This chapter focuses on the midwife as both a scholar and an academic. There are some shared assumptions about being an academic. These include academic freedom, the community of scholars, scrutiny of accepted wisdom, truth seeking, collegial governance, individual autonomy, and service to society through the production of knowledge, the transmission of culture, and education of the young. (1, p.76) These are the terms upon which the midwifery academic enters and contributes to the academy, and they provide a social mandate and a bias for exploration, discovery, independence, and service. They also highlight the obligation of the midwifery scholar to contribute both to the midwifery agenda and to the wider academic agenda. This chapter will explore the:
- Development of midwifery as a specialist branch of study
- Role of the midwifery scholar and academic in the development of midwifery knowledge
- Role of the midwifery academic in the academy
In pursuing these three themes, this chapter traces the developing concept of midwifery scholarship over recent decades and considers how this development has helped to shape midwifery as a profession, as a philosophy, and as a paradigm. It builds on the discussion in other chapters that explored educational aspects of the midwifery role (Chapter 10) and the midwife as educator (see Chapter 9), and shifts the focus to the midwife as researcher and knowledge broker, and the scientific and philosophical contribution of midwives to the academy and the wider policy and research agenda.
11.1 The Professionalization Agenda
Midwifery is as old as time itself, but its formal professionalization through regulatory recognition and status as a professional discipline varies from country to country. In some jurisdictions, (e.g. England, Netherlands), midwifery has been recognized as a distinct discipline and practice has been fully regulated for well over 100 years. In other countries (e.g. Canada, USA) regulation has only begun to be put in place in the late 20th century. In many countries, with and without regulation, lines remain blurred between the roles of midwives, family doctors, obstetricians, nurses, community health workers, and traditional birth attendants. (2)
Recent research has linked rapid and sustained improvements in maternal and newborn mortality and the quality of maternity care with the development of formal midwifery training, as well as motivated and respected licensed midwives who are integrated into the health system. (3) This finding emphasizes the need for robust education programs to prepare midwives for their role. In countries where midwifery practice has been established for some time, there has been a distinct movement towards professionalizing midwifery. This movement advocates for the recognition of midwifery as a distinct profession, as opposed to a discipline, and is heralded the proliferation of direct-entry education programs (without requiring entrants to be already qualified as nurses), the development of midwifery academic pathways including graduate entry to the profession, and the development of a midwifery research agenda. This movement is about reclaiming midwifery – regaining professional autonomy lost through domination of the profession by the medical and nursing professions – and gaining greater professional autonomy over practice as well as over the organization of work; all of which will enable midwives to provide women greater choice and control over their care. Sandall suggests ‘midwives are claiming a discrete sphere of knowledge and expertise, legitimated by a desire for a more equal partnership with women in an area where medical care has been criticized.’ (3, p.206)
In 2016, the International Confederation of Midwives (ICM) identified the three pillars of a strong midwifery profession as:
- Education to provide a highly competent, qualified workforce
- Regulation of the activities of the professionals
- Organization of the members in a strong association
To be recognized as a profession, any profession must:
- Define its role and how it relates to other professions
- Take responsibility for a prescribed body of knowledge – a substantive field of specialist knowledge, which professionals command and apply (5)
- Own the professional knowledge that creates and explains ‘the official accepted ‘facts’ about the social and physical world that form our consciousness’ (5, p.44)
- Regulate its membership, acting to uphold the profession’s reputation and standing, and protecting it from imposters
These four elements are considered to the hallmarks of being a profession. For midwifery, they infer a place for the midwife scholar within the academy as the custodian of midwifery as a particular branch of study, excelling at pursuits involving reading, thinking and studying midwifery, developing curricula, delivering higher learning relating to midwifery, and developing the midwifery knowledge base through research.
It can be argued that professionalization can be both enabling and controlling: enabling development of the role of the midwife as an autonomous practitioner with a specific remit; controlling: protecting the public from substandard practice It is also argued that midwifery is both an art and a science. The art of midwifery refers to the attitudes and actions based on recognition of the intrinsic dignity of the human person, compassionate concern for the human person, and the creative use of the science of midwifery in service to women and babies. The science of midwifery relates to having an organized body of midwifery knowledge developed through scientific research and logical analysis. (7)
Did You Know?
