Midwifery Presence
The concept of midwifery presence is firmly established in the theoretical results written by midwives in the US (Jordan & Farley, 2008; Kennedy, 1995). This has been adopted into the writings from the Scandinavian countries (Aune et al., 2013), the UK and more recently in Australia (Davis & Homer, 2016). Presence as a manifestation or embodiment of midwives’ being ‘with woman’ is characterised by support of the woman’s emotional, physical,
spiritual and psychological needs (Thorstensson et al., 2012) and is seen to contribute to a sense of calm and security (Davis & Homer, 2016; Thorstensson et al., 2012). Some assert that being present with the woman is a spiritual concept (Hunter, 2003; Hunter, 2015; Hunter, 2002). It is noted that providing presence does not necessarily require a specific or pre-determined outcome, rather, that the focus is to just be ‘with woman’ (Berg et al., 1996; Davis & Homer, 2016; Hunter, 2009). Findings from Swedish research differentiated the provision of basic support and a midwife’s presence (Hildingsson, 2015) and describes the phenomenon of ‘absent presence’ where a midwife may physically be in the room but not providing the support characteristic of midwifery presence (Berg et al., 1996).
Being With Woman across the Childbearing Continuum
Whilst much of the discussion in the literature included of midwives being ‘with woman’ is situated in the labour and birth setting (Berg et al., 1996; Davis & Homer, 2016; Hildingsson, 2015; Hunter, 2003; Hunter, 2002; Hunter, 2009; Lundgren & Berg, 2007; Reed et al., 2016;
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Thorstensson et al., 2012), there are some emerging writings that address the practice of being ‘with woman’ across the continuum of childbearing. In the antenatal setting, a characteristic of midwives being ‘with woman’ is the practice of effective communication (McCourt, 2006) that facilitates education of women and their support partners as well as informed decision making (Likis, 2009; Murphy & King, 2013). In the postnatal setting, midwives report that practicing from a ‘with woman’ philosophy facilitates a ‘pro-mother’ approach to addressing breastfeeding problems rather than forcing institutional, political or policy agenda (Lawton & Robinson, 2016). When midwives form a relationship ‘with
woman’, this can assist women to make sense of, and in engage in, their birthing
experiences by creating ‘space’ for women to know themselves and reveal their feelings and desires (Hunter, 2015).
Being ‘With Woman’ Empowers
According to the literature, being ‘with woman’ has the capacity to provide political agency by validating the female experience of childbirth and provides a platform for empowerment (Hunter, 2015; Tharpe, 2009). The role that midwives adopt in facilitating informed decision making also serves to enhance the agency and power of the woman and midwives alike (Aune et al., 2013; Hunter, 2015; Likis, 2009; Lundgren & Berg, 2007; McAra-Couper et al., 2014; Murphy & King, 2013). The philosophy of being with woman creates a therapeutic environment that is necessary for advocacy and empowerment (Berg et al., 1996; Davis & Walker, 2011; Hunter, 2015) and can act as an antidote to the dehumanising, ‘systems’- based approach to childbirth (Dabrowski, 2014; Fahy, 1998; Hunter, 2003).
Discussion
The findings of this integrative review have demonstrated evidence of an intentional development and integration of the midwifery philosophy of being ‘with woman’ by the profession of midwifery, within the last 20 years. The conceptualisation and embedding of ‘with woman’ practices have been facilitated by research and theoretical literature from midwifery leaders around the world. As well as reporting on the concept of being ‘with woman’, the insight gained through this integrative review has served to ‘map’ the
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progression and development of ‘with woman’ practices and to highlight how contemporary health care practices may intersect with the provision of ‘with woman’ care. The findings serve to endorse and augment the Australian College of Midwives’ assertion in their current philosophical statement, that being ‘with woman’ offers a foundation to the philosophy, relationships and practises of midwives (ACM, 2004).
There is agreement between research findings and professional commentary, that midwives being ‘with woman’ is a fundamental and hallmark midwifery practice. Writings from as early as 1998 indicate the facility of the ‘with woman’ philosophy to offer an alternative to the techno rational practices of a biomedical approach to childbirth (Carolan & Hodnett, 2007; Dabrowski, 2014; Fahy, 1998; Power, 2015). How this intersects with the applied practice of being ‘with woman’ is seen in the natural (vs biomedical) approaches to
childbirth that are characteristic of ‘with woman’ midwifery care (Reed et al., 2016). Whilst there is evidence that medically – focussed models of care may impact the provision of ‘with woman’ care, there is also an emerging proposition that being ‘with woman’ may actually facilitate movement between all care models and is not risk or birth place dependent (Davis et al., 2011). Further research is warranted to enhance understanding about the
intersection of midwives being ‘with woman’ within the context of a variety of care models.
Whilst the relationship with the childbearing woman is a previously understood feature, the emergence of insight around the impact and importance of midwives’ professional
relationship with a woman’s partner is new information and adds to the understanding of contemporary ‘with woman’ practices. This innovative and welcome perspective into the experience of birth support partners highlights that ‘with woman’ care extends to
incorporate partners or the woman’s significant others and enhances their experience of childbirth (Crowther et al., 2016; Jepsen et al.; Thorstensson et al., 2012). This development is consistent with the progression in other professions such as counselling and nursing, who recognise the importance of supporting the individual within the context of their social constructs (Coco, Tossavainen, Jaaskelainen, & Turunen, 2011; Lindsay, 2016; Romero, Riggs, & Ruggero, 2015).
