do remember we went, we went on holiday once with the family and I just worked. I worked on the phd the whole time in that holiday. So sacrificing some of some family stuff with the support of partners and friends was required.
Speaker 1Really, yeah do you get to pick your supervisors, or would they kind of come along with the project and funding?
Speaker 2no, that was I picked it. So I, I, um, had gone to the university, I'd got contact of a psychology department with a with some suggestion for some, some study I can't remember what, but it wasn't. They didn't, they didn't pursue it with me. And then, and then again I can't remember I ended up with a pharmacist as my supervisor within the university yeah, derby. And then, um, mary was my, mary was my external. I actually can't remember how that happened, really can't remember, but it was my topic. It was my topic. It was never his topic. Yeah, obviously, maternity, a randomized trial of maternity care wasn't really something a pharmacist was that interested in, unless there was drugs involved. But he was very good. Yeah, it's a shame I can't remember how I actually connected up with him really.
Speaker 2Well did he have the experience?
Speaker 1with random controlled trials. So that was the advantage. So again, did he have the experience with random trials?
Speaker 2yes, he did, he did, yeah, he did that, yeah, exactly, and so did mary, obviously.
PhD Viva Celebrations and Traditions
Speaker 1So, yes, so yeah, the two of them had that experience, the methods experience, yeah so how did you celebrate it when you finally finished, got it back, did everything like that and officially became doctor?
Speaker 2well, do you know, and I don't know, I've I've realized I've um encountered this with somebody else recently. It was kind of an antichloric it's never too late so again, it's never too late. No, that's right, um, because I have very. It was I mean the viva, and I don't know if you do a formal Viber in Europe, Some states, some places do we don't, but other places do yeah.
Speaker 2Right, okay. So I mean the Viber is quite a big thing, because you can't fail at the Viber, so you can go through all of that. In fact, my supervisor told me I'm not sure I wanted to hear this, but you know a story of of a mathematician friend of his who did fail because the algorithm or whatever he'd been working on for like three years was cracked a month before he submitted. And of course, at least in our discipline, you can always do something a bit, you know. You can, you know, analyze the data a bit differently or something, but anyway, whatever.
Speaker 2So actually the Bible was like a chat, you know. There was no difficult questions. She asked me a few things about the analysis, some of the analysis I'd done, and then I passed with minor amendments. So I kind of walked out of there knowing it was all done and it was like, oh, is that it? All those years of building up and all of the kind of effort of going to the viva and all of the things that happened. It just felt like an anti-climax, whereas actually in in um europe I don't know if you know how they do it in europe, do you?
Speaker 1um, I've had a couple of people, but they've done it different ways because of whatever happening at the time well, large parts of europe.
Speaker 2I know we're technically part of Europe, but you know not because of breakfast. Well, yeah, but anyway, large parts of mainland Europe. By the time the student gets to the well, first of all they produce a book which is a series, a bound together series of published papers. Yeah, so their PhD is like a PhD by publication, with a narrative wrapped around it, which is very interesting, I think, as a way of doing things. I was a bit sceptical, but I'm less sceptical now, anyway.
Speaker 2And then by the time they get to their where to come as Viva, they know they passed barring a major accident, and the Viva is a big public celebration. So what happens is they can invite their friends and their family along, and you know the university public and everybody else, anybody can come along actually, and I've been in some with you know great auditoriums full of people. And then they have a kind of semi-formal. So as an examiner, you're on the stage with the student and you you have a semi. It's like a drama almost. You know. You ask two or three questions. Each person on the panel ask two or three questions. They, they answer after having presented their thesis in a PowerPoint, and so on and so forth, and then there's a whole procession in and a whole procession out and they pass and they have a big party. Oh, excellent, much more like it.
Speaker 1I think there's, and I can't remember which country it is, but I think it's a Scandinavian country where they've got traditions with swords. Yeah, where they've got traditions with swords, and one I saw a picture of one where the supervisor had to pull the new, newly qualified doctor in a cart around the campus, or something like going back to these old traditions and thinking, oh, they sound so exciting brilliant.