Robbie Davis-Floyd is a medical and cultural anthropologist and Senior Research Fellow at the University of Texas, Austin. She is an acclaimed expert on childbirth and midwifery with a special interest in birth and training of obstetricians and midwives. She highlights the importance of the science of midwifery in her concept of the ‘post-modern midwife’ as one who is ‘scientifically informed’ and can draw from both the biomedical system and her ‘own folk system,’ knowing the limitations of both. (7, p.707)
You can read more about her work here: http://www.davis-floyd.com/
11.2 Boyer’s Model of Scholarship
Reflecting this dyad of art and science, Boyer’s (1997) model of scholarship identifies four types of scholarship, which if applied to midwifery move beyond teaching and research to a broader role involving the synthesis, integration and application of midwifery science. (9) Boyer’s model examines the scholarship of discovery, of integration, of application, and of teaching, and is used here to frame the discussion of midwifery scholarship.
11.2.1 The Scholarship of Discovery
Discovery most closely relates to the research role. A commitment to use robust methods to systematically follow an investigation to wherever it may lead contributes to knowledge development and furthers the intellectual climate of the academy.
In understanding the knowledge underpinnings of midwifery practice, it is vital to distinguish between ‘unsubstantiated prejudice and reliable knowledge.’ (10) It is research evidence that informs midwifery practice, expanding knowledge about appropriate practices to make childbearing safe and fulfilling and allowing continuous improvement to be made in the provision of skilled, sensitive care for women and babies. (11) For educators, conducting research is important to remaining current in teaching and clinical practice and in contributing to the body of professional knowledge. Participating in research and disseminating research results strengthens the midwifery profession and ensures the use of up-to-date curricula and teaching methods. (12) Luyben (2009) suggests the aim of midwifery research is to create a body of knowledge that underpins and improves midwifery practice and maternity care. Further, she advocates that achieving this aim involves maintaining focus on woman-centred care; the effectiveness and quality of maternity care; the multiple aspects (physiological, social and psychological) of the childbearing process and the impact of maternity care on these; the options available to women for maternity care; evidence-based practice and standards for maternity care; and developing a vision and sound basis for midwifery practice. (13) The ICM, in both its International Code of Ethics for Midwives (14) and in its position statement on the Role of Midwives in Research (15), emphasizes the importance of midwives employing up-to-date evidence in their practice to ensure safe birthing practices in all environments and cultures, and midwives being responsible for developing midwifery knowledge in order to improve the health of women and their babies. The ICM proposes that midwives should have a role in developing and sharing midwifery knowledge through various processes including peer review and research.
How can midwives in clinical practice help advance the scholarly study of midwifery?
Across countries, midwives have only been conducting research in the last 30 years. Until as recently as the second half of the 20th Century, in most circumstances, midwifery knowledge was passed down from midwife to midwife and little was documented or recorded as written knowledge. As a result, midwifery knowledge was based largely on tradition, intuition, authority and research generated within other disciplines. (13) Dr. Ans Luyben traces the development of midwifery research beginning with a statement by the World Health Organization (WHO 1987) that midwives should study the work of midwives and together with scientists, develop a body of explicit midwifery knowledge and raise a group of midwifery researchers. She traces the emergence of midwifery researchers in the USA, who focused largely on the effective provision of midwifery care, to midwives in the UK using research to challenge the issues they faced every day in practice, and later influencing and supporting midwives in other European countries to become research active. She also examines the ways in which the role of the midwife as researcher has been supported across countries, including the introduction of midwife researcher positions and the development of national professional guidelines reinforcing research as a part of the role of the midwife.
In the UK, up until the 1980s most of the research in relation to maternity care was conducted by obstetricians and dominated by the medical model of care. Research conducted by social scientists such as Sheila Kitzinger, Ann Oakley, and Marjorie Tew in the 1970s however, provided the foundation for the broad base of midwifery research today by shifting the focus to women’s and parents’ experiences of birth, becoming a mother, and challenging assumptions about the safety of birth in non-hospital settings (Clark, 2000). This was followed by early studies by midwives that challenged routine midwifery practices such as perineal shaving and enemas (Romney, 1980 and Romney and Gordon, 1981), the liberal use of episiotomy (Sleep, 1984).
