Is contemporary midwifery losing touch with reality?


Yesterday I wrote about recent research in midwifery that is either horrifying or horrifyingly stupid. It ranged from a paper on midwives’ clinical reasoning that concluded that a substantial proportion of midwives don’t use clinical reasoning, to a paper on midwives’ self-confidence that showed that it depended on the good opinion of their colleagues, not on objective outcomes, to a napalm grade stupid piece on midwives and knitting.

I noted that the papers cover disparate areas, but were united by the fact that the focus is not on patients and not on outcomes and that they are not quantitative, merely descriptive. Most importantly, they are not based on objective measures, but rather, on the midwives’ feelings about … themselves. In the world of philosophy, midwives would be described as devotees of metaphysical solipsism.

Wikipedia describes metaphysical solipsism as:

“the philosophical idea that only one’s own mind is sure to exist. As an epistemological position, solipsism holds that knowledge of anything outside one’s own mind is unsure; the external world and other minds cannot be known and might not exist outside the mind. As a metaphysical position, solipsism goes further to the conclusion that the world and other minds do not exist.”

In other words, the only thing that matters to many contemporary midwives, particularly midwifery theorists, is what they think and feel. They behave as if mothers and babies don’t have an independent existence. Their only purpose is as props for the midwife’s self-image. There is no objectivity, only the midwife’s subjective experience. To the extent that mothers and babies fail to follow the midwife’s plan to glorify herself or be lauded by her friends (by having a serious complication or dying), it’s always the patient’s fault or “meant to happen.” It is never the midwife’s responsibility since her only responsibility is to feel good about herself.

There is no objective reality, only the midwife’s feelings. Even the mother’s feelings are irrelevant since her mind and feelings don’t actually exist outside of the midwife’s mind. Baby dies? That doesn’t matter; all that matters is what the midwife thinks about the death. If she thinks it isn’t her fault, then it isn’t, because all that matters is what she thinks. Mother is dissatisfied by the midwife’s care? So what? She needs to adjust her thinking to comport with the midwife’s beliefs. There are no safety standards for homebirth midwifery? Who cares? Safety standards are predicated on an objective reality and contemporary midwifery is primarily concerned with the midwife’s subjective experience.

The authors of the paper on midwifery clinical reasoning implicitly acknowledge this focus when they report that their study was conducted using post structural, feminist methodology. What’s that?

Wikipedia comes to our rescue again.

A major theme of post-structuralism is instability in the human sciences, due to the complexity of humans themselves and the impossibility of fully escaping structures in order that we might study them…

The movement is closely related to postmodernism… Some commentators have criticized post-structuralism for being radically relativistic or nihilistic; others have objected to its extremity and linguistic complexity. Others see it as a threat to traditional values or professional scholarly standards.

Feminist post-structuralism:

emphasizes “the contingent and discursive nature of all identities”

Or as MJ Barrett writes:

Poststructural theorizing questions that which is assumed to be normal or common sense. Embedded within discourses of postmodernity, poststructural theorizing helps make visible the constitutive force of discourses and their relations with subjection and desire. It is a “mode of analysis [that] shifts attention from individualism to subjectivity, from text to discursive practices, and from signifier to signifying practices… Discourse and the ways in which it produces subjects, is a central focus of poststructural theorizing, and as such, so is an analysis of power.

What does this have to do with midwives’ clinical reasoning? Nothing, so far as I can tell, but it sounds really cool. Most importantly, it rationalizes turning the focus of midwifery away from what happens to women and babies toward midwives’ feelings. Hence we have midwifery papers like Including the nonrational is sensible midwifery written by one of the authors of the paper on midwifery clinical reasoning:

For example, when a woman and midwife have agreed to use expectant management of third stage, but bleeding begins unexpectedly, the expert midwife will respond with either or both rational and nonrational ways of thinking. Depending upon all the particularities of the situation the midwife may focus on supporting love between the woman and her baby; she may call the woman back to her body; and/or she may change to active management of third stage. It is sensible practice to respond to in-the-moment clinical situations in this way… Imposing a pre-agreed standard care protocol is irrational because protocols do not allow for optimal clinical decision-making which requires that we consider all relevant variables prior to making a decision. In our view all relevant variables include nonrational matters of soul and spirit.

Because it’s all about the midwife’s feelings:

Being open to the nonrational in midwifery practice makes room for midwives to self-reflexively acknowledge aspects of themselves, such as their fears, in a way that does not interfere with their practice. During birth, making room for the nonrational broadens both midwives’ and women’s knowledge about trust, courage and their own intuitive abilities including the changing capabilities of bodies. And by including the nonrational midwives can then most honestly be with the woman’s own fears as she opens her embodied self to her own unique process of childbearing.

What’s the problem with metaphysical solipsism?

It is often considered a bankrupt philosophy, or at best bizarre and unlikely… It also goes against the commonly observed tendency for sane adult humans in the western world to interpret the world as external and existing independently of themselves.

So midwives have adopted a bizarre and unlikely philosophical construct in order to rationalize their relentless insistence that the most important aspect of contemporary midwifery is the midwife’s feelings about herself. Not only are perinatal and maternal outcomes irrelevant, but babies and mothers have no existence independent of what midwives think about them. How very convenient!

Is contemporary midwifery losing touch with reality? It seems that way, especially when it comes to midwifery theory. It might be more accurate to say that contemporary midwifery refuses to acknowledge reality, which is that midwives have a fiduciary obligation to place the wellbeing of babies and mothers above their own interests. Instead they have a adopted a form of metaphysical solipsism, which places the midwives’ feelings and the midwives’ subjective experience, above all else.

Healthy babies and mothers are no longer the objective of many midwives; they’re merely the props in the midwife’s world, which is apparently the only world that counts.

The sad results is that it’s the midwives’ world. Babies and mothers just live (or die) in it.