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- Herausgeber: John Wiley & Sons
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- Sprache: Englisch
A practical, evidence-based approach to psychological and professional well-being for midwives
Midwifery is an essential profession with a life-saving role in perinatal care. However, studies show that midwives experience remarkably high levels of work-related psychological distress, leading to equally high levels of attrition from the profession. If these issues are not addressed, the loss of qualified midwives may seriously impact the profession’s ability to fight perinatal and infant mortality worldwide.
Surviving and Thriving in Midwifery offers a practical, evidence-based guide for midwives to achieve social, psychological, and professional success. Drawing upon extensive research as well as the personal experiences of midwives, the book invites readers to respond to a range of workplace challenges and develop robust strategies for coping, conflict resolution, and more. Thoroughly grounded in occupational psychology, it is a vital tool for any midwife looking to thrive in this critical profession.
Surviving and Thriving in Midwifery readers will also find:
- A global perspective on midwifery across the life course
- The author’s personal journey through their own experience of losing their fitness to practice through ill health, before regaining it and achieving lasting success
- Detailed strategies for building psychological safety in midwifery teams, setting boundaries, and many more
Surviving and Thriving in Midwifery is ideal for aspiring, student, and qualified midwives worldwide.
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Veröffentlichungsjahr: 2025
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Table of Contents
Cover
Table of Contents
Title Page
Copyright Page
List of Contributors
Author Contact Details and Biographies
Foreword
Preface
Acknowledgements
List of Figures
List of Tables
Chapter 1: Introduction
Intro to Chapter
Circumstances, Which No Man can Be a Judge of: Sarah Stone and the Improvement of Midwifery
Contemporary MIDWIFERY
What to Expect from this Book
Chapter 2: Unearthing Your Identity as a Midwife
Intro to Chapter
Personal Identity, Values and Vision
Navigating Your Professional Journey
Finding Your Chosen Community
Self‐Awareness and Personal Development
Tools for Self‐Awareness and Personal Development
In Conversation (Karen and Sally Exploring Sally's Personal Journey Through Constructing her Identity)
Chapter 3: Surviving and Thriving the Day to Day
Intro to Chapter
Managing Demands and Protecting Resources
Maintaining Compassion
Optimising Shift Work
Midwifing Outside the System
In Conversation (Sally and Karen Explore Personal Thoughts and Experiences on Maintenance of Occupational Health)
Chapter 4: Responding to Workplace Challenges
Intro to Chapter
Coping with Stressors
Problematic Substance Use
Tools for Adaptive Coping
Problem‐Solving and Decision‐Making
In Conversation (Sally and Karen Explore Personal Experiences of Responding to Workplace Challenges)
Chapter 5: Thriving in Interpersonal Relationships at Work
Intro to Chapter
Enabling Your Team to Thrive
Equality, Diversity and Inclusion
Psychological Safety and Trust
Successful Conflict Resolution
Managing and Challenging Workplace Incivility
In Conversation (Sally and Karen Explore Personal Thoughts on Interpersonal Relations at Work)
Chapter 6: Surviving When Things Go Wrong
Intro to Chapter
Surviving Traumatic Incidents
Developing Personal Insight and Forgiveness
Escalating Concerns
Maximising Opportunities for Learning
In Conversation (Karen and Sally Explore Personal Insight into What Happens When Things Go Wrong)
Chapter 7: Thriving in Evidence‐based Practice and Academia
Intro to Chapter
Typical Expectations and Tips for Career Advancement
Top 10 Tips for Academic Success
Writing for Publication
Using Evidence to Inform Practice
In Conversation (Karen and Sally Share Insight from their Academic Career Journey)
Chapter 8: Leading with Impact
Intro to Chapter
What is a Leader?
WHAT Kind of Leader Will You Be?
We are All Leaders
Leading with Compassion
Lifting Others Up as You Climb
In Conversation (Sally and Karen Explore Personal Insights on Leadership)
Chapter 9: Turning Visions into Practice
Intro to Chapter
Goal Setting
Be the Change You Want to See
In Conversation (Sally and Karen's Final Reflections)
Recommended Resources and Links to Organisations
Appendix
References
Index
End User License Agreement
List of Tables
Chapter 4
TABLE 4.1 ABCDE model worksheet.
Chapter 6
TABLE 6.1 Example of insight following hypothetical critical incident.
TABLE 6.2 Example of potential actions following insight.
Chapter 7
TABLE 7.1 Critical thinking questions.
TABLE 7.2 CRediT taxonomy.
TABLE 7.3 Quality appraisal tools.
TABLE 7.4 Common biases.
TABLE 7.5 The four phases of the RIOT framework.
Chapter 8
TABLE 8.1 Theoretical components of transformational leadership.
TABLE 8.2 Theoretical components of authentic leadership.
TABLE 8.3 Adaptive practices.
TABLE 8.4 Adaptive principles.
List of Illustrations
Chapter 2
FIGURE 2.1 Values Bullseye.