Did You Know?
In the UK until the 1980s, most of the research in relation to maternity care was conducted by obstetricians and was dominated by the medical model of care. In contrast, research conducted in the 1970s by social scientists, such as Sheila Kitzinger, Ann Oakley, and Marjorie Tew, provided the foundation for the broad base of today’s midwifery research by shifting the focus to women’s and parents’ experiences of birth, becoming a mother/parent, and challenging assumptions about the safety of birth in non-hospital settings. (10,16) This was followed by early studies by midwives that challenged what were at the time routine midwifery practices such as perineal shaving (17) and enemas (18) and the liberal use of episiotomy. (19)
Traditionally, midwives became involved in research and sought research training on an ad hoc basis (13) and the only graduate programs (masters and doctoral programs) available to midwives were in the sciences, social sciences, nursing or management domains. However, over the last 20 years and beginning in the UK and Europe, there has been an encouraging growth of graduate programs specifically aimed at midwives. The value of these programs exists not only in their focus on issues of particular relevance to midwifery and its professionalization, but also in their ability to draw in candidates with considerable experience and understanding of the field. Training midwives in research methodology and in evaluating research evidence enables midwives with academic training to question and make conclusions about the strengths and weaknesses of clinical practices in obstetrics. (20) Addressing issues through research and international debate helps to consolidate an international community of midwifery scholars. The development of a midwifery research agenda and the legitimization of research as a part of the midwife’s role brings areas that most in need of research into focus in order to build research capacity. Further development is required to ensure midwives are included: in clinical scholar programs, such as those that are already available to other healthcare professionals through for example the Health Research Board in Ireland, or the Canadian Institutes of Health Research in Canada; in research training positions (e.g. PhD studentships) in grant funding programs; and as in midwifery scholars in early career research training (e.g. post-doctoral) programs.
A notable development that occurred first in the UK was institutional support and the positive impact it had on the growth of maternity care and midwifery research. Clark identifies the establishment of the National Perinatal Epidemiology Unit (NPEU) in Oxford in 1978 as being instrumental in developing research and research capacity in midwifery in the UK. (10) The NPEU was responsible for the establishment of the national Midwifery Research Initiative (MRI) in 1988. Led by Mary Renfrew, it was the first major grant funded midwifery research program to be headed by a midwife. Through close collaborations with clinical colleagues and maternity service users, the provision of support for novice researchers, dispersion of expertise, and generation of networks within the maternity care system, the MRI was instrumental in establishing a solid foundation for midwifery research. During the 1980s the NPEU supported midwives undertaking research, while the MRI offered a more visible focus for midwives thinking about undertaking research. (10)
Did You Know?
Mary Renfrew is presently Professor of Mother and Infant Health in the University of Dundee, where she is also Director of the Mother and Infant Research Unit. An early pioneer of the role of midwife as scholar, Mary has worked internationally universities and hospitals in Oxford, Leeds and York, UK and Alberta, Canada. In 1996, she founded the multidisciplinary Mother and Infant Research Unit (MIRU) at the University of Dundee, with the aim to improve the health and care of childbearing, women, their babies and families, addressing inequalities in health. The research conducted at MIRU has informed policy and practice in infant feeding and maternity care, both nationally and internationally. Renfrew is the author of our Chapter 3: Midwifery Matters.
