By Caroline Flint

Pregnant women are sensitive to every word, gesture and expression, says Caroline Flint. She explains how midwives can bolster a pregnant woman's confidence in herself and her ability to mother and be a mother

As a woman, a mother and a midwife, I feel and `know' many things deep in my soul. Although this may not be as impressive as scientific evidence, those involved in childbirth often recognize that birth is mainly a spiritual experience albeit physical.

One of the crucial issues in midwifery today is that midwives have lost their instinctive and intuitive feelings about childbirth. They have been intimidated into thinking that these feelings are irrelevant and unscientific. They are amazed and delighted when these aspects of childbirth are revealed to them, sometimes by lay midwives with no formal training.

Midwives working in the obstetrics of fear are surrounded by the pathology of childbirth, `high risk women', intrauterine growth retardation, weight loss in pregnancy, uncertain dates, large or small for dates, and low oestriols. Contrary to this, in July 1981 Macvicar' said, `Obstetric practice should become easier since there are fewer mothers in the so-called high risk groups. Four out of five births now occur to mothers between 20 and 35 years. Before the age of 20 years, social factors tend to increase their risks of pregnancy, whereas after the age 35 years, medical complications such as hypertension and diabetes are more common.'

I was reminded recently of our concentration on the pathological as I was taking a woman's booking history. When I asked about her last pregnancy, her eyes opened wide and she said, `Oh sister, I had a lot of problems, it was a very worrying pregnancy.' When I enquired further, she said `Well,

Hall, Ching and MacGillivray2 pointed out in their paper on routine antenatal care: `Another problem is over diagnosis: for every case of intrauterine growth correctly predicted by the clinician, there were 2.5 false positives, and for every genuine case of preeclampsia or hypertension diagnosed another 1.3 were false positives.'

Pregnancy is a period of heightened sensitivity, a time of transition from one state to another. Pregnant women are sensitive to every word, gesture and expression. Kitzinger (3) describes this vividly. `The expectant mother is particularly sensitive to any suggestion that things may not be quite as they should be. She stores each word in her mind uttered by the obstetrician when he examines her. Since these tend to be few and far between, it is not difficult to remember what he said and to go home and brood over their exact significance'.

Much current practice encourages pathological responses from the women we are trying to help through the transition to motherhood.

What does motherhood mean? What does it mean to be a pregnant woman? What does it mean to a midwife? What does it mean to a child? What does it mean to you?

If we look at our feelings towards our own mother as children, we discover much about the nature of motherhood. Our mother

What does a mother need to give all this to her child? She needs confidence in herself as a person and a woman, and in her ability to mother. She needs to feel valuable as a person and successful as a woman. She needs to feel confident in her ability to cope with her child, to know that the child is hers, her responsibility, that it depends on her.

For antenatal care to be worthwhile, it must help a mother to feel confident in herself and her ability to mother and be a mother. It needs to increase her self-esteem.

When 130 women are herded together into an antenatal clinic, their self confidence and self-esteem feelings are actually decreased. A woman is shown that she is not special, that she is just one of hundreds and that the clinic staff care so little about her comfort that they leave her sitting for two or three hours with countless other women in exactly the same condition.

The National Childbirth Trust report, entitled `Change in Antenatal Care' starts: `The expectant mother is treated as the passive object of management, who is fed into the system and whose progress from point to point is controlled as if she had no wishes or preferences of her own ... Clinics are often grossly over crowded and have the atmosphere of a badly managed cattle market.'

The physical position of women throughout antenatal and intrapartum care in most obstetric units is horizontal. It is difficult for even the most articulate woman to think rationally, discuss, negotiate and inquire in such a disadvantageous position. A woman, horizontal or vertical, needs positive reinforcement of her ability to be a mother.

Women are often examined in silence and at speed. Interest is only shown when they present some pathological symptom such as `I haven't felt my baby move since Tuesday'. To increase a woman's self-confidence, we need to give positive encouragement and know her as a person. This can only be done by providing some degree of continuity of care, through the use of more flexible working days and by giving an expectant mother opportunities to talk, sitting upright and wearing her own clothes. Horizontal women do not feel in control of their situation and it is not helpful to their concepts of their own value and self-worth.

How can midwives increase a woman's confidence in herself and her ability to mother and be a mother in the labour ward`?

In the obstetrics of fear, concern is expressed for the baby's safety during labour. This is a valid and commendable concern but, when overemphasised, can indicate to a woman that her body is a place of danger to the baby. The phrase `We'd better get this baby out' is used by obstetricians and midwives

A woman needs to be able to trust medical attendants during labour so she can concentrate without attempting to form new relationships, and so she can relax, sure that everyone present knows what she wants of her labour.

This can be achieved by discussing labour during pregnancy, taking note of a woman's wishes and hopes for labour, and by giving her constant encouragement throughout labour.

The horizontal position of women in pregnancy is more important during labour. Dunn' in an article published in The Lancet in 1976, described the advantages of the dorsal position for both mother and baby. These included fetal distress caused by compression of the inferior vena cava and aorta, narrowing of the birth canal and constriction of the pelvic diameters because of the pressure on the sacrum and loss of mobility, less efficient uterine contractions, slower labour and increased pain. Fearing the pain of labour, we may be too eager to urge a woman to have an epidural or pethedine although, for many women, the most effective form of pain relief can be the support and encouragement of a known and trusted midwife. Modern methods of pain relief are useful and effective but one has only to see the pride, delight and feelings of triumph exhibited by a woman who has overcome this gruelling physical experience with her own resources to see that while pain relief must

Encouraging words and an offer of distractions during contractions are far more helpful to many women.

In the first fragile postnatal days, how can we help build the new mother? Again, the words used are vital and will be remembered years after midwives will have forgotten the name of the postnatal ward. Whether a woman wants to breast-feed or bottle-feed she must be helped and encouraged. Mothers who want to breast-feed but end up bottle-feeding often feel inadequate. Maternity unit staff need to look at why it is happening. Staff often think that, in their ward, there is demand feeding but in fact babies are fed to a scheduled time or are only allowed to suckle for a specific length of time. If a woman's confidence in her ability to cope is to grow, it may be constructive to signify that breast feeding is a relationship between two people and, like all physical loving relationships, needs to be worked on by the two people concerned, and that a third person may be an intruder. Unlike many midwives, I do not see the midwife's role in breast feeding as physical supervision but an emotional support. Breast feeding is best learned in an unhurried atmosphere and in privacy.

At the birth of a family, midwives' attitudes are essential to the well-being of the new mother and baby, and to the new father's feelings of involvement and pride. We need to look at and cope with important issues in order to function more effectively as the Central Midwives Board definition of a midwife - `A person who is specially instructed and qualified to take professional responsibility and to provide care for women during labour, the postnatal period and for the newly born infant up to the 28th day'.

1. MacVicar, J. (1981). `Changing birth patterns during a period of declining births'. Maternal and Child Health, July.

2. Hall, M.H., Cling, PK., MacGillivray, l. (1980). `Is routine antenatal care worthwhile?' The Lancet 2, p.78.

3. Kitzinger, S. (1962). The Experiences of Childbirth, Victor Gollancz Ltd.

4. House of Commons, Second report from the Social Services Committee, Session 1979-80. `Perinatal and neonatal mortality', HMSO.

5. Dunn, PM (1976). `Obstetric delivery today: for better or worse?'. The Lancet, 1, 790.

July 7 1982