There are gender differences in how society views substance use, with women often being viewed more harshly than men (Ettorre, 2015). This unsympathetic view amplifies when women are pregnant, leading them to be perceived as morally corrupt, scheming and dishonest (Miles et al, 2012; Ettorre, 2015). The societal expectations of ‘the good mother ideal’ can lead to the stigmatisation of women (Nichols et al, 2021), as they are viewed as unable to fulfil their role as good mothers (Weber et al, 2021). This view can be unwittingly reflected in the care provided to women, as some healthcare professionals, including midwives, may find it challenging to distance themselves from negative ingrained attitudes (Nichols et al, 2021). The European Union Drugs Agency (2023) suggests that along with a fear of having their babies removed from them, these attitudes can deter women from seeking help with their addictions.
Since the publication of ‘changing childbirth’ (Department of Health, 1993), midwifery-led continuity of care models have been the aspiration of maternity services across the UK. Through continuity of midwifery care, midwives believe a reciprocal midwife–mother relationship can be built, facilitating relational-based care (Rayment-Jones et al, 2020). Relational-based care develops over time as the midwife and mother expand their knowledge of each other: the midwife in terms of the physical and emotional needs of the mother and the woman in terms of the midwife's ability to support and advocate for her (Cummins et al, 2020).
Existing midwifery research has mainly explored hospital midwives' attitudes and beliefs about women with substance dependency, and continuity of care models have been used in some but not all studies; few were midwifery-led (Radcliffe, 2011; Miles et al, 2012; 2014; Whitehead et al, 2019). There would appear to be little research exploring how this relationship is experienced by community-based midwives providing clinical care to women via a midwifery-led continuity of care model. The present study aimed to explore this phenomenon.
Methods
This study used interpretative phenomenological analysis, a methodology with roots are in psychology and theoretical pillars in phenomenology, hermeneutics and idiography (Smith and Nizza, 2021). Interpretative phenomenological analysis blends the phenomenological theories of Husserl, Heidegger, Merleau-Ponty and Sartre with Schleiermacher, Heidegger and Gadamer's theories of hermeneutics. These blended theories explore the detail of the experience from the participants' perspective in depth. Figure 1 illustrates the three methodological influences (Charlick et al, 2016).
Interpretative phenomenological analysis has continued to evolve and mature as a research methodology. This study began before publication of two more recent works, Essentials of Interpretative Phenomenological Analysis (Smith and Nizza, 2021) and Interpretative Phenomenological Analysis, Theory Method and Research (Smith et al, 2022). Therefore, the research method and analysis used drew on Smith et al's (2009) earlier publication: Interpretative Phenomenological Analysis, Theory Method and Research.
Smith and Osborn (2015) describe interpretative phenomenological analysis as an engaging philosophical approach that simultaneously uses empathetic and questioning hermeneutics. It is empathetic in that it tries to understand a participant's experiences from a position of compassion, while asking probing questions of these viewpoints to uncover profound meaning. This introduces the concept of the double hermeneutic, meaning ‘the researcher is making sense of the participants' sensemaking’ (Tuffour, 2017). The researcher tries to understand the participant's position by exploring the context of the participant's lived experience of phenomena. Through the hermeneutic circle, the researcher journeys through the data, looking at the whole and the part of the text; this iteration of thought and analysis precipitates new interpretations (Smith et al, 2022).
Participants
Participants were recruited via convenience sampling from one safeguarding midwifery team in Scotland. The five participants had more than 10 years' midwifery experience, had worked in several clinical areas in maternity services and showed interest in caring for substance-dependent women before joining the safeguarding midwifery team.
Data collection
Data were collected using face-to-face, in-depth, semi-structured interviews and visual inquiry techniques. Social researchers can use visual inquiry techniques to focus participants' thoughts on the researcher's questions (Tsang and Besley, 2020). Roddy et al (2019) explain how generic images can be used repeatedly in different education and practice development settings to support the exploration of subconscious, deeply held beliefs and emotions. As midwives become enmeshed in women's life worlds (Miles et al, 2012), they can become emotionally affected by challenging cases (Halsall and Marks-Maran, 2014). Therefore, midwives may have found it challenging to articulate feelings and thoughts. Consequently, visual inquiry was chosen as a data collection tool for the study.