Acknowledging that although not all midwives can or should be researchers, Lavender identifies a number of ways in which all midwives can and should be involved in strengthening midwifery knowledge and practice. (21) These include:
- Providing support for midwives to audit their own practice and contributing to audits of their own organizations
- Accessing and making sense of the evidence and using it appropriately in their practice
- Challenging practice and guidelines when the evidence is weak
- Considering the strength of the evidence when advocating for women who express a preference for alternative practice options
- Providing a midwifery perspective on the priorities for research
- Engaging in local and national research networks
- Being thoughtful users of evidence
Midwifery academics can and should support midwives to engage in this way and should assist midwives interested in doing research to navigate the roadblocks involved, such as getting access to scarce funding, identifying collaborators, accessing sites, recruiting participants, and having appropriate research capacity. (22)
11.2.2 The Scholarship of Integration
Integration gives meaning to isolated facts and puts them in perspective. This is done by interpreting findings, drawing together one’s own research and that of other researchers, and bringing new insight to original research. According to Boyer it is ‘through this ‘connectedness’ that research ultimately is made authentic.’ (9, p.19) Integration is sometimes referred to as synthesizing. It can be argued that Boyer’s scholarship of integration needs to be extended to include how scholars provide leadership and strategic direction, collective reflection and critique, and in the case of midwifery promote the midwifery agenda through publication and scholarly writing. Mander refers to the three ‘R’s of midwifery scholarship – each of which is founded on requirement that midwifery scholars are also engaged in clinical practice. 1) Research – clinical practice enables the academic midwife to stay involved with grass roots clinical activity and ideas. (2) (w)Riting – clinical practice triggers ideas for publication, particularly around topics that need to be discussed but are too early for research. 3) Reality – universities are criticized for being ‘ivory towers’, but practice enables the academic midwife to keep her feet well and truly on the ground. (23)
Much of the research that informs the midwifery curriculum and midwifery has been conducted by other disciplines and may lack the scope and particular midwifery focus that it could have if midwives were involved in the research. Luyben (2009) suggests research conducted by midwives has a particular focus on midwives’ ways of working and in particular aims to improve midwifery practice. She cites Cluett and Bluff’s observation that one of midwifery research’s strength is the rich diversity of research methods, and suggests that this diversity allows midwifery researchers to go beyond medical questions to several other aspects of midwifery practice. (13)
Lavender (2010) exposes the lack of evidence available to support midwives, to inform maternity policy, and to support women to make decisions. Further, she suggests that many policy decisions are based on expert opinion rather than research evidence, due to the absence of research evidence. Lavender asserts that midwives do not generally appreciate this this lack of evidence. (21)
In addition, midwives tend to use social research methods rather than large-scale randomized control trials or population-based studies. While social research methods answer the types of research questions that midwives are concerned with, other stakeholders or policy-makers may not value such approaches as sources of evidence for practice. McVane Phipps (2010) suggests that large population-based studies are not suitable to answer questions about pregnancy and birth, as they are not congruent with a humanistic midwifery paradigm that places the pregnant woman at the centre of care, and the midwife working with the woman to make choices that are relevant to her own circumstances and belief system, the notion of not providing interventions in practice. Lavender (2010) suggests the parameters for what is considered to be evidence (empirical studies drawing on positivist research methods) may be difficult or pose ethical challenges to implement in midwifery contexts and may not adequately capture the social context of midwifery phenomena.
Did You Know?
There are three paradigms of health care, each of which casts influence on childbirth from their differing ways of defining the body and its relationship to the mind.
The three models are: the technocratic, which considers the mind and body to be separate and views the body as a machine; the humanistic model, which emphasizes a connection between the mind and body and views the body as an organism; and the holistic model, which insists the body, mind, and spirit are one and views the body as an energy field that interacts with other energy fields. (24)
Studies of this type often do not provide insight into the experiences of individuals and the humanistic perspective, or may prove to be challenging from an ethical or logistics perspective, but population-based or trial studies are generally accepted as the most valid approaches to determining population needs and outcomes, or the effectiveness of interventions. Rather than leaving these types of research to others, midwives need to engage in all types of research to answer the range of questions that are relevant to midwifery. In doing so, midwives will capture the midwifery perspective, particularly when it comes to interpreting the findings. For example, two recent studies in North America examined birth outcomes for planned out-of-hospital births in comparison to planned hospital births. One study conducted by Dr. Eileen Hutton and colleagues in Ontario (25) concluded that planned home birth attended by midwives in a jurisdiction where home birth is well-integrated into the health care system was not associated with a difference in serious adverse neonatal outcomes and was associated with fewer intrapartum interventions. These findings suggest planned homebirth is as safe as planned hospital birth. A similar study conducted by Jonathan Snowden and colleagues in Oregon (26) concluded that planned out-of-hospital birth was associated with higher perinatal mortality. Taken at face value, these findings suggest home birth is not as safe as hospital birth. However, if the findings are examined in more detail, issues arise that explain the difference in findings and that bring a more accurate interpretation of the safety of home birth provided by midwives who are properly integrated into the system. (27) On examining the findings, Hutton found that compared to the Ontario home birth population, the Oregon study included women birthing at home who should have been considered high risk, who had lower transfer rates to hospital during labour and who used a variety of regulated and non-regulated care providers for home care. She concluded that care providers in Oregon were likely not well integrated into the health care system, meaning they may not have had access to referral and other supports for women in labour. This example highlights the need for midwives to undertake their own research. If midwives are not involved in doing research, they cannot be sure that others are asking the right questions or coming to midwifery-sensitive conclusions that will provide the best information for care of clients.
