Storytelling in midwifery: Is it time to value our oral tradition?

Background

A recent experience of sharing practice at a storytelling circle, developed as part of midwifery supervision at a local NHS Trust birth centre, illuminated the value of sharing stories with midwifery colleagues. Two positional interventions, known as the ‘hip dip’ and ‘side lying release’ (Spinning Babies, 2016) were used in a difficult and prolonged labour to encourage the baby to rotate from a persistent posterior to an anterior position; shortly afterwards, the baby was born at home, as planned. This experience was shared with the midwives at the circle and the interventions were demonstrated and practised by the midwives present. A great deal of discussion and reflection followed, primarily focused on how the techniques may have worked to relax the pelvic floor muscles and ligaments and create more potential for the baby to rotate into a favourable position for birth. The technique has particular relevance for standalone birth centres; midwives practising in this environment are frequently faced with the dilemma of managing persistent posterior positions and prolonged labour, with no access to medical interventions such as augmentation of labour using synthetic oxytocin.

A few weeks later, a midwife from the story telling circle was excited to report that the techniques had been used successfully at the birth centre to correct a persistent posterior posi tion, resulting in a spontaneous birth. She was particularly happy, as the use of the techniques had been a last-ditch attempt to avoid trans fer ring the woman to the obstetric unit. I was delighted, and intrigued that use of these techniques appeared to have positively influenced another prolonged labour situation. However, I also immediately started to question whether it was the effect of the intervention in both cases, or whether the babies had simply spontaneously turned—because, of course, there was no ‘scientific’ evidence to support the use of the techniques. In the days that followed, I began to question my cynical response. Why was I so quick to devalue the experiences of using the techniques as ‘unscientific’, when they appeared to have had such an immediate and positive impact on birth outcomes?

Ways of knowing

There is extensive discussion in the literature relating to the art and science of midwifery practice (Carper, 1978; Hagell, 1989; Davis, 1995; Gilkison, 2013; Power, 2015). It is the scientific ways of knowing that have come to dominate our society (Davis, 1995; Davis-Floyd and Davis, 1996; Barnes, 1999; Shallow, 2001; Yuill, 2012). This has had profound implications for the art of midwifery practice. The current dominant scientific discourse is prevailing, powerful and reductive (Foucault, 1976; Fry, 2007).

Belenky et al (1986) describe how the current dominant ways of knowing (rational, masculine, technological, scientific) disadvantage women's ways of knowing, which tend to be more emotional, intuitive and personalised. Women have accrued and passed on knowledge about childbirth over many centuries, yet much of this knowledge is disregarded and devalued by the current dominant scientific discourses (Stewart, 2010) and by midwives themselves. In addition, Schon (1983) suggested that professional education undermines knowledge gained from practical experiences and reflection, by valuing intellectual and scientific forms of knowledge more highly. Central to knowledge discourses is the notion of power. Foucault (1980) described knowledge and power as synonymous. Although several discourses will exist in any society at a given time, society decides and gives authority to particular discourses at the expense of others. Many feminist writers—and, indeed, many midwives—have challenged the authority of scientific knowledge in relation to pregnancy and birth, because it subjugates other ways of knowing (Murphy-Lawless, 1998). The personal experience described above is a perfect example of this process at work, where the value of a technique is questioned and then minimised in relation to the lack of empirical evidence to support it. And yet there was so much more going on in terms of the process under-pinning the decision to use the techniques.

Experienced midwives utilise other ways of knowing based on their practice experience. Hunter (2008) described the types of knowledge utilised in midwifery practice; these include scientific knowledge (the dominant discourse that has been described), intuitive knowledge, and embodied knowledge. Intuition is defined by the Oxford English Dictionary (2016) as ‘the ability to understand something instinctively, without the need for conscious reasoning’. Hunter (2008) describes embodied knowledge as informal knowledge learned from personal experience and observation of colleagues. The utilisation of intuitive and embodied knowledge is at the heart of midwifery practice. Carper's (1978) taxonomy of knowledge describes intuition as the basis for the art of nursing practice. Reflecting on the example in this article, the decision to try techniques to correct the posterior position of a baby in labour was made based on the midwife's own clinical experience of looking after women in labour in similar situations. The experience, described in the storytelling circle, utilised the embodied and intuitive midwifery knowledge of the critical relationship of the baby to the maternal pelvis in a posterior labour. The application of this knowledge drove the decision to try an intervention when all else had failed. Why had I not valued this complex knowledge and decision-making more highly?

