Midwifery Education: Trauma or Transformation?
Editor’s note: This article was first published in Paths to Becoming a Midwife: Getting an Education, 4th Edition, 2010. It was subsequently published in Midwifery Today Issue 96, Winter 2010/2011.
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In the early 1990s, two events prompted me to revise my goals as a midwifery educator. First, a prominent California midwife and dear friend who, after considerable legal harassment, felt forced to become a nurse-midwife, shared her bitter experience of retraining. She was so disheartened by the condescending tone and hazing practices of her primary instructors that she finally complained to the program director, who casually responded, “Why is it that midwives always eat their young?” The second event occurred during a workshop on birth and sexuality at a Midwifery Today conference in London. The instructor shared her concern that her sister, who had recently given birth in a London hospital, might never recover from the “brutality” of the midwife who attended her.
I have always maintained that the ultimate goal of midwifery education is to generate practitioners capable of being “with woman” in the truest, most egalitarian way. For me, it has meant creating curriculum that encourages students to discover and develop their unique capabilities, while simultaneously and candidly assessing their character liabilities and fears regarding the work. But in the last few years I have become increasingly aware that the impacts of trauma on the human psyche are both insidious and nearly universal at this point in time. Perhaps more so for women than for men: in the United States, 1.3 women are raped every minute. Examples of the exploitation and victimization of women are found in virtually every culture on the planet.
Stay with me, please. I know this topic is grim and unsettling. Because it is, we tend not to identify as trauma victims unless we have blatant evidence. Our media perpetuates this disconnect by systematically bombarding us with violent images laced with banal commentary. Our children play video games where thing after thing, person after person, is blown up—for fun and entertainment. In short, we have normalized trauma.
…in the last few years I have become increasingly aware that the impacts of trauma on the human psyche are both insidious and nearly universal at this point in time.
As a young midwife, I became increasingly aware of the “walking wounded” women who had suffered in childbirth with their stories untold. As I came across them by chance in the laundromat or in the supermarket line, I realized that a huge segment of society was hurting and unhealed, silenced and invalidated. Sharing the details of their births, they became very emotional and sometimes deeply agitated and upset. But it wasn’t until fairly recently, in the last decade or so, that I was able to label this behavior as posttraumatic stress disorder (PTSD), the same syndrome that soldiers suffer when they return from war and find no one who will listen or can understand what they have been through. I remember a meeting some years ago with Sheila Kitzinger during which we discussed women who had had unhappy birthing experiences and yet, because the baby was fine, felt they had no right to complain. I told Sheila there was a book in this, but I was not going to write it. She went on to do research on the topic and soon began a series of workshops titled, “Birth as Rape.” She found that women who had suffered trauma while birthing exhibited the same behaviors as women who had suffered violent sex crimes: loss of voice; loss of boundaries; loss of trust in primary relationships; unexpected and inappropriate outbursts; misplaced anger; chronic health problems; etc.
How many of us involved in midwifery had unhappy birth experiences that motivated us to do this work? How many of us who were movers and shakers in the renaissance of our practice experienced trauma in our primary relationships as we struggled to raise small children and keep our partners happy? How many of us, even with the best birth experiences, learned exactly how terrifying harassment or investigation at the hands of our local prosecutor can be? And how many of us, with all the above combined with the demands of political activism and being on call 24/7, experienced burnout to the point of breakdown? With this in mind, it’s not so difficult to see how midwives might, out of stress, exhaustion, resentment, anxiety—or in a word, trauma—more or less eat their young!
This is the dark underbelly of our movement, the shadow side of our own self-sabotage. To whatever extent our traumas are unaddressed, we are likely to be reactionary, volatile or sometimes the opposite of passive and prevaricating. I used to be perplexed by the rise and fall of independent midwifery in Europe, confounded by the advent of the “medwife” (e.g., that brutal midwife mentioned in the London workshop), but now I see this as a larger struggle of our holistic paradigm versus the technocratic paradigm of medicine, with a misguided and ultimately unsuccessful attempt at compromise.
In case you are not familiar with these paradigms, the technocratic model is based on the beliefs that the body is a machine, that disease comes from without, that standardized care is best because it minimizes the risk of the unexpected and that the practitioner knows best. It is a model based on control. The holistic model redefines the patient as client and decision-maker in the health care experience, the authority on her own health status, responsible for educating herself on her care options and carrying out daily self care, with health a manifestation of emotional, psychological and physical factors. It is a model based on education and empowerment. There is yet another model that falls between the two—the humanistic model, which would modify the tenets of the technocratic model by making practices more humane, by allowing a bit of extra time for care, by emphasizing bedside manner and concern for the patient’s feelings and needs. In practice, the humanistic model may be little more than a kinder, gentler technocracy, in that the practitioner gives care rather than empowering the woman to care for herself and is thus still in charge.
Another way to frame these differences is provided by authors Belenky, Clinchy, Goldberger and Tarule in their book, Women’s Ways of Knowing. In it, they define a “midwife approach” to teaching, in which:
“Midwife teachers assist in the emergence of consciousness. They encourage students to speak in their own active voices. The midwife teacher’s first concern is to preserve the student’s fragile, unborn thoughts, to see that they are born with their truths intact, that these truths do not turn into acceptable lies.”(1)
In contrast, the “banker approach” to teaching, as defined by Paolo Freire, describes the teacher’s role as that of filling students with deposits of information that the teacher considers important. Students are not called upon to know but to memorize information, often without context. The teacher composes her/his thoughts in private; students are not allowed to see the process of gestation. The student can risk criticizing the teacher, but the teacher takes few, if any risks, as her/his position is already decided. “Banking-teaching anesthetizes,” states Freire. “It attempts to maintain the submersion of consciousness.”(2)
Sadly, a number of midwifery education programs employ the banker approach more than the midwifery approach, using teaching methods that are technocratic (or humanistic at best). Programs that are truly holistic in content and approach are rare. In moderating countless education roundtables for Midwifery Today in both the US and Europe, student participants have made clear their frustration with education that discounts their knowledge and instincts, forcing them to ignore their physical and emotional well-being in order to complete their training. They end up feeling not only powerless but also unprepared to practice autonomously.
