The Freud Museum

Events Archive

11 December 2004

Psychoanalysis and Midwifery

Organised by Kalu Singh (Freud Museum Friend) and Ivan Ward (Director of Education)

Conference Report

How useful is psychoanalytic knowledge outside the consulting room? One would imagine that this question need hardly be asked when one is talking to psychoanalysts and psychoanalytic psychotherapists. However, such has been the identification of the word 'psychoanalysis' with its 'therapeutic application' (as Freud sometimes called it), that we often forget the wider professional world which may be crying out for the knowledge and practical insights that psychoanalysis can provide. Comments on the conference evaluation sheets showed the truth of this: "Fabulous, thought provoking - I needed this..."; "A wonderful day, leaving me feeling excited and challenged"; "A fabulous re-energising day", "I feel as though by participating in the day I have valued myself as a midwife"; "Would encourage more psychoanalysts to contribute to midwifery journals and to provide input to midwifery training"; "This is the most important and valuable conference I have ever attended."

Suggested by long-time Friend of the museum, Kalu Singh, the conference was driven by a sense of shame at the state's undervaluing of midwives. Time and again throughout the day, speakers described the cultural shifts which marked the increasing medicalisation of pregnancy and birth, changing from a holistic approach encompasing psychological and 'spiritual' dimensions to a fragmented instrumental approach governed by a crude biologism (body-as-machine). Midwives are undervalued when birth becomes a bio-medical event rather than an interconnected process, and the psychological wellbeing of the mother-to-be is forgotten in the process. As Luke Zander put it in his chaiman's introduction, the medical model "measures the quality of maternity care by the yardstick of the cemetary".

In her exhilirating opening paper, Mavis Kirkham looked at the effect of these cultural shifts on the psychology of midwives working within the NHS (National Health Service). Midwives feel devalued, and this often expresses itself in tremendous amounts of fear, guilt and blame, and a lack of mutual support. The dominance of managers and bureaucrats, inventing "benign modes of mass manipulation" and for whom standardisation is sacred, means that many midwives are leaving the service because they do not want to be the homogenised "technological experts" that the NHS wants them to be. As one delegate suggested, it is as if the institutional stuctures embody the hostility and deep ambivalence men (and women) hold towards women's fecundity and creative power.

In the next paper, French obstetrician Michel Odent, famous for his advocacy of home birth, went back to the most basic physiological responses in order to show that all societies have disturbed the natural birth process through the transmission of 'beliefs and rituals' about labour. Not only external institutions but internal 'institutions' (of the superego) can sabotage basic mammalian processes. He argued that, like psychoanalysts, authentic midwives keep a 'low profile', and would often sit knitting in the room during labour, so he was delighted to learn of Anna Freud knitting during analytic sessions. During discussion of his paper he mentioned an intriguing rule of thumb about safety in cities across the world - the greater the rate of caesarian sections the more dangerous it is likely to be to walk around the city at night.

Using Freud's phrase 'the caesura of birth' in her title, Joan Raphael-Leff considered the fears and anxieties about pregnancy and birth which beset the midwife and mother-to-be, and the various defence mechanisms which are mobilised to cope with this. One defence is for institutions to depersonalise women and make them seem interchangeable, as Mavis Kirkham had shown. Another is to ritualise the process, as Michel Odent had described. Joan identified different types of ritual depending on how birth and women were conceived: women may be regarded as vulnerable, dangerous, obstructive, or (in ideal circumstances) as active participating agents. Joan's paper was a tour de force which included a dazzling array of images, deftly handled with the overhead projector, and theories extending across psychoanalysis, anthropology, social history and ethology. In an inspired piece of timing, the fourth edition of her book Psychological Processes of Childbearing was published the day before the conference.

