Along with these statements it is important to remember that we have the right to be treated with respect, express our feelings, to make mistakes, to change our minds, to ask for what we want, to say “I don’t understand” and to deal with others without being dependant on them for approval. According to Watson (1998) assertiveness is necessary in both verbal and non-verbal communication. It is apparent in our body language and the tone of our voices, therefore as midwives when we talk to clients in an assertive way it should be in a clear and positive way.
As a student it is sometimes difficult to be assertive surrounded by the great realms of power in which we train. However, as a professional we must possess the ability to be assertive. This assertiveness is often shown in the lecture halls of university’s when student midwives are referred to as “nurses” this non use of our proper title makes us assertive in ensuring that our separate identity is acknowledged by both tutors and student nurses alike. Our roles after all are that of “with woman” serving the needs of healthy, child bearing women, not the sick and dying. As midwives we have a duty of care to the women we look after therefore the care that we give should be supportive, spiritual, and assertive. Not in an aggressive or controlling way but as an advocate of her wishes. As an advocate the midwife can help her clients to persist assertively their attempts to gain the appropriate care and information, and when necessary to act on their behalf. (Bond:1986)
There is a need as a student midwife to develop communication and assertiveness skills. According to Watson (1998), a midwife uses an assertive approach to take full responsibility for her actions. In the labour room an assertive midwife can make a huge difference during labour. At this time many women are exhausted and in pain. The midwife will encourage the woman to change positions enabling her to move to a more physiological position, enabling a more effective delivery. On placement in a local birth centre I have witnessed first hand how the midwives encourage women through labour. Allowing these women to be assertive themselves by giving them the freedom to walk about freely, eating and drinking at will and actively supported at every angle. The women in their care are respected as individuals and can communicate with all the professionals. In the birth centre these women also enjoy informed choice, as everything is explained to them throughout each pregnancy. However, occasionally midwives can show an aggressive communication style when promoting the “Baby friendly Initiative” Women who have not expressed a preference to their feeding technique can be manipulated into breastfeeding her baby without really wanting to. This seems to be more apparent in young mothers who are not assertive enough in their wishes and will often go home early just to feel at ease with bottle feeding their baby. This means that as midwives we must be careful not to “over exert” our own preferences, leaving our clients to make informed choices of their own. However, many women have decided how they wish to feed their infant as soon as they know that they are pregnant, even before the first ante-natal visit. As midwives we should support them in these women in whatever method they choose. Emmons (2001:6) stated that assertive behaviour promotes equality in human relationships, enabling us to act in our own best interests, to stand up for ourselves without undue anxiety, to express honest feelings comfortably, to exercise personal rights without denying the rights of others. This enables us to respect the rights of others, something as midwives we should do with all the women we look after.
The growth of organisations such as the National Childbirth Trust (NCT) and the Association of Radical Midwives (AIMS) is evidence that child bearing women need midwives to have a voice and to be advocates for women within the maternity services. Bond (1992).
For many years pressure groups such as ARM (Association of Radical Midwives) have been active in bringing women’s needs and choices of care to the forefront of our minds. Their objectives are:
To share ideas, skills and information with colleagues and clients. To help midwives develop their role as advocates for women's active participation in maternity care. To support midwives in their efforts to provide continuity of care. To explore alternative patterns of care. To encourage the evaluation of developments within the sphere of midwifery practice. (ARM 2006)
As midwives we have a duty of care to these women. Legally and ethically midwives are responsible for their actions, The NMC (2004a) Code of Professional Conduct 1.3 states “You are personally accountable for your practice”. This means that you are answerable for your actions and omissions, regardless of advice or directions from another professional.” Therefore a professional must possess the ability to be assertive, for some women pregnancy can be a fulfilling experience. However, this “wonderful” experience can be shattered in a moment and leave lifelong consequences when things do not go according to plan. We must therefore remember that as part of our everyday practice the midwives’ Code of Conduct states that, ‘in all circumstances the safety and welfare of the mother and her baby must be of primary importance’.