Chapter 4
FIGURE 4.1 Stress‐appraisal‐coping triad.
Chapter 6
FIGURE 6.1 Key symptoms of primary, secondary and vicarious trauma.
Chapter 7
FIGURE 7.1 Relationship between practice, research and education.
FIGURE 7.2 RIOT Framework.
Chapter 9
FIGURE 9.1 Reflective goal setting cycle.
Guide
Cover Page
Table of Contents
Title Page
Copyright Page
List of Contributors
Author Contact Details and Biographies
Foreword
Preface
Acknowledgements
List of Figures
List of Tables
Begin Reading
Recommended Resources and Links to Organisations
Appendix
References
Index
WILEY END USER LICENSE AGREEMENT
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Surviving and Thriving in Midwifery
Written by
Sally Pezaro
Karen Maher
This edition first published 2025© 2025 John Wiley & Sons Ltd
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List of Contributors
Mariama Lilei Feika, MSc, BSc (Hons) RN, RMDirector of Nursing & MidwiferyAl Khor Hospital – Hamad Medical CorporationQatar
Sadie Geraghty, RM, PhDNational Head of Discipline (Midwifery)National School of Nursing & MidwiferyFaculty of Medicine, Nursing, Midwifery and Health SciencesThe University of Notre Dame Australia
Fiona Gibb, MRes, PgCert HELT, BM, RM, SFHEADirector, Professional MidwiferyRoyal College of MidwivesLondon, UK
Pandora Hardtman, DNP, CNM, RN, FACNM, FAANJohns Hopkins Program for International Education in Gynecology and ObstetricsJohns Hopkins UniversityBaltimore, MD, USA
Inderjeet Kaur, MscDirector of Midwifery ServicesFernandez FoundationHyderabad, Telangana, India
Harriet Nayiga, BScMFounding directorMidwife‐led Community Transformation (MILCOT)Kampala, Central RegionUganda
Ruth Oshikanlu, MBE, QN, FiHV FRCN, FRSA, PhDMBE Queen’s Nurse, Fellow of The Royal College of Nursing, Fellow of The Royal Society for Public Health; Independent Midwife, Health Visitor and Pregnancy Mindset Expert;CEO Goal MindLondon, UK
John Pendleton, PhDUniversity of NorthamptonWaterside Campus, University Drive,Northampton, UK
Dr Jan Smith, PhDChartered Psychologist, FounderHealthy You Ltd & MindYourselfHuddersfield, UK
Mary E. Fissell, PhDInaugural J. Mario Molina Professor in the History of Medicine,Department of the History of Medicine,Johns Hopkins University
Amanda Burleigh, RGN, RN, BScMidwifery Consultant
Author Contact Details and Biographies
Dr Sally PezaroSchool of Nursing, Midwifery and Health, Coventry University, Priory Street, Coventry, CV1 5FBE‐mail: [email protected]
Dr Sally Pezaro is a registered Midwife, an Assistant Professor at Coventry University in the UK, an adjunct Associate Professor at the University of Notre Dame in Australia, a Fellow of the Royal College of Midwives (FRCM) and an editorial board member of Evidence Based Midwifery, MIDIRS and the International Journal of Childbirth. She is also a regulatory panellist, Senior Fellow of the Higher Education Academy (SFHEA), an Invited member of the Ehlers‐Danlos Society's International Consortium and lead midwife for www.hEDSTogether.com. Dr Pezaro has clinical midwifery experience working in the United Kingdom, the Gambia and Ethiopia. Reflecting on her own experiences, Dr Pezaro ensures that her work, now in research and academia remains challenge led.
The Ehlers‐Danlos Society bestowed Dr Pezaro with the ‘Outstanding Consortium Member of the Year’ award in 2022. In 2021, Dr Pezaro also won a ‘Midwives Award’ from the Iolanthe Midwifery Trust and a ‘Partnership Working’ award from the Royal College of Midwives. In 2019, Dr Pezaro was honoured with a first prize award from the Royal Society of Medicine in ‘Leading and inspiring excellence in maternity care’ and was also the first runner‐up for the British Journal of Midwifery's ‘Midwife of the Year’ 2019.
The overriding vision for Dr Pezaro's ongoing work is to secure psychologically safe professional journeys and excellence in healthcare. Follow her on social media @SallyPezaro
Dr Karen MaherDepartment of Work and Organisation, Aston Business School, Aston University, Aston Triangle, Birmingham, B4 7ETE‐mail: [email protected]
Karen is a Chartered Psychologist and Lecturer at Aston Business School whose work specialises in Occupational Health and Work Well‐being. She completed her PhD in Work Psychology at Loughborough University in 2018, which focused on employee well‐being and shift working in the Fire and Rescue Service. Prior to moving to Academia, Karen was a Health, Fitness and Well‐being practitioner with expertise in GP Exercise Referral, exercise rehabilitation and weight management. Previous roles included Health and Well‐being Advisor within the Fire Service, responsible for behaviour change programmes for fitness, stress and weight/disease management for operational and support staff using one‐to‐one coaching and group programmes. Her research is currently centred on behaviour change within the workplace to improve the safety and health of workers with projects exploring maladaptive coping techniques in the workplace (substance use, counterproductive work behaviours), and adherence to safety policies and procedures. Karen was Chair of the Organisational Psychology Special Interest Group at the British Academy of Management from 2019 to 2022.