In Canada, basic research training is included in the undergraduate midwifery curriculum, to ensure that graduating midwives can use research methods to identify the needs and preferences of their clients, and evaluate their own practice in terms of its effectiveness and how well it meets the client’s needs. Chapter 13: Midwife as Researcher, written by Hutton, contains more information about the importance of research in midwifery.
In 2016, Eileen Hutton was the second annual Elaine Carty Visiting Scholar at the University of British Columbia, and gave a public lecture which can be opened from the following link: http://midwifery.ubc.ca/2016/03/01/2016-dr-eileen-hutton/
11.2.3 The Scholarship of Application
Academia serves the interest of the wider community by applying knowledge to problems and to individuals and institutions, and to using problems to define the agenda for scholarly investigation. This can be interpreted as midwifery research promoting and supporting evidence-informed practice and also as ensuring research is clinically relevant.
The concept of evidence-informed practice is a more recent iteration of evidence-based practice (see Chapter 12: Evidence-informed Midwifery for more), and recognizes the importance of professional judgement, individual and contextual factors, experiential knowledge combined with research-based evidence for effective and individualized practice. It also recognizes that very often in medicine generally, evidence is lacking. McVane Phipps emphasizes the need to consider all forms of knowledge, stating that rigid adherence to research as the only method to develop midwifery knowledge ‘discredits the vast store of wisdom passed down through all the ages of human existence that enabled women to give birth safely.’ (28, p.87) She suggests the true function of midwifery research is to verify or discredit beliefs about the benefits of intuitive and experiential knowledge and to question the ritualistic use of interventions that appear to interfere with the natural processes of pregnancy, labour and birth. Spiby and Munro recommend that midwives engage further and contribute to the guideline development process to bring the midwifery perspective to their development and to challenge guidelines that are not fit for purpose. (29)
Did You Know?
Midwifery organizations are increasingly involved in producing guidelines for practice. For example, since 1999 in Ontario, Canada, the Association of Ontario Midwives has produced evidence-based clinical practice guidelines (often shortened to CPGs). The value of having midwifery specific guidelines are that they are written to reflect midwifery values such as informed client choice and they can address topics that may be less relevant to other health care providers (and therefore less likely to exist) such as care of clients choosing out of hospital birth. The CPGs are available online here:
Spiby and Munro point out a potential challenge to autonomy and clinical decision-making as a result of the evidence-based movement. (29) One the one hand, the rapid growth in the development of evidence-based clinical guidelines and practice standards by organizations such as the National Institute for Health and Clinical Excellence (NICE) in the UK, use methods that synthesize the evidence to a level that would be impossible for most practitioners. While these pre-synthesized resources facilitate discussion between midwives and clients, Spiby and Munro suggest this approach could relegate midwives to a passive role of following pre-set guidelines, and at the risk of losing some of the critical skills that are honed through the stages of the evidence-informed cycle (formulating research questions, searching for and appraising the evidence to inform clinical practice, utilization, and evaluation). (29) Taking a passive role may lead midwives to have a less critical approach to practice in general and impact on the practice of individuals in areas that would benefit from empirical enquiry. They also claim that clients will continue to seek out evidence despite the availability of guidelines or where guidelines do not yet exist, and further, that regardless of the availability of guidelines, midwives should still be able to discuss the evidence with their clients from the context of their situation and needs.