If the morning sessions ranged widely across cultural history and the birth process in general, the first session in the afternoon focused on specific problems and cases. Pat Hughes gave a detailed account of her research into still birth trauma and the evidence to support different ways of handling it. Before 1976 the baby was removed from the mother and the parents were actively discouraged from seeing it. Then some psychoanalysts argued that this approach led to "unresolved mourning". The proposed solution was to create memories by encouraging contact with the dead infant. In 1985 the Royal College of Obstetricians and Gynaecologists adopted this approach, and it still stands today. Against her own expectations, Pat Hughes's research proved that contact with the stillborn did not improve outcomes for either the mother or later born children. In fact contact may be traumatic in itself, stimulating an illusory attachment and generating overwhelming guilt. Using her detailed research data she showed that changes in the protocols were driven by changes in cultural values, not evidence. Clearly her work has wider implications for psychoanalytic theories of psychic trauma.

Jessica James spoke next. As a parent-infant psychotherapist at the Anna Freud Centre she runs therapeutic groups for vulnerable mothers and babies and has attended many births as a doula (birth partner). Keeping psychoanalytic concepts in mind in her own work, Jessica argued that psychoanalytic thinking integrates all aspects of childbearing. She illustrated the point using, firstly, a short video clip of a mother and baby during a nappy change, and, secondly, a description of a typical exchange between midwife, mother and mother's partner during labour. Each person in the interaction has a different perspective, and the midwife, like the mother, tunes into the emotional needs of the other participants to guide the process by holding and containing anxiety, thus determining the capacity to manage. Mostly this is done unconsciously, but Jessica was arguing that awareness of the emotional substratum of these ordinary interactions would be immensely beneficial to the midwife's work. She introduced the concepts of "disruption and repair", "scaffolding", and "transference" to describe these subtle communicative processes.

The last paper of the day was titled "Discovering the psychological: A personal perspective". In an engaging powerpoint presentation Carol Bates interwove her personal journey of discovery into the broad sweep of recent cultural history from the 'benign paternalism' of the 1960s, through the 'baby-focused' approach of the 70s and the technological interventions of the 80s, to the 'public health' focus and concern with 'cost effectiveness' of today. In all this shifting cultural terrain, the importance of 'the psychological' has often been forgotten, yet now we find ourselves in the middle of an epidemic of caesarian sections and a population of women terrified of giving birth. Carol Bates argued that in the history of increased medicalisation, midwive's traditional skills have been downgraded and women's preferences have became irrelevant to policy formation. Her own experience of giving birth was crucial in her understanding of, and empathy with, expectant mothers. A long and passionate audience discussion followed Carol's paper, covering all aspects of the midwive's work.

For us, the organisers of the conference, the most gratifying element of the day was its tone : it seemed that our humility and respect towards midwives was graciously accepted. We felt a wave of emotion flowing from speaker to floor and back again, which seemed composed of pride, scholarly interest, polemical engagement and a call to external action. This felt utterly new in an arena that sometimes descends into nervous or complacent academic point-scoring. The speakers in their talks, and the delegates in their questions and comments and dreams clearly had a sense of their professional role, their group and civic responsibilities and their private persona. The last was most charmingly shown by a delegate recounting a dream about Prof Mavis Kirkham : and what more delicate honour for a teacher than to appear as a helper in their student’s dreams? That the telling was greeted by warm laughter and spontaneous applause showed a lovely and inspiring connectedness.



Speakers Biographies

Luke Zander is a founder member of the Royal Society of Medicine Forum on Maternity and the Newborn. For over 30 years, he was a general practitioner in an inner city practice in south London and Senior Lecturer in the Department of General Practice at St Thomas's Hospital Medical School. He has a special interest in the role of the general practitioner in maternity care and in furthering the integration of the hospital and community based services.

Mavis Kirkham is Professor of Midwifery at the University of Sheffield. Within WICH (Women's Informed Childbearing and Health Research Group), Mavis Kirkham is responsible for a number of research projects. These have included Informed Choice in Maternity Care (2001) and Why Do Midwives Leave (2002). This research was extended to include Midwifery Managers' Responses to Why Midwives Leave, published last year. Current research includes Why Do Midwives Stay and The Experiences of Midwife Returners.

Mavis is currently supervising a number of research projects on the childbearing experiences of groups of women who experience social exclusion and vulnerability. She is also undertaking a range of projects on peer support for breastfeeding. Mavis has done clinical midwifery and midwifery research since 1971. Her clinical commitments include regular shifts in a rural birth centre and booking a small number of women for home births in Sheffield each year. She has two daughters, one of whom is a midwife, and has had the honour of being the midwife booked to attend the birth of both of her grandchildren.