Foreword
When I was given the title of this book, I couldn't help but smile at the catchphrase survive and thrive. Survive and thrive, some days it feels like we hang on by our fingertips to sanity, oftentimes fuelled by lack of sleep, an overabundance of work, rage, hope and despair and joy in equal measure. We are midwives!
Survive and Thrive was an alliance of government, professional health association, private sector and non‐profit partners working with country governments and health professionals to improve health outcomes for mothers, newborns and children through clinical training, systems strengthening and policy advocacy funded by the United States Agency for International Development. Survive and Thrive then went on to become Survive, Thrive and Transform impacting millions of lives over the years of the project and beyond.
Though the programme has ended I must say that true words have never been spoken, interestingly, the campaign also dealt with addressing shortfalls in maternal health and child healthcare, sounds like this was written by and for midwives, doesn't it?
The key to survival in midwifery is truly about just that ability to adapt, evolve and grow.
More than twenty‐five years later, I can say although the sayings may sound tried and true that is exactly true. When I look at my career there is pretty much no aspect of women's sexual reproductive health that I have not tried on for size and I am grateful that we have so many competencies from which to choose.
How we survive doesn't have to look like how anybody else does it, as we are all rooted and grounded in the philosophy of midwifery which says and reminds us that we have a grounding and are rooted in the normal biological and psychosocial definitions of reproductive health across the lifespan. Sometimes surviving and thriving is about letting go. Letting go of myself and images of what it should be like. I'll never forget a particular couple that I worked with. This couple was special to me in that I was working in the expanded scope of midwifery practice and working with couples through artificial insemination to become parents. Needless to say, we succeeded and had a series of amazing antenatal visits and close to three years had gone by. By this time, I have been working intensively with this particular family for over two years. The pregnancy progressed while the couple were glowing. They were financially comfortable, supportive family all around them, things couldn't be better. And then one day she walked in at 36 weeks for her normal routine visit, and we could not find foetal heart tones. I was devastated and ran to get the sonogram machine from the next‐door. The sonogram machine confirmed my worst fears which I refused to believe because these things just don't happen. Within the hour the radiographer confirmed our worst fears the much‐loved little boy had passed on to his next journey before ever taking a breath in this realm. The difficult decision was to move forward with an immediate induction of labour which turned into a long two‐day process. The mother who had previously planned for an epidural now opted to have an unmedicated birth. Though it seemed simple, it was somehow complicated by the fact that most of the new nurses were uncomfortable with supporting an unmedicated mother. And so, I stayed by her bedside until this beautiful baby boy was born into our arms three days later. We cried together. Bereavement boxes, handprints, footprints and little locks of hair cut to be cherished. And the mother sat in the chair and rocked, and I sat on the couch and cried, and we all cried together. Forget the stiff upper lip; I could not hold it together. I did not think that I could go on, we had come so far together and now this. I wanted to quit midwifery altogether. The rollercoaster of emotions was just too much and so we grieved together, we got through and we stayed connected for years thereafter, even after I had changed jobs. Thus, I survived and thrived in a new environment leaving fertility care behind and my care was transformed by adversity.
One of my greatest concerns, like many others, is how to maintain the midwifery workforce of the current and into the future. We can all attest to the trends of textbooks that are being written as we continue to advance the evidence behind midwifery practice. Textbooks that provide the core of our practice. However, sadly lacking are the stories. Much of what we hear about our profession is shaped by a media that does not always understand us and really is made to sell different kinds of stories that are dramatic, feeding the public adrenaline rush. There are also the novels that romanticise reality often serving to paint a false paradigm of the day in and day out. This has left a gap. A gap in the narrative, and this is truly where I feel the beauty of this particular book can shine through. There will be good days and there will be bad days, there is simply no getting around that. This is why we need more of these kinds of books to add to our own mythology of midwifery. It is the stories of how to move on in trying times, the learning from the Aunties, the elders and the sisters to teach, to inspire and to keep us going.
Our stories are our lessons to the next generation. I am often asked how have you made it for so long? How did you do that. Well, the answer is simply survive, thrive and transform, harking back to the title of this book. With a solid basic foundation, we can do anything. Midwives can and must do everything if we are truly to change the face of maternal health nationally and globally. Not just sticking to the viewpoint from the perineum, but truly evolving into other spaces. The beauty of this book is that through a narrative tale, it gives us a pathway by which we may evolve into other spaces that we may not have been previously shown.