There have unfortunately been cases where the midwife in charge has not shown these important qualities when looking after women. In many cases now within district hospitals midwives are not “standing up” for the women they are looking after. This has been documented in many ways by Kitzinger, S. (2006) who writes; midwives like epidurals, because they keep women quiet, immobile and safely tucked up in bed. When a woman presents with a birth plan it has been greeted with “you can swing from the chandeliers as far as I am concerned. A midwife stood over a pregnant woman who was in immense pain and laughed saying ‘ it’s a bit different from what you were doing nine months ago’ These comments are unacceptable and thankfully, only used by a minority of professionals. However, what is said to these women can have lasting effects on her emotionally and can even stop her from having another child. Many women feel vulnerable in pregnancy, labour and the postnatal period. Therefore a midwife must be prepared to challenge care that she feels inappropriate on the woman’s behalf to give her the confidence to ask the appropriate questions. A midwife must also act as the woman’s advocate when she is unable to stand up for herself. It is important however to remember different cultures when asserting oneself. In Asian culture a person prefers not to say no, therefore yes may mean ‘no’ or perhaps. Therefore it is essential to establish whilst in conversation that instructions and implications have been understood. (Sully & Dallas: 2005) Midwives therefore must recognise and support the spiritual needs of women.
LeMon (1990) stated that assertive communication is the key to managing conflict. Regardless of its nature, assertiveness is the only response that gives someone the opportunity to resolve conflict appropriately.
Midwives are in an ideal position to have face to face communication with child bearing women. This enables both the mother and the midwife to find out the information they both want. Midwives require effective communication skills as good communication can make a person feel valued and listened to. This improves understanding, reduces anxiety and improves understanding, which in turn helps clients to make their own choices. (RCM 2001) As we move away from the high induction rates of the 1970’s more women are choosing to give birth at home and in local birth centres. Women want continuity of care, choice in the care they are provided with and control over the process of childbirth. All over the world midwives have made changes to the way they work by their assertive behaviour. Across the world unlicensed midwives have achieved licensure. Midwives have the right to practice in New Zealand equal to their medical colleagues. Lay midwives in Ontario, Canada fought to make midwifery legally recognised and licensed. In Germany midwives fought obstetricians who wanted births to be performed by them with the midwife as an assistant. German midwives organised opposition to this and won. In Romania around 1978 midwifery was abolished by the Ceaucescu regime midwives lost their jobs and their training was withdrawn (Murphy-Black). It was from this point on that women were to enter into maternity units with very limited education and hygiene awareness. The introduction of a workshop for these women in 1992, the first time that they had met, was held under the direction of the World Health Organisation and UNICEF. The women were asked for their initial assessment on how and what could be done to once again make midwifery a strong and recognised profession. Their priority was to form an association of which meeting could be held to discuss the ways in which pressure could be brought upon the authorities so that midwifery could once again be recognised. They saw clearly a need to exercise the collective will to achieve their goals.(Jenkins : 1992)
This shows that as midwives there are many ways in which we need to be assertive. Campaigning for better jobs, rates of pay, new facilities and for us to be heard as a profession. What will happen if we just sit back and do nothing? What we campaign for reflects on the care provided to our clients and the care that we can provide. Using political channels to our advantage has seen rewards. After receiving evidence from women and the RCM the Select Committee on Health recommended a complete reappraisal of the maternity services. The Select Committee (1992) recommended :
That the status of midwives as professionals is acknowledged in their terms and conditions of employment which should be based on the presumption that they have a right to develop and audit their professional standards. That we should move as rapidly towards a situation in which midwives have their own caseload, and take full responsibility for the women who are under their care. That all midwives should be given the opportunity to establish and run midwife managed maternity units within and outside hospitals. That the right of midwives to admit women to the NHS hospitals should be made explicit. (Murphy-Black : 1995)
Although a Select Committee does not have the force of government, their recommendations were heard and some implemented. Thus another way in which midwives assertiveness can change things.