Speaker 2Well, I went to an Iceland which is a bit like that, not not with pulling carts and all, but, you know, definitely with loads of ceremony. Or you know, rob, definitely with loads of ceremony, or you know, robes and walking all over around the place. I think they did walk around the university, actually, but not with a cart, but anyway, yeah, and I did one in Spain, which was a huge celebration, it was just marvellous. So, yeah, they've definitely got the right idea.
Speaker 1So yes, so no. I mean, opened a bottle of champagne, probably pulled you all up and said but it's done. You have to look at the next anniversary date of your phd and do it in style and kind of like how do people celebrate in?
Speaker 1australia. Um, it depends on the university because some don't have formal vivas and some do. So I've got a friend who is sitting her viva. She's had the markers, have come back and already given comments which have been brilliant, but she's still got a Viva and it's a closed Viva because we all want to sit there and kind of like help celebrate and cheer her on, but it's a closed Viva.
Supervisory Skills and Research Strategies
Speaker 1And then we've got I know that with my university we can send the Teams link out to anyone we want really, so they can kind of sit in and join and they're welcome to kind of come in, but the results are not related to the final presentation. Right kind of gives us depending on when we do it. We can do it, I think, before the final um draft get sent out for marking. So we've got a little bit of leeway, but it's the marking that is the, and I've had people that have kind of when I've been talking and asking, because I ask these type of questions to everyone in the podcast, anywhere from family dinners to massive parties to holidays overseas. I think it was Alison, I can't remember, who said that she had been saving up for a pair of shoes in Paris.
Speaker 2Oh, that sounds like Alison. That sounds like Alison. Yeah, that would be right.
Speaker 1A pair of shoes and I don't know whether they had the red label on the soles or not. Oh yeah, pair of shoes and I don't know whether they had the red label on the on the soles or not. Oh yeah, they were definitely a kind of like a Paris pair of shoes, yeah, which I think is fabulous, and it should be something like that.
Speaker 2It should be something very unique, yeah, and also you know it's there with you then, forever afterwards, isn't it because you mean, you keep the shoes, you know?
Speaker 1it's not, they go, they just go on the shelf and you never get rid of them. Doesn't matter whether you're kind of looking at like that, yeah, yeah. So when you look at the way that you were supervised and you have done multiple supervisions since what skills or what tricks did you learn from your supervisors that you now pass on or use with your students?
Speaker 2well, I think, I think the first thing I said before is to be really, really clear with them at the beginning of what the what the step change is from the master's to the phd, um, just so they can. They won't, they don't, obviously they don't believe it anyway. You tell students they don't believe it, you know, but at least it's in the back of their minds. But when they do finally realize it's true, um, and then we do have got a formal system. We didn't. When I, when I first started supervising, we had. It was incredibly informal and people could be, you know, students for decades, decades. But now that's not the case. I'm sure it's probably true for you as well. Yeah, we've got time limits. Yeah, so I mean, every time we meet, we meet. We tend to meet monthly at least, sometimes more often, but generally monthly and either online or line or face to face, and we have a formal supervision record and the students fill it in. Some of you know full pages and some fill in just a few lines, um, so that we're, in terms of timekeeping, in terms of being on top of things, we know where we're going. And there's formal processes in the universities for you know yearly progression and transfer and all that stuff. That's there anyway, um, and then I suppose it's just really a question of saying, ok, have a view of the whole thing, but let's look at it in a bite sized chunks so you can have a have a sense of progress as you're going.
Speaker 2Different students like to write differently, so some not very many really recommend this. We'll use the whole final year for writing, but most will write steadily as they go along. So we tend to encourage them to do that. Um, and I think also the other thing we say I mean, quite a lot of our students were do their phd part-time while they're working clinically. And again, that is really hard, especially with the short staffing that is currently endemic. And and again, I don't know if it's true in australia, but you know there's a, there's a lot of, as we've discussed earlier on, there's a lot of toxicity currently, but actually across the whole of public health sector, not just in in maternity. Yeah, so they're dealing with all of that emotional stress at work as well as the short staffing of the long hours and all the rest of it.