Thriving in midwifery is also about finding joy in the little things. It's not just chocolates and flowers and thank you's, but the gentle smile, the gentle touch. It's the ability to find a midwife friend who gets it even if she is half away around the world and you don't talk to her every day. On the days you can't find that friend, pick up this book. Pick up this book and know that you are part of a vital profession with a legacy of strength. Midwifery is ancient as wisdom, modern as time.
Pandora Hardtman, DNP, CNM, RN, FACNM, FAAN
Chief Nursing and Midwifery Officer
Johns Hopkins Program for International Education in Gynaecology and Obstetrics (Jhpiego)
Preface
SALLY
I have wanted to become a midwife ever since my sibling came into the world and I saw what the awesome human body could do. I have practised as a midwife in the United Kingdom, The Gambia and Ethiopia. Yet it has been over a decade now since I almost did not survive midwifery. After a turbulent time with ill health and incivility, I went where I was celebrated and could grow from my experiences. Now each day, the research and academic work I do in midwifery is me working not just to survive like I did back then, but to thrive.
I wanted to share my personal story throughout this book in the hope that it may give light and solidarity to other midwives in darkness, or those who are unsure how to maximise their potential.
When we deny our stories, they define us. When we own our stories, we get to write a brave new ending.
– Brené Brown
I am a Tall Poppy. Yet making sense of the world around me does not come easy, and I must work hard to push to new levels of understanding every day. In this book, I share what I have learnt over the years in the hope that it will enable other midwives not just to survive but thrive in the profession more easily than I have. Nevertheless, success requires more than just one person. As such, this book draws from several diverse voices in midwifery to bring surviving and thriving in the profession to life. I also draw upon the wisdom of my dear friend, colleague and co‐author Dr Karen Maher in this book, to gain perspective from the field of occupational psychology.
This book is the gift I want to give to my earlier self.
KAREN
Over the years, I have reflected on why some work leaves me energised and other work leaves me drained and came to the realisation that, if what I was being asked to do did not align with my core values, over time it would deplete me. The longer this goes on the more likely I am to feel symptoms of stress and strain. My core value is about supporting people to navigate challenges, both internal and external, to become the best versions of themselves, which was why I was so happy to be invited to be part of this book.
Part of becoming the best person we can be is about looking inwards; pick up any self‐help book or wellness manual and it pretty much centres around the individual and how they can change. However, helping people become the best version of themselves sometimes involves challenging the system, the structural issues that create barriers to thriving. This is very much the way Sally and I have approached this book, providing the tools to be able to help you navigate the system you are working in whilst calling out those things that need to change and how you can be part of that.
Prior to becoming an academic, I worked in occupational health with frontline workers in the emergency services and noticed the toll their work has on their well‐being and their families. Whilst still working in occupational health, I retrained as a psychologist as it was the psychological part of my job that fascinated me. However, my experience working in practice still shapes the research and psychological work I hold dear, and I strive to support those who carry out a critical role in society. I very much take an evidence‐based approach to address practical issues and want my research to have a societal purpose. For me, academic work is only useful if it makes a difference to those we include in research, rather than being lost in an academic journal for all eternity. That involves sharing our knowledge in ways just like this book, where it will be read by exactly the people who may benefit.
It is important to add that I am not a midwife so my voice may feel different as you navigate the book, but hopefully you can see the value in bringing a psychological perspective to the world of midwifery.
We are on this planet for such a short time so let's do what we can to thrive and flourish!
Acknowledgements
Writing this book has been a culmination of conversations and collaborations engaged in by both of us over the course of our careers. Firstly, we would like to give heartfelt thanks to the midwives across the globe who have contributed their comments and thoughts for inclusion in the book. For ethical reasons we have kept these contributions anonymous but we value the richness these voices bring to the concepts under discussion in each of the chapters. We are also grateful to all the colleagues and contributors (too many to mention but each are credited alongside their contributions with mutual agreement) who have inspired the direction of this book along with the themes and sections within it.
Throughout this book, we use many retrospective examples to outline the concepts and ideas we explore. As such, we must also express gratitude to those who shared their examples and acknowledge the vulnerability and openness that allows for the learning to happen from these experiences.
We are also inspired by the many midwives and student midwives who demonstrate passion and enthusiasm for their profession, and the desire and determination to survive and thrive despite adversity every day. This book is predominantly written for you.
Lastly, we understand that our lived experience has shaped our writing of this book and acknowledge the privilege it brings to our experience of midwifery, academia and navigating the world. Through this position we seek to challenge injustice and promote equality, diversity and inclusion through collaboration and public acts of advocacy. These values have guided our exploration of topics within the book. We may not always get it right, but we remain committed to learning how we can best elevate the voices of others.
List of Figures
Figure 2.1 Values Bullseye. Source: adapted from Lundgren et al. (2012).
Figure 4.1 Stress‐appraisal‐coping triad. Source: Adapted from Lazarus and Folkman (1991).
Figure 6.1 Key symptoms of primary, secondary and vicarious trauma.
Figure 7.1 Relationship between practice, research and education.