So what is a student to do? Best to investigate programs thoroughly before making a decision. Take a look at the curriculum—not only content but design. Are there learning activities that promote self-knowledge, personal growth and critical thinking—not just at the end of the course (when banker-style programs have their “integration”), but from day one? Is student feedback actively encouraged from beginning to end? I had an interesting conversation with a graduate of a school that offered a weekly support group for students, and I immediately wondered, support for what? As she shared her experience of instructors that were domineering and dismissive, it became clear that the group was more for damage control than for cultivating student growth and transformation.
Let’s focus on the aspect of transformation. For most students, this is a necessary component of preparing for midwifery work. On the first day of class I warn my students to not be surprised if, during their course of study, they feel compelled to make changes in their primary relationships, their current way of making a living or their style of communication—which can affect everything else. I also let them know that midwifery academics and skills are relatively easy to acquire compared to the realignment of one’s personal life that walking the path of the midwife requires. From the very first day they learn to be counsel to each other, to check in at the beginning of each meeting from the heart, in truth-telling mode versus talking-head processing, so the air may be cleared to focus on the work at hand.
Ultimately, this is important because when we midwives go to births we take two bags—one with our equipment, the other an invisible bag with unprocessed recent birth experiences including disappointments, unmet needs or expectations that could affect the birth we are about to attend. There is no way to be rid of this invisible bag—but we had better know what is in it if we want to provide care that is truly motherbaby centered.
Coming back to the theme of trauma: Apart from choosing an educational program unlikely to cultivate this, you can and should do whatever work you can to address previous traumas on your own. Keep in mind that abuse takes may forms—physical, sexual, emotional, gynecological and obstetrical (to name a few). In terms of healing, the process is more than thinking things through. Indeed, evidence suggests that as trauma typically forces us into a heightened state, we may need to reach a similar state to reprogram our beliefs and responses. Look for therapies that induce this state, such as Eye Movement Desensitization Reprogramming (EMDR), a form of psychotherapy that rapidly takes you into very deep meditation, allowing your emotions to flow freely while you observe and learn from them with relative detachment. With the right practitioner, hypnotherapy can render similar results. For more details on this, see my new book (co-authored with international doula trainer, Debra Pascali-Bonaro), Orgasmic Birth: Your Guide to a Safe, Satisfying and Pleasurable Birth Experience.(3)
Note that labor is also a heightened state in which imprinting and reprogramming can occur. Thus, if you have unidentified or unprocessed trauma, you are likely to be activated by birth, particularly if it becomes complicated. If you find yourself struggling with unpleasant feelings as you assist births or find yourself wanting to bring birth under control, you have work to do on trauma. Another sign is a pattern of behavior in relationships typical of trauma and abuse victims—the “Rescue Triangle,” in which we play roles of perpetrator, victim and rescuer, round and round in a circle.(4) If you find yourself in a situation like this, the only thing you can do is step out of it! In doing so, you clear the field to be fully present to whatever is happening in the moment, and the opportunities for growth and transformation fan out like the rainbow feathers of a peacock’s tail. Again, there is no shame in needing healing—in many indigenous cultures, you cannot be a healer without a major wound—but the key is to be aware of it as you surrender to the healing process.
What is this like? It is like being taken apart and put back together. It is the process of descent—the dark night of the soul. It is akin to transition in labor, when women feel they are dying. As a student midwife, be prepared to shed your skin, to transform into something you may not be able to envision in your ordinary mind. This is because birth is not ordinary, it is not “normal”—it is extraordinary, and in order to assist, you must come in contact (and come to terms) with this part of yourself.
In summary, the only midwifery education program worth its salt is one that “midwifes” you in a way that readies you to midwife the women you will serve. For all the time and money you will invest, this program should not only provide you with state-of-the-art midwifery knowledge and skill but also must:
- Support you in developing an awareness of your strengths and weaknesses.
- Encourage you to develop your unique style and voice.
- Support your process of becoming from the inside out.
When you choose a program that does these things, you are well on your way to practicing in a fashion that is not just autonomous but also sustainable. And you make a personal contribution to keeping true midwifery alive and well, not only in the US but also internationally. From Western Europe, where midwifery has been subsumed by medicine, to Eastern Europe, where midwifery is just emerging, midwives and mothers are counting on you to make the right choice. Midwifery is the ground whereby revolution in women’s leadership and the primacy of the family may be realized in our world. Don’t take your decision lightly! Every step in this direction counts.
- Belenky, M.F., et al. 1986. Women’s Ways of Knowing: The Development of Self, Voice, and Mind. New York: Basic Books. 218.
- Freire, P. 1971. Pedagogy of the Oppressed. New York: Seaview. 63–68.
- Davis, E., and D. Pascali-Bonaro. 2010. Orgasmic Birth: Your Guide to a Safe, Satisfying and Pleasurable Birth Experience. New York: Rodale Press. 116–19.
- Karpman, S. 1968. Fairy tales and script drama analysis. Transactional Analysis Bulletin 7(26): 39–43.