Speaker 2So I do say to them look, you are going to have to find time where you can book chunks of time, not just a day here, a day there, but you know a week, whether you choose to do that in your annual leave but remember you need your annual leave because otherwise you're going to burn out completely or whether you negotiate that with your manager, or whether you work your shifts that way, or whatever you do, you are going to need to have a good series of time, a number of days, days, because you know in your head you can't just pick things up. You have to be thinking to be, um, integrating what's gone before with what's going to happen next, and all the reading and everything else. Yeah, I suppose that's. That's one of the main things um, we tend to recommend most of our students to. I don't know if you come across this, but there's a book by crotty which is yes, yeah, okay. So I think. I think that's because one of the things that students get held up, we've got it there I probably have.
Speaker 2In fact, I know I've got it here because I'm using it I just found that first chapter because most the thing that phases most students that are clinical is the theoretical perspective stuff, isn't it? And I do find that giving them that to read rather than some other heavy tone. It's still scary for them but it actually makes.
Speaker 1It gives them a little bit of an insight into what kind of things we're asking them, because he brings it nicely down into epistemology, um, theoretical perspective, methodology and then methods, and then kind of sitting from that, you can kind of then go okay, methods is easy, how am I doing it? Methodology okay, then how am I also analyzing it? How am I collecting it? The theoretical perspective, I think, is where a lot of people fall down and also change their mind, because it starts off as oh, I think we're going to analyze it this way, we're going to use this and you get into the data and then you kind of go actually the results aren't telling me this, the results are telling me this and I've got to change into this yeah, yeah, exactly exactly so.
Speaker 2I think that's a. That's a really good intro. The other thing we do, um with our students is we are we. If they want to, we offer them and this is not just ones doing qual but ones doing quantas we offer them a kind of a self-reflexive interview, and it can be with one of the supervisor, it can be with a friend or anybody else, just to sit down and work out their perspective on the topic that they're looking at.
Speaker 2Because, again, I think people are increasingly aware of the idea of reflexivity, but they tend to write it in the third person. Like you know, to be reflexive one has to do xyz. To be reflexive one has to. And we want them to say I think this, yeah, I am doing this because so that reflexive interview helps them to understand things that are sometimes quite hidden to them, unconscious to them, about what their prior beliefs are.
Speaker 2And again, I think it's particularly important in clinical practice because very often I don't know your view on this, but people were right, we know, we think what we have found is that or um in our you know what we? By we, they mean midwives, basically you and I say to them look you, the reader is not we, they're not part of your in crowd. So you actually have to unpack what you mean by we here, because you're coming with a set of preconcept, pre-conditions and preconceptions when you use we and us and our, that actually everybody else reading your thesis might not share. Yeah, so that's actually quite helpful for them, I think, to become critically analytic of their positioning.
Speaker 1Especially, even though we're global midwives, all of our experiences are very different, yeah, and your interpretation of what you're reading is based on your own kind of experience. So, yeah, it has to be kind of a bit more explicit than what it is and sit there and go.
Speaker 2no, you're making assumptions yeah, exactly, and I mean when you're talking about women's voices, so you know, you're at your. If it's, for example, if it's a phenomenological study of women's, you know, birthing, people's views and experiences, and then, and then you have a chunk of stuff and then, and then the the interpretation goes, as we know da, da, da, da. Well, you know, basically, what are you saying here? You know, is the we the women, is the we that? What overlay you putting on the women's views here from your own perspective?
Speaker 2So, and then we say to them go look back at that in a year, another year, another year, because you would have forgotten, yeah, at that point, what your preconceptions were. And when you come to analyze your data, you need to understand the lens you're analyzing it through from those preconceptions, preconditions or preconceptions, which is so, as I said, you know, even though we don't tend to talk about reflexivity and quantitative research, of course everybody has a position, you know, in quantitative research as much as qual, so you still need to have that um unpacking, I think. I guess that's probably one of the other things. There's probably loads of other things I can't remember that's, that's okay.