Figure 7.2 RIOT Framework. Source: Reproduced from Pezaro et al., 2022 / with permission of ELSEVIER.
Figure 9.1 Reflective goal setting cycle. Source: Reproduced from Travers, 2022 / with permission of Springer Nature.
List of Tables
Table 4.1 ABCDE model worksheet.
Table 6.1 Example of insight following hypothetical critical incident.
Table 6.2 Example of potential actions following insight.
Table 7.1 Critical thinking questions.
Table 7.2 CRediT taxonomy.
Table 7.3 Quality appraisal tools.
Table 7.4 Common biases.
Table 7.5 The four phases of the RIOT framework.
Table 8.1 Theoretical components of transformational leadership.
Table 8.2 Theoretical components of authentic leadership.
Table 8.3 Adaptive practices.
Table 8.4 Adaptive principles.
CHAPTER 1Introduction
INTRO TO CHAPTER
The Lancet Series on midwifery published in 2014 outlined the specific and vital role of midwives in the provision of high‐quality perinatal and newborn health and care around the world (ten Hoope‐Bender and Renfrew 2014). Nevertheless, there are global reports of midwifery workforce shortages linked to recruitment and retention issues. Moreover, the midwives currently in post are not always empowered to practise in the way they need or want to. Furthermore, some have limited autonomy and others require upskilling. These global challenges may not be solved in one book. Yet this book is needed to offer midwives a personalised toolkit from which to draw when they themselves need to survive and thrive in the face of challenges.
Due to their role in public health and reproductive services, empowered midwives also have the potential to contribute towards achieving the world's sustainable development goals (United Nations 2015). Yet we have highlighted how midwifery is often undervalued and underserved (Pezaro et al. 2022b). Where conventionally, professions are granted autonomy and social recognition for the services they provide, midwifery often lacks such status.
Nursing in comparison with midwifery has a robust history with widely revered figures, such as Clara Barton and Florence Nightingale. Although such figures have complex historical legacies, crucially those complexities derive from real life, serving to ground the identity of nursing. Thus, historical and reflective narratives of midwifery might similarly serve to ground the contemporary identity of midwifery.
Midwifery can be conflated with other professions (e.g. nursing), which challenges the creation of a distinctive professional identity and status. For midwives to be fully valued and play a crucial role in reducing global maternal and neonatal deaths, we argue their professional identity must be firmly instantiated.
History can tell us who we are, where we come from, and thus may guide us as to where we are going. Therefore, we start this book by introducing a historical narrative of midwifery, written by Professor Mary Fissell, as much of what is available on the history of midwifery is rooted in mythic or fictional characters such as Agnodike or Sairey Gamp. We then give an overview of the challenges faced within contemporary midwifery and explain what to expect from this book overall. As you read the historical narrative below, reflect on what we can learn about ourselves as midwives in terms of where we come from, who we are and where we may be going in future.
You may notice gender and culture wars apparent in this historical narrative, dressed up as Man versus Woman. It is important to reflect on how our history has shaped us as a profession, but at the same time avoid judging the past by present standards and ideals. We recognise the challenges midwifery faces in relation to gender inequalities and will address some of these issues later in the book. For now, we request, with whichever gender you identify (or not), you read the following with only a curiosity for how midwifery of the past was perceived.
CIRCUMSTANCES, WHICH NO MAN CAN BE A JUDGE OF: SARAH STONE AND THE IMPROVEMENT OF MIDWIFERY
Sarah Stone (c. 1680–1737) was really tired. The early eighteenth‐century Somerset midwife had travelled 10 miles on horseback over terrible roads to support a soap‐boiler's wife in childbirth, whose usual midwife could not be found. On the way there, a man ran up to her, and asked if they had seen another midwife, who, it turned out, was a further 8 miles away. After supporting the soap‐boiler's wife to birth her baby, Stone called in at the other woman's house and was told that they had found another midwife and the baby would be born in the quarter of an hour. So, Stone rode home. But it was not to be. Five hours later, the second husband came to Stone and begged her to return, saying her women feared the baby would never be born.
After her services had been refused earlier, she had to travel back to the same house on the same bad road. Once there, Stone demonstrated to her skills, ‘as soon as I Touched her, I was sensible of the reason of this poor Woman's being kept so long in distress’ (Stone 1737, p. 71). Her hands knew what was the matter; ‘touching’ was a newly coined technical term for manual examination (Giffard 1734, pp. 26, 44, 50, 53). Stone aided the woman to give birth quickly and concluded the case by saying ‘for ’tis an undoubted rule, If Pains do no good, they do a great deal of harm’ (Stone 1737, p. 73). Repeatedly, Stone abstracted such general rules from her daily practice, creating new knowledge and disseminating it in print. She wrote movingly about the pains birthing women suffered and criticised other midwives whose incompetence left women labouring for longer than necessary.
