Midwifery is unquestionably a noble profession. However, in past years, midwifery training and education has arguably overlooked the psychology of childbirth and its impact on parents, families and the midwife.
A recent document by the Royal of Midwives (RCM), concerning standards and competency, states that:
‘Midwives ensure that women have a safe and satisfying pregnancy, childbirth and postnatal period. The care that they provide to women, babies and their families is of the utmost importance to our society. The importance of maternal mental health during pregnancy and after birth has gone without the prominence that it deserves for too long.’
While the document will be familiar to midwives, it does not explain how midwives might benefit from a more detailed knowledge of psychological approaches to care. The author noted that the standard of mental health provision for parents and families is varied throughout the UK, and suggested that a local audit framework to assess the quality of mental health provided to both mothers should also include fathers throughout the period of pregnancy and childbirth.
The document also endorses the need for specialist midwives in perinatal mental health, while acknowledging that all midwives should possess mental health literacy to ensure effective gate-keeping and early intervention.
Attachment disorders, anxiety, depression, first episode psychosis and suicide are all possible before and after childbirth, affecting parents, families, friends and communities—as well as midwives themselves. Yet it is suggested that in many instances, mental ill-health is unrecognised or not adequately addressed.
Psychoanalysis and psychotherapy are fundamentally concerned with understanding seemingly irrational behaviours. While frequently considered unscientific, the ideas may have much to offer midwifery practice, including ensuring midwives' safety and wellbeing.
Attachment theory
Attachment theory, for example, is critical to healthy parent-child relationships. It was first discussed by the psychoanalyst John Bowlby (1962; 1969), with later contributions by child psychologist Mary Ainsworth (1989). The ideas refer to the emotional bonds that infants form with mothers, fathers and other caretakers.
Disturbances in secure attachments in infancy can result in varied, and difficulties with oneself and others can last into adult life. Disorders in attachments can also underpin difficulties with social and professional behaviours. Adherence to health programmes can be affected and affect mental ill health more generally.
The influence of insecure attachments can also be passed on generationally (Steen et al, 2014). There is, therefore, a moral imperative for all health professionals to become proficient in assessment, gate-keeping and early intervention. A detailed knowledge of attachment theory should arguably form part of all health curricula.
Psychological concepts
The ideas of attachment, along with the psychoanalytic ideas of transference and countertransference, dependency, jealousy, envy and loss, in culturally specific contexts, have all been considered to have the potential to enhance a midwife's understanding of the emotional impact of childbirth and parenthood (Jones and Jones, 1990; Jones, 1996; Raphael-Leff, 2002).
Taylor has written extensively about psychoanalytic ideas and midwifery - particular ways obstetrics have impacted on the development of midwives as ‘custodians of the normal’. Psychological awareness, she believed, is important for midwives to advance their practice and the profession more generally.
According to Taylor (2018):
‘The normal and desirable psychological state which new mothers' experience involves a state where the boundaries of the self are fluid and levels of empathy between mother and baby are high. Midwives are constantly in contact with this state, and therefore are themselves either in a state of empathy, or not. To maintain the latter is a struggle.’
What Taylor implies is that for midwives to overlook this empathic connection has implications not only for parents and babies, but also for themselves, both personally and professionally.
A clinical recollection
I recall an occasion, while working in psychological medicine, a teenage mother stabbed herself in the abdomen. Initially, this was viewed as self-harm, which in part was accurate. However, following referral to the psychological medicine team, and during psychological assessment, it became apparent that the attack was primarily on the unborn child.
Jealousy and envy both overwhelmed the woman as attention was given over to the baby. Feelings of insecurity, alongside of being overlooked as mother and young adult became all-consuming, with resulting anger towards her child.
More specialised mental health assessments permitted personal attachments to be acknowledged and addressed, and meant that treatment and care could be adapted to the mother's specific emotional needs, allowing her to explore her concerns in safety.
While I am not suggesting all midwives attain competencies in psychoanalysis or psychotherapy, the ideas have currency in the context of childbirth and parenthood, for mother and father, families and the overall organisation of healthcare.
Conclusion
The value of psychological approaches to healthcare cannot be dismissed and are a critical component of all healthcare delivery, regardless of speciality. Midwives may find continuing professional development useful, especially if it explores varied psychological methods of providing care to families.
Personal and family life-events can also influence our choice of occupation, including midwifery, and as Taylor (2004) suggests, these events may affect professional practice. For this reason, reflective approaches to midwifery curriculum development, as well as contemplative approaches to the supervision of clinical work, might also enhance midwives' practice.
Alongside theory, clinical placements in mental health settings, such as mother and baby units, could provide enriching experiential knowledge, allowing student midwives to observe the difficulties in parental bonding and forming secure attachments first hand. Personal experiences will also enhance midwives' professional competencies and in doing so bridge a perhaps decisive theory-practice gap, to the benefit of all concerned with healthy childbirth and parenting.