Redefining Normal in Maternity Care
Speaker 1I mean, that's the thing is. We can talk about this for ages. You're involved in a lot of studies, you're involved in a lot of things, but I think what I'd like to kind of like almost wrap up on is the change that is happening with language, in particular, in the change from, because if you do look at the statistics, normal birth now is an induction followed by c-section. That is, when you look at the rates in c-section, yeah, so how, how have you gone within the political climate, especially within the uk and I know that you've come over here and you've done some talks recently um related the same topic, but going from normal birth to you said, spontaneous birth as opposed to physiological birth. So what is the the shift and and how are you maintaining the drive in that area when the political pressure is so much against it?
Speaker 2yeah, it's. It's a very interesting point and it has been very difficult to negotiate. I mean, there's been attacks on the, our university, because of um, you know, because of the work that we do, um, I. I think it depends which perspective you take it from, whether it was kind of epistemological or whether it's ideological, I suppose. I mean, I suppose ontologically and epistemologically, if you like. You know, in terms of the nature of the nature of things and how you understand them, it should be that physical.
Speaker 2You know, in terms of evolution, it should be that physiological labor and birth is the norm for women and birthing people, in that we have evolved to do this thing the way we do it with our bodies, to optimize that outcome. Arguably, in the same way, as you know and I think I'm sure you've heard me say this before we talk quite happily about normal development or child development or, you know, or normal blood pressure, or normal walking or any other way that we talk about. We use the word normal in everyday parlance, if you like, kind of colloquially, but of course we know that that for many people, many women, um, who, for whom their experience is anything but normal in their, in their own, from their perspective, that can be really triggering. Yeah, when the word normal is used um critically, and I think the other thing about that is that I think when we were talking about all this, when the normal birth campaign was up and running, from the rural college of midwives, for example, I think those of us involved in that never always took for granted that where there was a problem, then intervention was necessary. You know, we always, we always, we never. That was never an issue, you didn't, you didn't have to talk about it because obviously, if there was a problem or if women wanted different things, then those things should be dealt with.
Speaker 2All you're interested in is those women who wanted um, you know what we're now calling physiological or spontaneous labor and birth, um and how to support them when things were going well, whereas I think we, what we, what we, what we missed seeing is that there was actually a turn happening in in um, in society, whereby the whole notion of normal, of anything, was being critiqued. You know, normal gender, normal weight, normal height, normal, everything was being critiqued as a, as a kind of um, as a kind of absolutist um, hegemony, if you like, and actually we should be much more relativist in the way that we we are in the world and we we missed that turn and I think then we ended up in this position where we were defending what we believe to be this kind of um, this kind of colloquial notion of normal and the notion that where women wanted that and needed it, then we needed to support it with this whole other dialogue that was going on. Yeah, and that's where I think we got stuck, um, and you know, women were traumatized by it, and so were staff, you know. So we're midwives, still are being, in many ways.
Speaker 2I think the problem now is that if we can't talk about it, then we can't re, we can't reframe maternity care, yes, so that women have the optimal opportunity to have us, whatever we're going to call it, you know, spontaneous physiological labor and birth, because we can't talk about it anymore, and if you can't talk about something then you can't create that space for that thing. Um, so I think we are using tend to be well, the rcm says spontaneous, which I never have a problem with, particularly spontaneous onset, spontaneous labor, spontaneous birth, those are the kinds of terms we should use and they you should add them up. So spontaneous onset, forceps, birth, whatever, whatever you know they're just kind of components to add up, um, but unfortunately, I think the trouble with that is that I mean, I don't disagree with that, but one of the things I feel about it is that, of course, if you talk about this as spontaneous, people think it's, it's happens like that really quickly, yep and there's no, there's no suffering.
Speaker 2That really quickly, yeah and there's no, there's no suffering, as you say you know, there's no hard work involved in that, just kind of oh there it goes, pop, like, like in, like in telly, like on the tv. Physiological, I think, is probably a bit better, although I do use these terms interchangeably, because it actually is directly connecting with what where I started, which is the evolutionary physiology of women's bodies, and I would definitely argue I mean, I know fourth wave feminism may not agree, but I would definitely argue there's something essential about the woman's body. It is not a relative thing, you know, it is an essential biological, biological thing that does essential biological things, you know, in the process of labor and birth, and actually what happens during labor has big, you know, has implications for both and also for the postnatal period and also for mothering, and also for breastfeeding and also for, you know, the immune response, and also for the next generation. Yes, so we have to take that seriously. That isn't a relative thing that you can wish away. It's a thing.