Stone's history contrasts with the narratives historians often tell about eighteenth‐century English midwifery (Wilson 1995). For it was in Stone's own lifetime that men began to assist with the birth of babies in England. The period is often portrayed as a turf battle between men, armed with the new technology of obstetrical forceps, and women who had long been the primary carers for pregnant and parturient women. Casting the eighteenth century in this way has caused us to overlook the work midwives did to make births safer; Stone is an excellent example of such pioneering work. In this essay, I will show how Stone sought to improve the practice of midwifery, and put her work in the larger context of enlightenment midwifery in Europe (Grundy 1995; Marland 1993).
We know about Stone's life and practice because she published a book of her cases in 1737; she was only the second midwife to publish in English. She was born around 1680, and married Samuel Stone in 1700; two of their children were baptised in the same Bridgwater parish over the next few years. Stone trained with her mother, who was a noted local midwife, and then served as her mother’s deputy for six years, basically in joint practice. Her mother died in 1708, and Stone embarked upon a solo practice (Bridgewater St Mary's Parish Records;1682–1714). One of her biggest constraints was that noted above: the roads were terrible. Over the course of her career, Stone moved to Taunton, then Bristol, and finally London, where she died not long after the publication of her book. Her daughter, trained by Stone, worked in Bristol as a midwife.
Stone worked both as a regular midwife, with a list of clients who booked her in advance for their births, and as a consultant midwife, called in when things went wrong, as in the case described above (Woods and Galley 2014). Her caseload was staggering; she claims to have assisted as many as 300 births a year when she was in Somerset. Even half that number is astonishing, and indicates that much of her work was consultant, summoned in a crisis, possibly seeing a client for only a few hours. Her book was likely written in part as advertising when she moved to London. By then Samuel was dead, and she would have wanted to attract customers in the metropolis.
While self‐promotion may have been a factor, Stone's goal was to improve the standards of midwifery. She dedicated her book to the Queen, whom she described as ‘the Nursing‐mother’ of the nation; the book was intended to ‘prove instructive’ to female midwives, especially rural and lower‐class ones (Stone 1737, pp. vi, vii). By the 1730s, Stone had encountered the new breed of male midwife, and she was scathing about them, saying ‘that almost every young Man, who has served his Apprenticeship to a Barber‐Surgeon, immediately sets up for a Man‐Midwife’ (Stone 1737, p. xi). She repeatedly characterised man‐midwives as boyish and ignorant (Stone 1737, p. xiv). While Stone had attended anatomical dissections, she did not consider such training to be sufficient, ‘For dissecting the Dead, and being just and tender to the Living, are vastly different’ (Stone 1737, p. xiv). She staked a claim to women's particular expertise in midwifery, ‘there is a tender regard one Woman bears to another, and a natural Sympathy in those that have gone thro’ the Pangs of Childbearing’. Men lacked understanding because they had not given birth; those were ‘circumstances, which no man can be a judge of’ (Stone 1737, pp. xiv–xv). A combination of empathy and experience made a judicious midwife.
However, Stone was also very critical of female midwives who did not know enough to be skilled practitioners. In a difficult situation with a woman who had been in labour for four days already, Stone argued with the midwife who had been attending the woman. ‘I asked her Midwife the reason, Why she did not deliver her? She told me, Because God's time was not come: (a common saying amongst illiterate unskilful Midwives)’ Stone retorted dryly, ‘that it appeared to me to be God’s time then’. Stone described the mother as ‘to the eye of Reason, very near death’, but she managed to save her life (Stone 1737, pp. 44–45).
Another case demonstrated similar failings in rural midwifery care. A woman in Bishop's Lydeard went into labour on a Friday and on Saturday she birthed a child. When the midwife went to deliver the afterbirth, she found that there were twins. The midwife assured the mother that ‘when the other Apple was ripe it would also fall’. Stone commented ‘O ignorance!’. On Sunday the husband sent for Stone, fearing his wife would not live. She told the story with great drama, ‘we rode as fast as possible, and ’twas but 5 miles from Taunton, yet we had two messengers sent after us for expedition, for all her Women thought her dying’ (Stone 1737, p. 66). Stone managed to assist in the birth of the second child after an hour and a half of hard work. The moral pointed to the skill and knowledge needed in a midwife, ‘For ’tis certain, if the Midwife understands her business as she ought, she might bring the second child soon after the first: for generally in the birth of twins, when the first is born the other should be brought by Art’. Stone added that she never put a woman ‘to any more than ten‐ or fifteen‐minutes pain after I had delivered her of the first child’ (Stone 1737, p. 68). Stone declared that this case rested upon a basic fact that ought to be known by all midwives: when one twin was born naturally, skill and manipulation were needed to deliver the second one.
In addition to elucidating these kinds of fundamental rules, Stone also modelled knowledge‐making for her midwife readers. She recorded exceptional cases, problems that might only happen to a midwife once in her career. Many of Stone's colleagues encountered very few difficult births because they had relatively low caseloads, assisting in the birth of perhaps 20 babies a year, with perhaps a single birth per year presenting difficulties (Wilson 1995, p. 33). Stone, with her mix of regular and consultant midwifery, saw as many or more difficult births in a year than some midwives saw in their entire career.