Lavender draws attention to the growing consumer engagement with evidence in maternity care settings in the UK, largely driven by midwifery client’s dissatisfaction with the care provided and their awareness that interventions are being used without adequate evaluation and without taking their views and experiences of clients into account. (21) A similar pattern has been seen in other countries and it can be argued that comparable consumer involvement and lobbying was critical to the establishment of midwifery in British Columbia, Ontario and other provinces in Canada. Interest of clients in the evidence raises the imperative for midwives to be capable of discussing both the evidence and its resulting recommendations with their clients. An ability to discuss the evidence is a crucial aspect of the informed choice pillar of the midwifery model of care in Canada. The midwifery academic can contribute to evidence-informed midwifery practice both by promoting and disseminating the evidence for practice, helping to interpret and apply the evidence, and by generating evidence to contribute to the body of midwifery of knowledge.
There is a need for midwifery scholars and academics to promote evidence-informed practice and to build capacity amongst students and midwives to evaluate research, so that they have the skills to understand, interpret and apply new knowledge. Simply knowing the evidence is not a guarantee that midwives will adopt an evidence-informed approach to practice. Lavender draws attention to significant variations in how midwives use evidence in practice, with some but not all variations emanating from lack of knowledge of the evidence. (21) Some midwives may choose not to depart from traditional approaches to practice despite evidence to support a departure, or be reluctant to use the evidence in practice unless pressured to do so by peers or organizational protocols. They may also use the evidence only when it justifies their actions or supports their personal beliefs or purposes, or not adopt evidence-based practice because of contrary, negative personal experiences. The academic midwife has an active role to play in both knowledge creation and knowledge translation thus ensuring that clients have access to the best available and balanced information on which to base their care.
11.2.4 Supporting Clinically Relevant Research
A second aspect of the scholarship of application relates to identifying priorities for research based on problems or issues arising from clinical practice. Academic midwifery departments may feel under pressure to pursue broad scope, large scale, grant-funded projects rather than smaller, narrow scope studies that more closely align with specific issues midwives see regularly in practice, or with the humanistic or holistic approaches to practice. (28) However, whether research is conducted on a large scale or in local small-scale studies, the results it generates must have an impact and be relevant to those who will use the findings. In planning studies midwifery scholars and academics must therefore work closely with midwives in practice and consult with clients when generating strategic research priorities.
Think of three midwifery interventions that you commonly see used in labour.
- What do you know about the effectiveness of these interventions? What, if any, alternatives are there to these interventions? What does the evidence say regarding the intervention and it’s alternatives?
- What do the guidelines say about these interventions? How are they supported or not supported by evidence?
- What type of evidence is available? How adequate is the evidence? Are there any gaps in the evidence?
11.2.5 The Scholarship of Teaching
The scholarship of teaching includes educating and enticing future scholars. In his discussion of this aspect, Boyer emphasizes the importance of the educator having extensive knowledge, creating a common ground of intellectual commitment, stimulating active learning, encouraging students to be critical, creative thinkers and life-long learners, and educators also being learners. (9) Educators must do more than simply transmit knowledge; they must be part of transforming and extending it as well.
To use evidence to inform practice, midwives must be able to access that evidence, make sense of it through effective critique and interpretation of findings, and reconcile evidence with the knowledge they have gleaned from their own experiences. (21) As noted earlier, Lavender (21) found significant variations in how midwives use evidence in practice, with some but not all of the variation emanating from lack of knowledge about the evidence. Lavender observed that even when they have the knowledge, midwives may:
- Choose not to depart from the traditional approaches to practice despite the evidence to the contrary
- Be reluctant to use the evidence in practice unless they are pressured to do so by their peers or organizational protocols
- Use the evidence only when it justifies their actions or supports their own personal beliefs or purposes
- Not adopt evidence-based practice because of contrary negative personal experiences
Therefore, having the skills to interpret and apply the evidence and knowledge of the evidence is not a guarantee that midwives will adopt an evidence-informed approach to practice. This suggests an important role for the midwifery scholar in promoting evidence-informed midwifery as a leader and change agent – beyond individual student cohorts.