Interviews took place between July and October 2019. The researcher and their academic supervisor formulated an interview guide, which was piloted with a woman with substance dependency. Initially, the study aimed to explore the experiences of both safeguarding midwives and pregnant women with substance dependency. The researcher completed all interviews with participating midwives by the end of October 2019 and planned to begin recruiting women in 2020. However, at this time, all research activity was suspended as a result of the COVID-19 pandemic. In June 2020, research activity slowly recommenced, but there were subsequent challenges with recruitment of women because of the reduction in face-to-face clinical contact with midwives, which meant no women had come forward to participate. Therefore, the researcher and their academic supervisory team decided to continue with in-depth analysis of the midwives interviews only.
The interviews lasted 30–60 minutes. Visual inquiry cards were arranged on a table, and midwives were asked a question and requested to choose an image related to their answers. They were then asked why that particular image met their response (Roddy et al, 2019). All interviews were recorded using an encrypted digital recorder, uploaded onto the health board's secure server and transcribed as soon as possible.
Data analysis
Transcription can be viewed as the first stage of analysis (Davidsen, 2013). Bryman (2016) suggested that repeated listening to participants' interviews can bring the researcher closer to the data, bringing hidden meaning to life; therefore, the researcher decided to transcribe the interviews personally. There is no one way to analyse data using interpretative phenomenological analysis (Smith and Osborn, 2015); this study used Smith et al's (2009) suggested six steps to aid the in-depth exploration of each participant interview.
First, each transcript was read and re-read many times, each allowing for immersion in the narrative of the participant's perception. Finlay (2014) described the researcher's immersion in the data as ‘dwelling with the data’, inviting the researcher to explore the detail of participants' understanding of the phenomenon in their lifeworld. Any initial thoughts or prominent data were logged separately from the transcript and used in step two.
Next, in initial noting, data were analysed closely, and any initial thoughts from step one were developed. Anything incongruous or interesting was systematically analysed, and descriptive, linguistic and conceptual content was identified. Descriptive comments focus on what participants describe as what matters to them in their lifeworld in their own words. Linguistic comments explore how the participant used language in the interviews to uncover meaning. This includes the rhythm of speech, metaphor use and the reiteration of a word, phrase or metaphor to describe the phenomenon. Conceptual comments involve asking questions of the text through the hermeneutic circle and double hermeneutics, to make sense of the participants' sensemaking of the phenomenon.
The third step was to develop emergent themes. In this step, the focus moves from the text to the researcher's initial notes. The researcher seeks to condense the data by clustering similar thoughts and descriptions to formulate related themes. At this point, the researcher breaks down the whole text into parts and then reassembles them to construct new knowledge. The transcript should always be the core of the analysis, and the analysis must always come back to the text.
The next step is searching for connections across emergent themes. The researcher considers the interconnectedness of each emergent theme, and Smith et al (2009) suggested listing them in chronological order as they arose in the interview. Then the researcher moves on to the next participant's transcript, repeating steps one to four. To continue the idiographic premise of interpretive phenomenological analysis and bring new themes to light, the researcher ‘bracketed’ knowledge gained from the analysis of the transcripts. In the final step, the researcher considered the interconnectedness of themes across transcripts, showing convergence and divergence of each participant's feelings about their experience of the phenomena.
Ethical considerations
All midwives were designated numbers to protect their anonymity. As the midwives were from a small team in their health board, certain factors that may have been used to identify them, such as the board, age and length of time in the team, have been omitted (Tracy, 2020).
Midwives caring for women with substance dependency can uncover distressing narratives that can be challenging to comprehend and accept (Miles et al, 2012). It was acknowledged that some might feel emotional distress when recounting their experiences, and so a range of support services were made available to the study's participants.
Ethical approval was obtained from the University of the West of Scotland School of Health and Life Sciences Ethics Committee in November 2018 (reference: UWS - 4532). As this study was undertaken with midwives employed in the NHS, ethical approval was also obtained from the NHS Health Research Authority in June 2019 (reference: 19/WS/0053).
