Advocacy
Making decisions is challenging and complex, especially within midwifery practice, and has an impact on the type and standard of care that is provided (Smith 2016). Reasoned and safe choices based on evidence and intuition can be achieved through this partnership with women (Daemers et al. 2017). A sympathetic and empathetic approach to decisions is perceived by women to result in a more positive birth experience (Boyle et al. 2016). However, pain during childbirth is one aspect that can hinder the decision‐making process (Whitburn et al. 2019) and requires midwives to exercise the concept of relational autonomy to protect the woman when she cannot make reasoned decisions (Brown and Salmon 2018). In this respect, autonomy (discussed earlier in this chapter) ‘is a key concept in understanding advocacy’ (Cole et al. 2014, p. 576).
Advocacy has had an important role in professional/service user relationships. One of the ‘key messages’ in ‘Midwifery 2020: Delivering expectations’ is in the section ‘Developing the midwife's role in public health and reducing inequalities’ which states:
Midwives should use their advocacy role for influencing and improving the health and wellbeing of women, children, and families. This will include making the economic case for committing resources so that the midwife can deliver public health messages in the antenatal and postnatal periods and ensuring that there is a midwifery contribution at policy, strategic, political, and international level (p. 7).
Working alongside women, midwives exercise what has been referred to as ‘skilled companionship’ (Dierckx de Casterlé 2015) as they journey ‘with women’ through the birth and postnatally. Through this concept, midwives integrate skills and companionship and bring together the scientific and moral aspects of care. This requires midwives to be committed to provide an empathic presence during childbirth events. Women thus feel accompanied and supported. However, ethical challenges may arise should women make choices which are considered detrimental to the health of themselves, their baby or the midwife (Jenkinson et al. 2017). In such situations, midwives may experience ethical uncertainty or, perhaps, unpreparedness to respond ethically to women's needs and preferences. There may, for example, be a conflict of principles between respect for autonomy and beneficence/non‐maleficence and justice. The midwife should use her advocacy role by taking the lead to facilitate making decisions for the woman and meeting her holistic needs and interests through empathetic, intuitive and sensitive support and ‘companionship’.
Empathy, Intuition and Sensitivity
A definition of empathy is the action of understanding, being aware of, being sensitive to and vicariously experiencing the feelings, thoughts and experience of another (Medical Dictionary 2019). Both empathy and intuitive knowledge are integral components of what is perceived by experts as creating competence and is expressed through touch and physical closeness or emotionally through spiritual oneness ‘with woman’. Facilitative or cathartic interventions enable emotional and supportive approaches to acknowledge the woman's worth and demonstrate mutual respect. Sensitivity to women's needs is another aspect of the ‘with woman’ concept and is illustrated below. In addition, a midwife who makes an effort to be compassionate demonstrates empathy and intuition as spiritual care (Linhares 2012, Crowther and Hall 2015), as documented by Moloney and Gair (2015).
Observation that the nature of midwifery practice changes in an environment in which the midwife is engaged in being ‘with woman’ rather than doing, concurs with Brown's (2012) findings of watching and waiting and not just doing. Leap's publication in 2000 remains at the centre of this midwifery philosophy and was perceptive in suggesting that midwives give when they do less (Leap 2000). A key element of ensuring midwives and healthcare professionals are ‘with woman’ in their daily contact with childbearing women is well‐developed communication skills. In this respect, Gibbons (2010) suggests that communication goes beyond just words into the environment which is created in order to encourage comfort and privacy and promote unspoken dialogue. Positive first impressions created by midwives influence the quality of rapport and the relationship that is grown between woman and midwife (NHS England 2016). Raynor and England (2010) suggest that attitudes of acceptance and warmth, sharing a genuineness of transparent thoughts and feelings demonstrated in empathetic understanding by the midwife placing herself in the woman's position, are a humanistic approach to therapeutic verbal and non‐verbal communication.
The ‘Good’ Midwife
The concept of being a ‘good midwife’, as explored in systematic reviews by both Nicholls and Webb (2006) and Byrom and Downe (2010), identifies well‐developed communication skills, compassion, kindness, knowledge and midwifery skills as key elements. Attitudes and feelings together with midwifery knowledge create clinical competence to fulfil being ‘with woman’ (Carolan 2011). Halldorsdottir and Karlsdottir (2011) debate the primacy of the midwife's professionalism as central to the role of the ‘good midwife’ and identify essential key elements of professionalism, wisdom, competence, interprofessional competence and personal and professional self‐development as supporting attributes. A ‘good midwife’ is perceived by women to be able to provide them with information and is competent in fulfilling their needs whilst they feel listened to (Overgaard et al. 2014). In addition, women want to be individuals cared for by a midwife who provides ‘presence’ and makes them feel safe and cared for through their attitude and behaviour (Dahlberg et al. 2016).
One aspect which develops skills and knowledge essential to the ‘with woman’ competence is the reflective process: both internal as a reflective process and shared through discussion or story‐telling. Johns and Freshwater's (1998) interpretation of reflection, although now dated, is still relevant in that practitioners' experience informs embodied knowledge translated into clinical decisions to become intuitive knowledge. The relationship between a midwife's practice experiences and self‐development through reflection transforms perceptions and beliefs and ultimately results in skilled empathetic midwifery practice and competence. One paper from Australia explores the issues surrounding the situation when a woman declines recommended care (Jenkinson et al. 2017). The authors examine, from a feminist perspective, how the woman's and the midwife's autonomy may be upheld with specific guidance from clinicians providing care in this situation and suggest that models of care which support reflexive practice may enable midwives to advocate the right of refusal and maintain the ‘with woman’ concept empathetically.
Table 2.1 summarises the literature in relation to ‘with woman’ concept from an ethical perspective for both women and midwives. Rodgers' framework (1989) underpins the analysis in terms of antecedents, attributes and consequences.
Conclusion
Rodgers's framework (1989) suggests that related concepts exist as part of a network of concepts that provide significance to the concept of interest. In the analysis, related concepts were identified related to the continuity of carer, the ritual companion and the ‘good’ midwife in examining the literature. The impact of the continuity of carer concept suggests attributes of confidence to offer choices of sound judgement by midwives in their relationship ‘with woman’. The consequences are respect for ‘women’ autonomy, empowerment to make the right decisions, fulfilling women's expectations and preserving