Midwifery academics must support midwives to develop the knowledge and skills to become thoughtful users of research findings, beginning in the undergraduate curriculum, where students must be introduced early to the importance of evidence-informed practice and learn the skills to find and interpret evidence. The curriculum should follow through by building skills in knowledge acquisition, focused on the latest evidence and enabling students to become midwives who can provide evidence based information for clients, can choose the appropriate, evidence-informed course of action for each client as an individual, and who can also appreciate where the evidence is lacking. (21) In Canada, basic research training is included in the undergraduate midwifery curriculum, aimed at ensuring graduating midwives can use research methods to identify the needs and preferences of their clients, and to evaluate the effectiveness of their own practice and how well it meets the needs of each client.
In Canada, the majority of midwifery academics are active in clinical practice, which is considered vital to maintain their clinical credibility. In addition, emphasis is placed on midwifery academics ensuring that their teaching is informed by their own research and the two are interdependent, that is, teaching emerges as a result of one’s own and others’ research and questions that arise from teaching and practice feed into and stimulate their research. The challenge is to not neglect the crucial role that clinical practice plays in the life of the academic midwife. (23)
11.3 Midwifery Scholarly Work
The recent publication of the Lancet series on midwifery is an example of midwifery scholars working collaboratively to set the agenda for quality maternity care and to begin a discussion about the contribution of midwifery to improving perinatal outcomes. (3) Another example is the remarkable publication by midwifery scholars in Canada, Reconceiving Midwifery, stimulated national and international discussion about the status of midwifery in Canada, the achievements made to date and the remaining challenges. (30) It traces the history and politics involved in the establishment of midwifery in Canada, the development of midwifery education, and access to midwifery, including unregulated midwifery, before defining the challenges and opportunities remaining for midwifery in Canada. Similar publications and position pieces by scholars such as, Bourgeault’s Push! The Struggle for Midwifery in Ontario (31), the Atlantic Centre of Excellence for Women’s Health Prairie Women’s Health Centre of Excellence’s Proceedings from the Midwifery Way Forum (32), added to the debate that generated some shared understandings about the priorities for midwifery in Canada.
Midwifery scholars must challenge the practice of midwifery, ensure that the values of midwifery are not lost over time, and support midwives to embrace the principles of midwifery. Citing examples such as, antenatal diagnostic tests, the systematic use of electronic fetal monitoring on admission and during labour, the use of the term low risk, restriction of food in labour, Mead suggests midwives have been guilty of offering clients many practices and technologies without sound evidence, and ‘even when evidence demonstrated that the argument put forward was potentially flawed.’ (33, p.140) Mead suggests that midwives struggle to uphold the principles enshrined in midwifery of woman-centred care and that midwives are the guardians of normal birth and submits that these principles are introduced from the beginning on midwifery education programs but before very long, students realize ‘the gap between the theory and practice, and the common adoption of practices that are not based on evidence and not recommended by international authorities.’ (33, p.141) This suggests midwife educators and scholars have an important role in interrogating midwifery practice with students and practising midwives.
Within the wider academy, the midwifery scholar represents midwifery and promulgates midwifery priorities. Midwifery scholars provide the expert view on normal pregnancy and birth, which they use to influence thinking amongst other disciplines and amongst policy makers. They draw on the evidence, or generate evidence where none exists, to demonstrate value of midwifery care for women, their families and society. They identify emerging midwifery concerns and generate insight into the experiences of those concerned. They synthesize the required literature to illustrate the current state of knowledge and thinking across countries on issues of importance. They provide periodic reflections on the current state of midwifery and maternity care, and make recommendations for next steps.
11.4 Future Directions for Midwifery Scholarship
Midwifery is a relatively new academic discipline and as such midwives are commonly new to research. Although the number of midwives conducting research is increasing, midwifery research capacity remains uneven both within and between countries, with some areas and/or countries having considerable capacity and others very little. European initiatives, such as the EU COST (Cooperation in Science and Technology) and European Research Framework programs (currently FP8), promote collaboration between partners in different countries and across professional disciplines, thereby helping to share expertise and generate greater coherence in the focus of research. The foundation of these initiatives is collaboration, cooperation and networking.
