Commentary

Woman centred maternity care and professional

positioning: A response to Dornan

Joan Cameron *

University of Dundee, School of Nursing and Midwifery, Ninewells, Dundee DD1 9SY, United Kingdom

Received 29 September 2008; accepted 5 October 2008

Keywords: Midwifery; Obstetrics; Woman centred; Maternity services

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International Journal of Nursing Studies 46 (2009) 288–290

In his editorial on childbirth in the UK, Dornan (2008)

expresses his opinions on the structure of the medical and

midwifery professions and the organisation of childbirth in

the UK. While I would not wish to deny him the right to

express these opinions, I feel that it is essential that the

factual inaccuracies and the assumptions based on these

inaccuracies are challenged.

There was no UK Midwives Act in 1902 as Dornan

asserts (Dornan, 2008). The 1902 Act related only to mid-

wifery practice in England and Wales. Midwifery legislation

for Scotland followed in 1917 and in Ireland in 1918

(Donnison, 1988). The various Midwives Acts enacted

throughout the UK almost certainly protected the role of

the midwife and ensured that midwifery practice continued,

unlike the situation in many parts of the world notably North

America, where midwifery practice has almost disappeared.

The Central Midwives Board did have members of the

medical profession but it was not comprised solely of

doctors as Dornan states.

Dornan (2008) declares that Changing Childbirth

reflected the policy of the UK Department of Health. This

is incorrect. Although the National Health Service exists in

each of the 4 countries in the UK, there is no UK wide

National Health Service. Each country devises its own health

policy. Thus ‘Changing Childbirth’ was a policy devised by

the Department of Health (DoH) in England for the NHS in

England (DoH, 1993). Wales, Scotland and Northern Ireland

all had and still have their own maternity policy strategies

and documents.

* Tel.: +44 1382 632304; fax: +44 1382 642738.

E-mail address: j.cameron@dundee.ac.uk.

0020-7489/$ – see front matter # 2008 Elsevier Ltd. All rights reserved

doi:10.1016/j.ijnurstu.2008.10.002

The maternity strategy ‘Changing Childbirth’ was a

response to the Winterton report: an inquiry into the mater-

nity services in England (House of Commons Health Com-

mittee, 1992). The Inquiry received representations from

doctors, midwives and a range of user representatives. Four

of the nine representatives on the Expert Group responsible

for producing the ‘Changing Childbirth’ report were lay

members (DoH, 1993). Voluntary organisations representing

women as users of the maternity services had a key role in

shaping the services.

Changing Childbirth had three central concepts at its

heart: continuity, choice and control (DoH, 1993). I would

suggest that these are strong evidence of being woman

centred. At least some professionals thought so, claiming

that the strategy robbed them of power and placed it into the

hands of women (Holroyd et al., 2002; Keenan, 1996).

Women have always wanted choice in relation to place of

birth—hence the reason for the campaign for women to have

the right to choose to give birth in hospital in the 1950s. I am

certain that the women who marched never envisaged that

their ‘right to choose’ hospital birth would be used to force

women into institutionalised birth.

Given Dornan’s lack of understanding of the political

situation within the UK, his statement that ‘not one other

country in the developed world’ has developed a risk-based

approach to maternity care requires to be handled with

caution (Dornan, 2008). The definition of a ‘developed

country’ is one where there is a high gross domestic product

and a high human development index (Irogbe, 2005). Tra-

ditionally this list includes Canada, the United States of

America, Australia, New Zealand, Japan and most of the

countries of northern and western Europe. A cursory glance

.

J. Cameron / International Journal of Nursing Studies 46 (2009) 288–290 289

at the websites of the professional organisations for mater-

nity professionals in these countries demonstrates that the

concept of risk is widely used to determine the management

of care of a pregnant woman. One country where risk is a

major determinant of the provider of maternity care is the

Netherlands. It also has one of the lowest caesarean section

rates in the developed world (De Vreis, 2004).

Dornan (2008) states that midwives encourage low risk

care the expense of women’s health but fails to provide any

evidence to support this. There is a significant body of

evidence to suggest that midwifery care is safe (Flint,

1991; McCourt and Page, 1996; Turnbull et al., 1996)

and is associated with fewer interventions (Flint, 1991;

McCourt and Page, 1996; Turnbull et al., 1996) and provides

care that women is evaluated positively for women (Flint,

1991; McCourt and Page, 1996; Turnbull et al., 1996;

Morgan et al., 1998).

The suggestion that Dornan (2008) proposes for inter-

professional learning is interesting. However, it too, lacks a

credible evidence base. Despite the undoubted enthusiasm

for interprofessional learning from politicians to profes-

sionals, there is little to suggest that it improves working

practices and enhances patient outcomes (Ireland et al.,

2008).