Midwifery knowledge

The modern profession of midwifery is relatively new and has borrowed heavily from medicine and other health professions in constructing its own knowledge base (Hunter, 2008). The impact of this ‘borrowed’ scientific body of knowledge is that the profession has ended up ideologically in conflict with itself (Wilkins, 2010). The scope of practice in midwifery is focused on normality in pregnancy and birth (Nursing and Midwifery Council, 2012), with emotional care prioritised alongside physical care. The current dominant scientific paradigm, in which midwifery currently exists in the UK, has little to offer this model of care. If we accept the randomised controlled trial as the gold-standard measure of scientific research (Stewart, 2010), with particular emphasis on measuring the effect of interventions, it has limited application to normal midwifery practice. Midwifery, in its purest form, is about non-intervention and is respectful and supportive of the physiology of pregnancy and birth. In direct opposition to the use and measurement of interventions in practice, the place of well-judged non-intervention or ‘the art of doing nothing well’ has long been recognised in midwifery (Kennedy, 2002: 1759; Nightingale, 2013) and is critical to facilitating normal birth outcomes.

Oral culture

Rolfe (2000) suggests that, historically, nursing and midwifery have an oral culture, where the generation of knowledge and facts occurs through narrative or ‘storytelling’ rather than through scientific papers. He describes the work of the post mod ernist philosopher Jean-François Lyotard, who stated that scientific knowledge is a relatively new concept in relation to the tradition of narrative knowledge. He suggests that narrative knowledge is a legitimate alternative.

In broad terms, scientific knowledge involves the transmission of facts from one who knows to one who does not, and is generated via empirical research and publication. Narrative approaches can accommodate a far broader epistemology (Fry, 2007) and involve the passing on of more diverse knowledge—as in the manner of the story telling circle. Interestingly, in relation to the oral cul ture identified, a number of practices in mid-wifery have seen wide spread adoption prior to there being published research data to support them. These include the non-suturing of perineal tears during the 1990s, the use of water for labour and birth during the same period and, more recently, the use of hypnosis for birth. This supports the view that the narrative tradition of knowledge-sharing in midwifery is still evident and has a widespread influence on practice. The sharing of experiences in the storytelling group is a typical example of this ‘passing on’ of knowledge.

Feminist perspectives

We have briefly touched on the way in which scientific knowledge can disadvantage women's ways of knowing. Feminist theory is concerned with the way that gender influences our concept of knowledge and research practices (Anderson, 2005). Oakley (1981) identified that male-orientated bias is inherent in scientific research, which is highly gendered with its roots in science and rationality. This, in itself, may have the effect of producing a limited and distorted epistemology of women. Standpoint feminism, which is a specific feminist theory, is focused on knowledge being explored from the standpoint of women and their experiences (Hartsock, 2003). Standpoint feminism attempts to critique dominant conventional epistemologies and, arguably, is highly appropriate for adoption into midwifery practice, research and the associated generation of knowledge. Yuill (2012) identifies that midwives claim to be autonomous professionals, but in reality their practice is oppressed by the use of quantitative research findings that are frequently used to direct and dominate the management of care in maternity services. This has the effect of marginalising midwifery knowledge. Keating and Fleming (2009) capture this in their research investigating midwives' experiences of facilitating normal birth in an obstetric unit, where midwives regularly navigate a sea of competing obstetric and midwifery ideologies. The midwives in the study identified that greater value was placed on midwifery practice incorporating intuitive and experiential knowledge on night duty (when it is predominantly labouring women and midwives who are present), compared with day shifts, where this knowledge was devalued in favour of technology. This reflects my own experience of midwifery practice and illuminates the process described earlier, where the devaluing of intuitive, embodied knowledge occurred in favour of the perceived need for a more rational, scientific evidence base.