A tragic birth in Taunton models for Stone's readers how to make knowledge from an exceptional case. Stone was called late at night to see a wool comber's wife. The woman had gone into labour around noon, called her midwife, and been delivered standing up. The woman's midwife, described by Stone, as ‘a feeble ancient woman’, was unable to deliver the placenta. The navel‐string (what we'd call the ‘umbilical cord’) broke close to the placenta, and the mother bled copiously (Stone 1737, p. 54). By the time Stone arrived, the mother was past recovery. Stone tried to imagine what had happened and deduced that it was a combination of a very short navel‐string, the standing posture which accelerated labour and the weakness of the midwife who did not support the child, whose weight, combined with the too‐short cord, initiated the bleeding. Up till this point, the reader is led to believe that this is a perfect storm caused by the rare intersection of three different factors.
But Stone continued this case by describing how three or four years later, she attended a gentlewoman whom she had assisted in childbirth several times before. When the infant could not be birthed, she remembered this earlier case and found that the cord was pulled tight. She kept a tight hold on the cord, allowed the baby to birth, and then, in under seven minutes, the placenta. Both mother and child did well. Stone thus modelled for the reader how to draw upon previous experience to make a working hypothesis in a difficult case, test the hypothesis with her hands (feeling the navel‐string strained), and act upon the tested hypothesis. She noted a general rule to be abstracted from these two cases, namely that women should give birth in bed, rather than standing, and that a midwife should be one of ‘judgement and activity’, that is both wise and able to act decisively (Stone 1737, p. 58).
Stone was exceptional in English midwifery; her cases are written in almost novelistic detail and give us vivid pictures of her practice. We simply do not know how many other highly skilled consultant midwives were practising in eighteenth‐century England. However, Stone's plan to improve the standards of midwifery by combatting ignorance was echoed by subsequent English midwives such as Elizabeth Nihell and Martha Mears, who published their own books to educate midwives (Cody 2005). Further afield, other midwives similarly sought to improve standards. Justine Siegemund (1636–1706) published a midwifery guide in the form of a dialogue between herself and one of her pupils; it included a novel method for a shoulder delivery. At her funeral, it was said that she had assisted in the births of almost 6200 babies over the course of her career (Tatlock 2005). In France, Angélique Marguerite Le Boursier du Coudray (c. 1712–1794) developed a new programme for training provincial midwives using life‐sized obstetrical models to demonstrate a wide variety of presentations. Louis XV commissioned her to take her teaching programme to various cities and towns. From 1760–1783 she trained 4000 students and her students taught another 6000 (Gelbart 1998).
Such enlightenment‐era midwives were actively teaching and improving practice. Narratives that emphasise conflict between male midwives and female ones often describe men as the innovators, and women as left behind. There is an alternate history, however, that reveals a series of women like Sarah Stone, committed to using the medium of print, as well as face‐to‐face teaching, to help their fellow midwives develop stronger skills and create innovative methods to improve their profession.
Mary E. Fissell, PhD (she/her/hers)
Inaugural J. Mario Molina Professor in the History of Medicine,
Department of the History of Medicine
Johns Hopkins University
CONTEMPORARY MIDWIFERY
Midwives' scope of practice and regulation varies worldwide. Thus contemporarily, the midwifery profession may be somewhat lost in its professional identity, direction and place within the world. Both the art and science of midwifery are balanced to varying degrees around the world too, and so different voices in midwifery can come into conflict. Nevertheless, midwifery needs to remain relevant and contemporary in an ever‐evolving world, where the needs of both midwives and people who birth evolve and change. In more recent times, we have had to overcome challenges in embracing digital technology too (Takian et al. 2012). Like Sarah Stone in the previous section, when we know better, we must do better.
Despite the need for us to thrive, throughout the world midwives experience several types of work‐related psychological distress. These include both organisational and occupational sources of stress such as workplace bullying, poor organisational cultures, medical errors, traumatic clinical events, critical incidents, occupational stress, workplace suspension, whistleblowing, investigations via professional regulatory bodies and employers, and/or pre‐existing mental health conditions (Pezaro et al. 2016). Indeed, whilst midwives have a proud history of speaking out and must continue to engage in whistleblowing where change is required, the consequential bullying, ostracism and blame, combined with structural issues such as insufficient governance and reporting mechanisms are significant (Capper et al. 2024). In recent years, midwives have additionally worked through the global COVID‐19 pandemic along with other professional groups in healthcare. The terms moral distress, compassion fatigue, burnout and post‐traumatic stress disorder describe the emotional states reported by those working through the COVID‐19 pandemic caused by care delivery challenges; insufficient staff and training; challenges with personal protective equipment and frustrations, leading many to consider leaving the profession (Maben et al. 2022). Under the immense pressure and difficult working conditions (e.g. during the COVID‐19 pandemic), one's duties can be internalised, and thus relied upon to motivate and sustain staff in the face of personal hardship and oppressive conditions (Anzaldua and Halpern 2021). However, the impact of acting strictly from duty further collapses the space for mental freedom and worsens one's ability to engage with authentic reactions of outrage, fear and grief. In internalising such emotions, we may still be wounded and in need of recovery from all work‐related psychological distress associated with being a midwife. Unfortunately, there is a lack of evidence‐based interventions available to support both midwives and student midwives in work‐related psychological distress (Pezaro et al. 2017), though interventions such as Schwartz Rounds may be useful for some (Ng et al. 2023). In rising from the ashes, a re‐imagining of the midwifery profession may now be appropriate as we work to survive and thrive despite adversity in an ever‐changing world. In a recent manifesto for change it is suggested that we must prioritise the essential needs of staff; take a systems approach to staff support and share good practice; normalise and anticipate psychological health management; give equal emphasis to psychological and physical harm; nurture compassionate leaders and foster learning over blame cultures (Maben et al. 2023). How might these elements be realised in your area of practice?