Challenges and Hope in Maternity Care
Speaker 1No, there are consequences when that's interrupted or modified and that cascade of intervention. We know, and also, looking at the C-sections and the lower section, c-section could also be cutting into the cervix because it's going through that. So that has consequences for future births, we also know, for future pregnancies, but we also know that the whole microbe microbe as well, and so there's so many things that are related. When we start interfering in that process and yes, some women need that system absolutely we kind of we're playing around too much.
Speaker 2Yeah, it's all babies and bathwaters, isn't it? We don't want to be throwing out what works and I think. But again, I would come back to saying that this is actually a societal. I think there are societal norms here that we're kind of running counter to, because the risk of real society is definitely a thing, because we we know so much about there are very rare risks that have major consequences that we know a lot about. I mean, you know we're all living in that now, aren't we? With all the kind of wars and, and you know, israel, hamas, ukraine, all the stuff that's going on with American elections, everything else.
Speaker 2So that level of kind of running fear that is in or or kind of you know the what's the word come with the word. But that sense of impending doom I think is runs through a lot of the conversations that are around isn't is no less running through that conversation to happen around maternity care. So trying to change it so that women do come into labor and birth confident with, you know, and competent, with the support of competent and confident midwives and doctors and obstetricians who are working together in mutual respect, who understand the physiology of labor and birth and the consequences, who are minded to support women who want that and need that, to be the best with that, but who also are able to respond rapidly and effectively when, when an intervention is needed or wanted. How we move from where we are now to where to that is is the question. And I mean I think if you'd asked me a few months ago I'd have been, I've been quite pessimistic. I've been quite pessimistic for a year or so. I'm beginning to be a bit more optimistic.
Speaker 2I have, I do have, a sense that there is a bit of a turn away from, you know, a beginning of an understanding that actually these rising rates of cesarean section cannot be sustained, you know, for all kinds of reasons, and that we have to be doing something about this. That's more than just adding more, adding more interventions on top of interventions to make those interventions less problematic. So I think and certainly with the World Health organization would agree with this the world health organization definitely thinks that this needs, I mean needs to be sorted out, um, for, for all kinds of public health reasons. So I don't know. There's hope, there's always hope, and I think that I, I suppose, if we are going to have any parting words, what I would actually say in terms of phds is I really hope that midwives do grasp the nettle of doing their PhD studies in this area of physiological labour and birth and the consequences of it, because I do see very many sadly midwives just following on.
Exploring Gaps in Midwifery Research
Speaker 2I talk about, you know, follow your passion, not the fashion. Yeah, yeah, I do see quite a lot of people doing their phds in mental health and in, you know, um, inequalities. These are important things. I'm not saying they're not important, but or in, I know, induction of labor, or or in to their own section, but but they're things that everybody's doing stuff on. Everybody's doing stuff on that and that's really important, it needs to be done, but nobody, almost nobody, is doing stuff on physiological labor and birth and what it means and what the consequences are and what the implications are and how we support it and that kind of thing.
Speaker 2I mean, you know, I'm saying that there are people that are doing it, obviously, but proportionally, yes, there's far less research going on in that area and that is our area of expertise specifically. Yes, so you know, I do hope that some, you know, at the same time as doing stuff on inequalities, mental health and all that stuff from a midwifery perspective. I do hope that some will, even though it's much more difficult to get funding for it. But I do hope that some will engage with that area and I particularly hope that those who are interested in in um, you know, actually looking at the epigenome and the microbiome, that are interested in doing basic science even, you know, would pick that up and run with basic science as well, as well as doing the kind of qualitative and quantitative trials and stuff that we do, because that's where the gap is in the basic science oh, I can do that in education as well.
Speaker 1Thank you so much for joining me very very welcome, it's been.
Speaker 2It's been a pleasure.