Narrative approaches and midwifery

Let us come back to the starting point of this work, the storytelling circle. We have learned that, his torically, midwifery is an oral culture. There is evidence that the process of passing on know ledge and experience in midwifery orally (rather than via empirical research and publication) persists. The oral tradition is ingrained in the processes of the storytelling group, with the sharing of intuitive, embodied, experiential knowledge. This is underpinned with feminist epistemology, which is focused on knowledge being explored from the perspective of women and their experiences.

We have identified that the prevalent scientific discourse, which subjugates midwifery know ledge, is a poor fit in terms of providing a relevant knowledge base for the prac tice of mid wifery. If the profession is to develop an approp riate knowledge base, new approaches to research and education must be identified. Walsh and Evans (2014) state that, despite the growth of midwifery research over the past 20 years, discussion and debate regarding the phil osophical under pinning of research methods has been cons picuously absent. This requires urgent attention if mid wifery as a profession is to progress the generation of an appropriate body of professional knowledge.

The storytelling circle, which has been explored in relation to midwifery discourse and knowledge, is a good example of the use of narrative. Narrative pedagogy is defined as an approach to thinking about teaching and learning that evolves from the lived experiences of teachers, clinicians and students (Nehls, 1995). Narrative inquiry is an umbrella term that captures the personal and human dimensions of experience over time and takes account of the relationship between individual experience and cultural context (Clandinin and Connelly, 2004). Narrative inquiry is based on social constructivist, constructivist and feminist principles, where stories of lived experience are co-constructed by those involved. The process of narrative inquiry captures complex, multilayered information that can be used to inform practice (Diekelmann, 2001). Polkinghorne (1995) describes stories as socially situated knowledge constructions that value the complexity, depth and texture of real-life experience.

There is some literature on the use of story telling or narrative as a tool in education (Davidson, 2004; Schwartz and Abbott, 2007; Haigh and Hardy, 2011; Weston, 2012). However, it is generally used to encourage students to appreciate alternative perspectives—for example, those of service users—and to connect theory to practice and facilitate reflection. Storytelling as a tool is different from the broader use of narrative as a strategy for teaching or research. There is very little literature on the use of narrative pedagogy or inquiry in relation to midwifery, which is surprising. As we have seen, experiential knowledge underpins midwifery, and the generation of knowledge via the sharing of stories from practice is not uncommon. Narrative approaches to education and research capture the essence of this by focusing on social reality, lived experience, complexity of practice and the co-construction of knowledge (Clandinin and Connelly, 2004).

Conclusion

The professionalisation of midwifery is a relatively recent development, with the move into higher education institutions and the generation of mid wifery knowledge via research. As a result, the profession has borrowed heavily from medicine and other health professions in constructing its own knowledge base (Hunter, 2008). The time may have come to recognise the limitations of the randomised controlled trial on midwifery practice which, in its purest form, is about enabling physiology.

The practice of midwives passing on their experiences via storytelling as a legitimate knowledge form is supported by feminist philosophy. Midwives should be encouraged to value this ‘way of knowing’ more highly. In addition, more research in the context of UK midwifery practice should be undertaken to develop the knowledge base. The use of narrative as a strategy for developing midwifery education, research and professional knowledge has been explored. Although biomedical knowledge is, of course, critical to high-quality midwifery practice, narrative pedagogy and inquiry has the potential to further develop the art of midwifery practice via the generation of knowledge that is potentially highly relevant to the profession. There are data that suggest narrative approaches may enhance and develop insight, empathy, connectedness and intuition (Davis-Floyd and Davis, 1996; Fry, 2007; Hunter, 2008), skills that are at the very core of woman-centred midwifery practice. This may contribute to enabling midwives to develop a relevant and powerful discourse that is not borrowed from others. Isn't it time that we consider this as a profession, and give equal value to alternative ways of knowing? In doing so, we may finally feel able to validate the oral tradition at the heart of midwifery practice.

Key Points