Recent books:
Kirkham M ed. (2003) Birth Centres: a social model for maternity care. Elsevier Science Ltd, Oxford.
Kirkham M ed. (2004) Informed Choice in Maternity Care. Palgrave, Basingstoke.

Michel Odent was born in France in 1930. He studied Medicine in Paris and was originally educated in the 1950s as a surgeon. In 1958-1959, during the independence war in Algeria, he was in the French army, practicing war surgery and civilian emergency surgery. It is via the caesarean section that he developed his interest for birth physiology and became an obstetrician. He is familiarly known as the obstetrician who introduced in a state general hospital - in the 1970s - the concepts of birthing pools and home-like birthing rooms.

After his hospital career he practiced home birth and founded the Primal Health Research Centre in London (UK), whose objective is to study the long term consequences of early experiences. The Primal Health Research data bank can be explored on the web (www.birthworks.org/primalhealth). He recently developed a preconceptional program (the 'accordion method') in order to minimize the effects of intrauterine and milk pollutions by synthetic fat soluble chemicals such as dioxins or PCBs.

He is the author of more than 50 papers in the medical literature (see Pubmed: Odent M) and of 12 books published in 21 languages. The Scientification of Love (revised edition 2001), The Farmer and the Obstetrician (July 2002), and The Caesarean (April 2004) are his latest published books.

Professor Joan Raphael-Leff is Head of the MSc in Psycho-analytic Developmental Psychology at the Anna Freud Centre and Visiting professor at the Centre for Psychoanalytic Studies, University of Essex. Over the past 30 years since qualification as a psychoanalyst she has specialised in the area of emotional problems of reproduction and has over 90 publications in this field, including 9 books -- one of which, 'Psychological Processes of Childbearing' is now in its new fourth edition.

Other publications include
Pregnancy - the inside story;
Split Milk - Perinatal Loss and Breakdown;
Parent-Infant psychodynamics - wild things, mirrors and ghosts;
"Transition to Motherhood" - Royal College of Midwive's learning resource;
Female Experience: three generations of British Women Psychoanalysts on work with women (edited with Rosine Perelberg)

Jessica James runs classes for expectant and new parents, through active birth yoga, couple preparation and post natal groups. She has attended many births as a doula and was a representative on Hackney maternity services liason committee for many years. She is a group analyst and parent-infant psychotherapist at the Anna Freud Centre and runs therapeutic groups for vulnerable mothers and babies at the centre and in the community.

Patricia Hughes graduated in medicine from the University of Glasgow 1970 and after experience as a junior doctor in obstetrics and medicine, trained in psychiatry in Glasgow and London. She qualified as a group analyst at the Institute of Group Analysis in 1985, and as a Psycho-analyst at the Institute of Psycho-analysis in 1992. She is now Reader in Psychiatry at St George's Hospital Medical School and Consultant Psychotherapist in SW London and St George's Mental Health Trust. Since 2002 she has been Dean for Undergraduate Medicine at St George's medical school. She has a strong interest in teaching medicine, psychiatry and psychotherapy, and her main recent research interest has been in the impact of stillbirth on families, and in the impact of this tragedy on attachment patterns in mothers and their children.

Carol Bates MA RM ADM PGCEA is the Education & Professional Development Advisor at the Royal College of Midwives. She qualified as a midwife in 1967. She has worked at the RCM since 1996 and prior to that was Director of Midwifery Education at University College Hospital, London. Carol led an innovative diploma course for qualified midwives at UCH that addressed the psychological processes of childbearing and integrated infant observation seminars into the curriculum led by the Tavistock Centre. Carol has produced open learning resources for midwives that focus upon midwifery clinical practice in normal labour and birth and care of the newborn. Her particular interest is exploring feminist thinking around all aspects of pregnancy, labour and birth. Carol is midwifery adviser to AIMH (UK). She has two grown up children and a Bassett Hound.

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