Whilst there has been much written about the changing profile of those who birth around the world in terms of demographics, we are also supporting individuals with multiple and long‐term conditions more frequently in contemporary midwifery practice. For example, research in the field of childbearing with hypermobile Ehlers Danlos Syndrome (hEDS) and Hypermobility Spectrum Disorders (HSD) has gained much interest as we begin to understand more about the effect of these conditions upon pregnancy and birth (Pezaro et al. 2018b; Pezaro 2021b). These conditions, commonly underdiagnosed are now understood to affect approximately 1 in 20 pregnancies worldwide and have profound and life‐threatening consequences in childbearing as they affect connective tissues throughout the body (Pezaro et al. 2020a). Work in this area is gaining traction as we discover more and highlight the needs and care considerations for perinatal staff working with such populations (Pearce et al. 2023a,b). More details on this field of research are available via www.hEDSTogether.com, where toolkits, education and decision‐making tools can be freely downloaded for use.
There are also many underserved, minoritised and marginalised groups requiring improved outcomes and care in contemporary perinatal services. Year after year, we see that global majority people (e.g. non‐white people) are four to five times more likely to die in childbirth when compared to their white counterparts. Yet it is important to avoid one group acting as ‘saviours’ for another. Equally, it would be inappropriate to expect any one group to ‘fix’ the inequalities we observe. For the betterment of midwifery, perinatal services and society it will be important for us all to work towards reducing inequalities in all areas moving forward and embrace diversity. Indeed, whilst the art and science of midwifery remain the same, midwifery work is undertaken in a context where diversity is becoming more visible. For example, the profiles of birthing people in receipt of midwifery care are diversifying in terms of their age, gender, health profile, long‐term conditions and social dynamics. Indeed, trans men and nonbinary people are a growing population of childbearing within ‘maternity’ services. Unlike the term cisgender, used to describe a person who experiences a normative relationship between their gender and sex, trans can be used as an umbrella term referring to individuals and groups who do not experience a normative relationship between their gender and sex. Sensitivity to gender diverse folk's experience of navigating systems presently and inadvertently designed to exclude them can allow the profession to redesign and deliver care that is inclusive, and person centred for all. In pursuit of reduced inequalities, we may also decolonise our services where presently white, cisgender, heterosexual and patriarchal norms remain oppressive and exclude diversity. We will explore how we might do this later.
The contemporary midwifery profession is similarly diversifying. Significantly, midwifery is now less mono‐gendered, in that men are joining the profession. Yet, how might midwives, who are also men, navigate a profession dominated by women, particularly in a global context where healthcare is typically delivered by women, and yet led by men (World Health Organisation 2019)? The following contemporary insights are offered by John Pendleton, a cisgender man, who is also a midwife and published academic in the field of gender and the midwifery profession.
Surviving and Thriving as a Man Working as a Midwife
Working as a midwife is frequently cited as being a tremendous privilege, and this remains true for men who enter this historically mono‐gendered profession. Nevertheless, as relatively recent arrivals we face some unique challenges. In the United Kingdom (UK) we have only been part of the profession for 40 years (Speak and Aitken‐Swan 1982) and our presence in the profession was vehemently opposed by all key maternity stakeholders (McKenna 1991). Despite there being no shortage of midwives that necessitated opening up the profession to men, nevertheless legislative changes were driven through bringing the UK into line with EEC directives of 1976 opening the doors for the first pioneers. Globally, men are still banned from midwifery in at least five countries including Japan (Sannomiya et al. 2019).
Into this background of not being wanted or needed, it is perhaps not surprising that men in midwifery are vanishingly rare – currently 0.3% of the UK population (NMC 2019) with similarly low numbers elsewhere. This does present some unique challenges for us, not least in how to make sense of our experiences. Unlike our counterparts in nursing and allied health professions, we are almost entirely absent from academic literature and empirical enquiry, and the history of men's wider involvement in maternity services is frequently positioned as in conflict with the values and skills of midwives (Pendleton 2019