Results
A total of 53 emergent themes were initially identified. Using further analysis techniques described in Smith et al (2009), these were refined, resulting in five superordinate themes:
Several subordinate themes supported each superordinate theme, as shown in Table 1. However, some subordinate themes were interlinked with other superordinate themes. These were care and compassion, mutuality and midwife reflection/reflexivity. Figure 2 is a diagrammatic representation of how these subordinate themes connected with other superordinate themes.
| Transformation | Tug of war | Reciprocity | Proxy parenthood | Midwives' twitch |
|---|---|---|---|---|
| Then | Maternity services | Seeing me, seeing you | Protection | Formal knowledge formation |
| The importance of time | Competing multiagency philosophies and priorities | Knowing me, knowing you | Courageous conversation | Informal knowledge formation through experiential learning |
| And now | Midwifery continuity | Courage actions | ||
| Midwife reflection/reflexivity | Normalise, not stigmatise | Tenacity | ||
| Mutuality | Care and compassion | |||
| Listening | ||||
| Walking the tightrope | ||||
| Balancing relationships |
The fifth theme, midwives' twitch, is a theoretical exploration of midwifery intuition in practice. As the focus of this article is on how midwives build and maintain relationships with women, the discussion concentrates on the first four superordinate themes.
Transformation
The first theme included four subordinate themes: then, now, the importance of time and midwife reflection/reflexivity. Each theme described a distinct difference in midwives' experiences caring for women before and after joining the safeguarding team.
‘I had just joined safeguarding and went out with one of the midwives. She took me to a girl who was in and out of addiction services, living a very chaotic lifestyle, was still using. I actually sat and she told me her full story, all about her childhood … everything that happened to her … I was quite upset … she was in my mind for a good few weeks after … [I kept] thinking … it could be any one of us; that could have been anybody. If I had been born into that family … the things that poor girl was exposed to, nobody really cared about her, she was abused by everybody her whole life physically, sexually everything … and she spoke about using the drugs and how it helped block things out, and I feel as if I had a lightbulb situation at that point … People don't always pick their path … No one would pick to become that heroin addict’.
Tug of war
This theme involved two subordinate themes incorporating the relationships between midwives, maternity services and multiagency teams.
Overall, midwives believed their relationships with other midwives and the wider maternity team to be good, but dependent on previous working relationships.
‘I've worked in the hospital for so many years … you've got a better way in, whereas some of the colleagues I work with in the team have never worked in the hospital, so they are not known, so there can seem a bit of a … barrier there’.
The main frustration for all midwives appeared to be their perception that other midwives did not understand the full extent of their safeguarding role or the women's lifeworld.
‘They don't understand all you do and what the women have to go through. I think there needs to be more awareness’.
Midwives described their multiagency relationships as respectful; however, there appeared to be fundamental differences in philosophies and priorities at times. This was particularly evident when child protection issues were present, and midwives were advocating for women to social workers.
‘I know child protection is a massive thing, but [social workers'] whole ethos is child protection … As a safeguarding midwife, I'm working within social work, but fundamentally, I'm a midwife, so my concerns are for a mum and her unborn baby … to protect her and to be her voice’.
The concept of advocacy was something all midwives emphasised and appeared to feel strongly about.
‘I'm able enough to stand up and say what I need to say to advocate for these mums if need be. Sometimes, it's like … a tug of war. I'd say sometimes we don't meet in the middle. There is definitely a battle’.
Reciprocity
The theme reciprocity was the most complex, with several overlapping subordinate themes. Midwives valued working with women, supporting them in their recovery and pregnancy journey by not ‘doing for’ but ‘doing with’.
Midwifery continuity
Midwifery continuity was central to the theme of reciprocity, enabling midwives to build and maintain relationships.
‘I think because we've got continuity, it helps that we are their midwives, and they get to know us’.
The importance of getting to know women on a deeper level was emphasised.
‘I think the most important thing is where you have built up that relationship, and they can then tell you things that they have maybe never told anyone else in their life’.
Seeing me, seeing you
Through building relationships, midwives could see aspects of their own life experiences in those of the women they cared for, which appeared to facilitate deeper connections.
‘It's probably because of my own life experiences and the life I had as a child and a teenager that I can relate’.
Knowing me, knowing you
Midwives highlighted how working in the safeguarding midwifery team enabled them to learn about the women's families and broader societal environments, which aided their relationships.
‘I think it is becoming part of the safeguarding team because you're going into these families, working with them for long periods of time, getting to know them and their family background’.
Normalise, not stigmatise
Midwives demonstrated awareness of the societal and professional prejudices women sometimes experience. They used different techniques to reduce stigma and promote normality. Some actively encouraged women to make their own choices about care.