However, assertiveness can be used in an aggressive way, this is noticeable at all levels. LeMon wrote that “in each one of us is the animal instinct called “fight or flight”. This means that when we are frightened or threatened we have instinctive responses. An aggressive person is one that fights and shows aggressive behaviour that may include physically invading someone’s space or by bullying them. (LeMon: 1995) Bullying is something that midwives have to deal with on a daily basis. According to Keeling (2006) the number of reported incidents in the workplace appears to be increasing. A survey by the Royal College of Midwives discovered that 51% of respondents had been bullied by a more senior colleague, 41% by a midwifery manager and 21% by a supervisor of midwives. (RCM, 1996) In normal circumstances the first point of contact for a victim would be the supervisor of midwives. However the bully is frequently the victim’s manager or supervisor.
Clients can be bullied in the same way by professionals. The midwife that does not listen to a woman when she is telling her that she is the victim of domestic violence is as guilty as the person inflicting that violence. In the same way as the woman who wants a natural birth with little or no intervention, where will she be if as midwives we do not speak for her? The ideal is that every women’s birth experience is a positive one, regardless of whether it all goes the way she envisaged. Midwives that take the time to work with women to achieve their goal are the assertive midwives that we need to be. Being a midwife means “with woman” this role needs assertive advocates of women who will stand up for their rights and challenge professionals when they feel that things are not as they should be. There are also spiritual and ethical issues of assertiveness. In the context of midwifery we should acknowledge the relationship of the mind, body and spirit to the changes that take place within the woman during pregnancy. (Hall : 2005) The Changing Childbirth Report (1993) states that we should provide translation, interpreting and advocacy services based on an assessment of the needs of the local population.
So, if we are a little more assertive in a situation where we would have previously been submissive, aggressive or manipulative, then we as midwives will make a difference. If we can communicate our client’s views and wishes in an assertive not aggressive way then we as midwives can make a difference. And finally if we can achieve what women want, if it is important enough to us then all the hard work will be worth it.
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References
Barnard, P. (1992) “Developing Confidence”. Nursing Times 47 (4) 9-10
Bond, M. (1992) Assertiveness and the Midwife. London: Southbank Polytechnic.
Department of Health (1993) Changing Childbirth report. Part 1 report of the Expert Maternity Group. HMSO : London
Farrell, G.A. (2001) “From tall poppies to squashed weeds: why don’t nurses pull together more?” The Journal of Advanced Nursing 35 (1) 26-33
Hall, J. (2005) Midwifery, Mind & Spirit emerging issues of care Elsevier Ltd Oxford.
Jenkins, E R (1992) Report of a visit to Romania, prepared for the World health Organisation. Unpublished.
Keeling, J. (2006) “Bullying in the workplace, what it is and how to deal with it” The British Journal of Midwifery 14 (10) 616-621
Kitzinger, S. (2006) Birth Crisis London: Routledge 26-27
LeMon, J. (1995) Assertiveness: “Get what you want without being pushy” p36-37 National press publications: USA
Murphy-Black, T. (1995) Issues in Midwifery p 6-7 Churchill Livingstone : London
NMC (2004a) the NMC code of professional conduct, standards for conduct, performance and ethics. NMC, London.
Poroch, D. & McIntosh, W. (1995) “Barriers to assertive skills in nurses” Australian and New Zealand Journal of Mental Health Nursing. 4 113-123
Rakos, R. (1991) Assertive behaviour: Theory, Research and Training. London: Routledge
Royal College of Midwives (2001) The midwife’s role in public health. Position paper 24. London
RCM (1996) “In place of fear: Recognising and confronting the problem of bullying in Midwifery” British Journal of Midwifery 14 (10) 620-621
Sully P, & Dallas J. (2005) Essential Communication Skills for Nursing. London : Elsevier
Watson, M. (1998) “Assertiveness: an essential tool for the midwife” The Practising Midwife 1 (3) 30-32