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Whilst the reference to ‘midwifery presence’ is yet to be found in Australian midwifery vernacular, the concept appears in research and theoretical writings globally and describes the manifestation of how midwives are ‘with woman’ (Aune et al., 2013; Davis & Homer, 2016; Pembroke & Pembroke, 2008). With origins in the field of philosophy, the broader concept of presence or, ‘therapeutic presence’, first appeared in nursing literature in the late 1970’s (Boston & Bruce, 2014; McKivergin & Daubenmire, 1994) and has since been explored in diverse fields such as teaching (Solomon & Nashat, 2010) and most recently, neuroscience(Geller & Porges, 2014). In line with the dynamic and progressive expressions of midwives being ‘with woman’ in the theoretical and practical contexts, the adoption of midwifery presence in modern writings assists to describe the more applied elements of the complex ‘with woman’ phenomenon.
The majority of literature addresses midwives being ‘with woman’ in the context of support offered during labour and birth (Berg et al., 1996; Davis & Homer, 2016; Hildingsson, 2015; Hunter, 2003; Hunter, 2002; Hunter, 2009; Lundgren & Berg, 2007; Reed et al., 2016; Thorstensson et al., 2012). There are recent writings that have emerged however, where ‘with woman’ practices are explored within the context of antenatal and postnatal care. Further research is warranted into how midwives exhibit being ‘with woman’ in antenatal and postnatal periods and settings.
Another feature of ‘with woman’ philosophy bearing impact on midwifery practice, is a transference of ‘power’ to the woman through the facilitation of informed decision making and the creation of ‘space’ that encourages this (Hunter, 2015; McCourt, 2006). This is noted as being in direct contrast to the biomedical approach to childbearing which adopts a paternalistic approach to care (Dabrowski, 2014; Fahy, 1998; Power, 2015). The outcome of midwives being ‘with woman’ in a way that empowers women and their families, illustrates again, the impact of professional philosophy on practice. The constituents of empowerment are generally intrinsic which means that manifestations may be more discrete and therefore more challenging to qualify than other elements of being ‘with woman’ (Shimamoto & Gipson, 2015). Despite this, the impacts are no less important for women, or indeed, midwives (Power, 2015). This emphasises all the more, the importance of having a contemporary understanding of the professional philosophy that advises practise.
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The strength of this review lies in the integration of both research and theoretical data to develop a holistic picture of what is currently reported on midwives being ‘with woman’. By employing this integrative and inclusive methodology, knowledge generated by research as well as wisdom shared through midwifery leaders’ experience has been critically appraised and synthesised. This review approach reflects modern midwifery practice itself, that is an artful blend of care informed by research based evidence as well as professional intuition where positivist and constructivist approaches are joined to provide woman-centred, holistic care (Power, 2015).
Within contemporary literature, most of what is understood about midwives’ experiences of the phenomenon of being ‘with woman’ is derived from research that describes midwifery care in general from women’s perspectives or commentary from midwifery leaders. A significant finding of the review was the distinct lack of research that has explicitly explored the phenomenon of being ‘with woman’ from the perspective of practising midwives. In order to gain a more comprehensive understanding of this founding philosophical construct, further research is recommended, specifically, to understand midwives’ experiences of the phenomenon of being ‘with woman’.
The outcome of the search revealed a number of articles that made isolated
reference/inference to a midwife being ‘with woman’ but did not proceed to report on the phenomenon of midwives being ‘with woman’. This adds strength to the findings made in this study, that whilst the philosophical and theoretical elements of being ‘with woman’ are apparently well embedded and accepted within the midwifery profession throughout the developed world, there is a gap in understanding how ‘with woman’ practices might be understood or experienced by midwives. The importance of determining this is three fold. Firstly, Sandall et al (2013) presents compelling evidence that ‘with woman’ approaches to childbearing which may be supported by midwifery-led models of care such as those found in caseloading, midwifery group practices and privately practising midwives, is associated with good outcomes and is desired by women all over the world (Sandall, Soltani, Gates, Shennan, & Devane, 2013). Understanding and preserving midwifery practice, inspired by the philosophical mandate to be ‘with woman’ will ensure that into the future, women and their families can continue to receive this exemplary care. Secondly, the capturing of
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practices driven by professional philosophy serve to add to the body of knowledge and wisdom around the ‘workings’ of the profession. Understanding midwives perspectives of being ‘with woman’ in a range of models, and; with women whose health, or choice, requires a transition or movement between models is needed. Having records of this knowledge is important in an increasingly medicalised society as it can serve as an anchor to re-focus and underpin the care that is provided by midwives (Davis & Walker, 2011). Finally, the mandate to develop graduates that are not just technically proficient practitioners but midwives who enter the workforce imbued with professional philosophy and theoretical knowledge that intersects with midwifery practice is keenly felt (Fahy, 1998; Power, 2015). Having a contemporary understanding of the expressions of the ‘with woman’ philosophy will enable this to be incorporated into the practise dispositions of future midwives.
Conclusion
This review brings together research and theoretical evidence to report on the phenomenon of midwives being ‘with woman’. There is agreement between both paradigms regarding the fundamental elements of midwives being ‘with woman’. The themes and sub-themes are supported by a range of research approaches as well as theoretical writings from professional leaders. New and emerging developments of how ‘with woman’ practice translates into the clinical setting have been noted. The findings contribute a contemporary and holistic understanding of the phenomenon of midwives being ‘with woman’. Gaps in knowledge have also been identified, specifically the lack of evidence around midwives’ experiences and understanding of being ‘with woman’, and recommendations for research in this arena have been made.
36 Table 2 Characteristics of the 34 included publications
39 Key to Abbreviations
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