‘I'm there supporting them … in their lives … making them feel empowered so that they can make decisions. It's giving it back to them … that ownership’.
Mutuality
Although midwives were clear about their role and responsibilities toward women, there was also a feeling that for the relationship to work, there had to be mutual respect, honesty, trust and a willingness to work together to make a difference.
‘For me, it's about honesty and that has to go both ways’.
Midwives were aware that some women working were not accustomed to being cared for in a mutually beneficial way.
‘A lot of these girls just close off and say … “no, I'm not going to engage, tell me what to do”’.
Listening
When asked what they thought women valued about their relationship, midwives believed it was their ability to listen and acknowledge their experiences as truth.
‘It's just somebody to listen to them, somebody to be there, somebody to be at the end of the phone when they maybe don't have anyone else’.
Walking the tightrope
A dichotomy between professional and personal acceptance of women's behaviours could exist, leading to feelings of walking a tightrope between professional and personal beliefs.
‘I don't really have to respect them out of uniform, because out of uniform, I have a different mindset almost, but in uniform, when I'm there with those ladies, I'm there to support them’.
Balancing relationships
Midwives were aware of how building reciprocal relationships could foster dependence.
‘The cost is that they attach and attach really, really hard sometimes’.
One midwife articulated how their close relationships with women formed emotional bonds that were not always comfortable.
‘But I was only working with them for a very short time, so I wasn't getting emotionally involved with them, which I suppose is easier’.
Nevertheless, some were aware of the cost to self through their emotional effort and commitment to caring; however, they felt that this was worthwhile.
‘There definitely is a cost to it, but if I never did it, then I wouldn't be being myself so that I wouldn't do it any differently’.
Proxy parenthood
There were four subordinate themes in proxy parenthood. Although all midwives strongly refuted the concept of proxy parenting, they described approaches to women close to that of parents, such as boundary setting, protection, nurturing, compassion, chastising and empowering.
Protection
The midwives expressed their wish to support and protect women, which they considered essential to their role.
‘To protect her and to be her voice’.
To enable this, all midwives indicated that openness and honesty were integral to the foundation of a trusting relationship.
‘It's about us trying to be honest and open, explaining this is because of this, I'm doing this because, I'm concerned because’.
Courageous conversations
Midwives appeared to use a ‘tell it like-it-is’ approach to their relationships with women. They clarified this ‘boundary setting’ with women at the beginning of their relationship, and the language used could be considered adversarial.
‘If I am not happy with what you have done, and you have lied to me or whatever, I will tell you that I am not happy’.
Midwives pointed out the importance of being frank about their child protection role and the possible removal of babies at birth where required.
‘You're explaining “I'm safeguarding and I'm here just to help” and talking about support, and their first question is “are you going to take my baby off me?”, and you go, “I can't answer that, but this is what we need to do”’.
The relationships appeared to flourish although these conversations could be challenging. One midwife highlighted how even when decisions in child protection meetings were to remove the child, their relationship was such that women would still engage afterwards.
‘One of the biggest things I think that still shocks me to this day is when the decision is for their child to be removed, they still will come and give you a hug at the end of it or say, thanks for being there’.
Courageous actions
Midwives sometimes found themselves making decisions that placed them in possible at-risk situations to ensure women's wellbeing. One midwife related an experience with a social work colleague when trying to engage with a chaotic substance-dependent woman they were concerned about.
‘So, the two of us decided to go to the chemist because we knew she used to come and get her script at the close of day. So, on a Friday night around half past five, we hovered around this chemist waiting for this lady who never appeared. Then we decided to go to her house together … we found this lady in the kitchen who had been injecting, but we got her checked out and into homeless accommodation; we just needed to make sure she was safe’.
Tenacity
Midwives believed all women were worthy of opportunities to change, no matter how far into their addiction they were.
‘Everybody deserves a chance, and everybody's got a story, everybody just needs that one person’.
This, along with their understanding of the woman's lifeworld, supported the relationship and promoted trust.
‘You keep going and say, “I'm not going away. You can push me away as far as you want, but I'm here, and I'll do whatever I need to help you”. I think it's at that point that they start to trust you because they think, “I've never really had anybody who comes back”; people do walk away’.
Care and compassion
All midwives voiced or displayed actions of care and compassion for women, although this could come at a cost to themselves.