Perhaps the most worrying of Dornan’s opinions relates

to the health care provision in developing countries (Dornan,

2008). His description of the type of professional required to

provide care, coupled with the assertion that they would not

require stringent academic credentials flies in the face of the

education and health policies being promoted by developing

countries (WHO/AFRO, 2008). The lack of trained birth

attendants is not due to the lack of academic qualifications in

the population but due to ‘poaching’ of staff by countries

such as the UK (Lancet Editorial, 2006) and the lack of

social infrastructure due to wars and famines (Committee on

Population, 2004). Countries such as Rwanda, Malawi,

Liberia and Zambia have committed themselves to devel-

oping educational programmes to meet the needs of their

populations (WHO/AFRO, 2008). They recognise that they

need access to highly qualified staff to take forward pro-

grammes of education and research and are working in

partnership with a range of organisations to develop appro-

priate skills and strategies. Their approach includes acces-

sing postgraduate education up to doctoral level. By

developing the skills and building on their knowledge base,

they will be in a prime position to develop systems of health

care that meets their needs, rather than relying on models

prescribed and imported by other countries (Ketefian, 2008).

Dornan (2008) suggests that his opinions represent a

move away from the professional positioning that has char-

acterised the development of the maternity services in the

UK. Northern Ireland provides very limited information

about its’ maternity statistics. Indeed, a publication co

authored by the Royal College of Obstetricians and Gynae-

cologists of which Dornan is a Vice President called for

Northern Ireland to be more open about the normal birth rate

in the country (Maternity Care Working Party, 2007). North-

ern Ireland is also the only country in the UK not to have

birth centres. However, this is about to change as an

announcement was made recently giving the go ahead to

develop stand-alone community maternity units staffed by

midwives (Northern Ireland Executive, 2008). If I may be

allowed an opinion, I would suggest that Dornan’s paper is

not about providing care that is centred on the needs of

women but a plea for the continuing participation of obste-

tricians in all aspects of maternity care in Northern Ireland.

Conflict of interest

The author is a midwife and was seconded on a part-time

basis to the Changing Childbirth Implementation Team.

References

Committee on Population, 2004. War, Humanitarian Crises, Popula-

tion Displacement, and Fertility: A Review of Evidence.

National Academies Press, Washington.

Department of Health, 1993. Changing childbirth. Part I. Report of

the Expert Maternity Group. HMSO, London.

De Vreis, R., 2004. A Pleasing Birth: Midwives and Maternity Care

in The Netherlands. Temple University Press, Philadelphia.

Donnison, J., 1988. Midwives and Medical Men: A History of the

Struggle for Control of Childbirth. Historical Publications,

London.

Dornan, J.C., 2008. Is childbirth in the UK really mother centred?

International Journal of Nursing Studies 45 (6), 809–811.

Flint, C., 1991. Continuity of care provided by a team of midwives—

the know your midwife scheme. In: Robinson, S., Thomson, A.

(Eds.), Midwives, Research and Childbirth, Vol. 2. Chapman

and Hall, London.

Holroyd, S., Bailey, V., James, V., et al., 2002. Professional attitudes

to changing childbirth in Nottingham, UK. International Journal

of Nursing Studies 39 (2), 177–186.

House of Commons Health Committee, 1992. Second Report on the

Maternity Services (Winterton report). HMSO, London.

Ireland, J., Gibb, S., West, B., 2008. Interprofessional education:

reviewing the evidence. British Journal of Midwifery 16 (7),

446–453.

Irogbe, K., 2005. Globalization and the development of under-

development of the Third World. Journal of the Third World.

http://findarticles.com/p/articles/mi_qa3821/is_200504/

ai_n13642807 (accessed September 29, 2008).

Keenan, M., 1996. The GP’s guide to home birth. http://www.

medicine.ox.ac.uk/bandolier/band32/b32-8.html (accessed Sep-

tember 29, 2008).

Ketefian, S., 2008. Doctoral education in the context of international

development strategies. International Journal of Nursing Studies

45 (10), 1401–1402.

Lancet Editorial, 2006. Poaching nurses from the developing world.

Lancet 367, 1791.

McCourt, C., Page, L., 1996. Report on the Evaluation of the One-

To-One Midwifery Practice. Thames Valley University, London.

Maternity Care Working Party, 2007. Making normal birth a reality:

consensus statement from the Maternity Care Working Party.

National Childbirth Trust, London.

J. Cameron / International Journal of Nursing Studies 46 (2009) 288–290290

Morgan, M., Fenwick, N., McKenzie, C., 1998. Quality of mid-

wifery care: assessing for the effects of different models of

continuity for women’s satisfaction. Quality in Health Care 7,

77–82.

Northern Ireland Executive, 2008. Minister outlines services for new

Omagh hospital—news release 14 January 2008. http://

www.northernireland.gov.uk/news-dhssps-140108-minister-

outlines-services (accessed on September 29, 2008).

Turnbull, D., Holmes, A., Shields, N., et al., 1996. Randomised

controlled trial of the efficacy of midwife-managed care. Lancet

348, 213–218.

WHO/AFRO, 2008. Report of the consultative meeting on nursing

and midwifery education and practice in Africa. http://www.

afro.who.int/dsd/reports/consult_meeting_en.pdf (accessed on

September 29, 2008).