There has been substantial growth in midwifery research networks and networking in recent years. Luyben advocates that it is almost impossible to carry out research without a supporting network with access to experts for counselling, as well as statistical and computer support. (13) Networking and conferencing are ways in which midwifery researchers share their results, seek feedback on their work and generate further collaborations.
Recognizing the value of collaborative networks and emphasizing the importance of research as ‘the foundation of midwifery’s Three Pillars and ongoing education and research as the lifeblood of any vibrant profession,’ (p.1) the ICM established the Research Standing Committee (RSC) and the Research Advisory Network (RAN). (34) The RSC provides strategic leadership in relation to research and together with the RAN aims to provide member associations across countries with up-to-date information on all aspects of midwifery practice, education and service. The RAN comprises members from many countries and aims to facilitate research collaboration among members and provide expertise and advice to the ICM and the RSC on research issues. The RSC recently conducted an international survey (using the RAN) to identify global midwifery research priorities. (35)
Midwifery scholars can look to the international community research agenda through the initiative of the ICM. To encourage involvement of all midwives, not just those presently in the research community, the ICM established a midwifery discussion list ‘to provide an open forum for discussion on issues relating to research on midwifery and reproductive health…to create an international network of people who are eager to share information (e.g. workshops, seminars, conferences and new research) and to promote links, collaborative working, joint problem-solving and mutual support.’ (36, p.1)
Research networks may also take the form of communities of practice. For example, the British Columbia Midwifery Network, which launched in October 2014, is a collaborative initiative aimed at linking midwifery academics, midwives, students and researchers across British Columbia who are working in the area of midwifery and perinatal care, in order to build research capacity and a program of research around clinically relevant areas. (37) The initiative aims to support midwives to engage with research and to support them in that process.
11.5 Challenges for the Midwife as Scholar/Academic
This chapter has emphasized the importance of midwifery scholarship and the integration of midwifery scholars to the academy. However, attracting midwives from clinical practice to full-time academic positions has proved difficult. In the UK, Mander has proposed that, due to the nature of midwifery as a practice-based discipline, there is often a mutual lack of understanding by midwives about the nature of the academic role and by academics of the midwifery role. This is in part believed to be because each party may have limited experience of the other. (23) However, in some jurisdictions like Canada, midwifery academics are expected to be active in clinical practice and, very often, midwives in full-time clinical practice are involved as clinical educators or as part-time or sessional instructors in midwifery education programs. The Canadian scenario poses its own set of challenges in terms of workload and reconciling scheduled teaching duties with 24/7 on-call commitments. Nonetheless, the Canadian context does not include the concern found in other countries regarding the clinical credibility of midwifery educators (38) or the theory-practice gap. (39) For the midwifery academic, meeting the requirements of a full-time academic appointment and the clinical requirements to remain on the midwifery register includes can be a challenging.
Academic appointments may not be attractive to midwives due to the use of short-term contracts, salaries for academic and research positions that are not commensurate with clinical positions, or the academic appointment and promotion process that is traditionally aimed at recent graduates rather than professionals with commitments who are already well established on a career track.
This chapter explored the role of the midwifery scholar and academic and makes the case for the pivotal role of scholarship to the development of midwifery and its recognition as a profession. Four types of scholarship were identified that relate to: doing research, integrating research, supporting and promoting the application of research (evidence) to practice, and teaching. While acknowledging that midwifery is relatively young as an academic discipline and as such has relied heavily on research produced by scholars from other disciplines, this chapter presented the importance of shifting midwifery scholarship to centre-stage to capture midwifery nuances, to ask the types of questions that midwives would ask, and to use study methods that capture the essence of midwifery. This chapter called on midwives to be more involved as scholars and academics, to lead on all aspects of midwifery scholarship, and to focus research on issues that can make a difference to midwifery practice, clients and society. Finally, this chapter highlighted the potential for the midwifery scholar/academic to promote the interests of midwifery and of clients and their families within the academy and amongst policy makers through scholarly debate and publication.
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