‘For safeguarding, because it's mentally and physically draining, the work that you do, because it's not just a job, I genuinely care about all these mums, genuinely 100% care about the outcomes. You can't do the job if you don't really care, can you?’
Discussion
The midwives in the present study demonstrated how working with women transformed their attitudes and beliefs towards them. This reflects the finding of Miles et al (2014), where midwives also reported a change in attitudes through working with women. However, unlike Miles et al (2014), where midwives equated engagement as the indicator of a successful relationship, midwives in the present study believed the relationship was successful if they gained the woman's trust and honesty about substance use. The relationship between the midwives and women was an essential and highly valued facet of their work, as it gave them the feeling of making a difference and a degree of job satisfaction. Therefore, when women were not honest about their substance use or disengaged from their care, midwives felt the loss keenly.
Comparable to the findings of Miles et al (2012; 2014), in the present study, midwives' relationships with women were based on partnership, honesty, trust, care and compassion. They spoke of respect, concern, worry, responsibility, care, compassion, empathy, guidance and support. Similar to Rayment-Jones et al's (2020) findings, midwives went above and beyond because of their resolve that all women were worthy of maternity care irrespective of their substance use. They wanted to ensure women had the opportunity to change, improve their chances of recovery and have healthy babies. The midwives in this study were based in the community setting, and each had a designated caseload. This facilitated a degree of autonomy in their working day and allowed them to search for women.
However, in contrast to other studies, all midwives in the present study displayed a depth of emotional connection, suggesting a deeper bond with women than they realised (Miles et al, 2012; 2014). They acknowledged that this could be detrimental and spoke of ‘the emotional cost’ of caring for women. However, it was a cost they were willing to assume. Additionally, some midwives disclosed experiences that they believed facilitated a deeper connection with the women in their care.
The introduction of trauma-informed maternity services is being explored by NHS Scotland (Scottish Government, 2023) and NHS England (2019). This study suggests that midwives caring for vulnerable women in the perinatal period have personal life experiences that may harm their emotional wellbeing over time. Midwives indicated that they felt unprepared for the role of safeguarding midwife with no understanding of the emotional effort required. If trauma-informed maternity care is to be introduced, appropriate training and support would be necessary to ensure midwives' long-term wellbeing.
Limitations
The study sample size was small, although within the guidelines for an interpretive phenomenological analysis study (Smith et al, 2009). However, interpretive phenomenological analysis' idiographic focus can create new and rich knowledge with limited participant numbers (Smith et al, 2009). The findings of the study cannot be generalised, but they may resonate with and be transferable to midwives involved in caring for vulnerable women, particularly those engaged with social work and child protection processes.
Implications for practice
Midwifery continuity of care models are now integrated into Scottish Government (2017) policy. As midwifery-led continuity of care is crucial for developing and maintaining relational-based care, the author recommends further expanding this model to include women of all risk and in all maternity care settings.
The study's midwives considered themselves unprepared for the role of safeguarding and believed that shadowing the team would have given them a greater understanding of the role. The author recommends that midwives and student midwives who show an interest in specialist areas of maternity care shadow the relevant teams as part of their ongoing professional development. Building a multidisciplinary community of practice around safeguarding, including all agencies and disciplines involved with caring for women, should be considered. Practitioners' ability to reflect on and learn from each other may assist in improving relationships and their understanding of each service's unique philosophies and roles in caring for women with substance dependency.
Conclusions
After joining the safeguarding midwifery team, midwives' attitudes, beliefs and understanding of women with substance dependency were transformed. When midwives had limited contact with these women, either through their working environment or organisational policy, they found relationships superficial and challenging. However, once they were able to spend time with them and appreciate their life stories, the midwives experienced a profound change of perspective. Midwifery-led continuity of care was integral in enabling midwives to develop meaningful reciprocal relationships with women with substance dependency. The midwives' relationships with the women were based on partnership, honesty, trust, care and compassion. However, the depth of emotional connection displayed by midwives could be detrimental, and at times, they demonstrated the emotional cost.
The transformational change in the midwives' attitudes and their developed sense of self helped them appreciate and support women's recovery. It became evident that the midwife–women relationship affected how they interacted with the wider multiagency team and other healthcare professionals. Although the midwives saw child protection as an integral part of their role, it was not at the forefront. They were first and foremost advocates for women. Working in a midwifery-led continuity of care model assisted midwives in developing a degree of agency, autonomy and courage to do this.