Introduction

Each woman reaches pregnancy by a different road. Some women will have chosen very carefully to have become a mother and be excited by the prospect. Others will have become pregnant earlier than they had wished, whilst some will be unhappy to be pregnant. This last-mentioned group may include those women who have become pregnant by violence or force. It is important therefore that midwives remember that each woman and her family will need care which is planned and organized to support in their individual journey to becoming a family. Midwives need to have great sensitivity and awareness of the processes and dynamics of communication. They may then address the anxieties, fears and worries, often not spoken about by women, but which still need to be made explicit so that appropriate care is offered to women in their individual family units.

In any work on psychological processes or communication, it is important to remember that before we begin to work with others we should examine ourselves, because how we behave and how and when we speak will impact on women, students and other healthcare practitioners with whom we work. In addition, the relationships we develop with a woman and her partner will influence the way a woman experiences her journey to motherhood, and the psychological aspects of her care.

Relationship

It has been recognized for many years that it is the depth and strength of the relationship between client and therapist that makes the difference (P Clarkson, personal communication, 2000) (see website for Case scenario 12.1). This bond or working alliance enables the client to explore their situation and change or remain the same, depending upon their decisions following explorations of their circumstances.

The concept of relationship is so obvious that it is often taken for granted; however, anecdotal evidence and research (Griffith 1990) suggests that it is frequently missing in general practice. Yet, this is an area where clients may have a lifelong provider of care. If this is true in general practice, it could be similar in midwifery.

Women are having fewer babies than formerly. Pregnancy is a time when women may feel vulnerable because so many changes are occurring at such a rapid pace. The meeting with the person who will provide care at this time is important. Some people really enjoy change, it is exciting; others dislike change, as it provokes anxiety, which they try to avoid because they wish for stability or for their life to remain the same.

For some women, the relationship between themselves and the midwives whom they meet may become very important. Women who are without an extended family network or friends are often socially isolated. It is common knowledge that such ordinary human relationships can have a psychotherapeutic value (Clarkson 1996). Women who have a poor relationship with their own mothers and few friends may experience difficulties in pregnancy, childbirth and the first year following the birth of their baby, if they do not receive adequate support from the midwife or a therapist (J Harman, unpublished PhD thesis, 2008). A sound relationship with the midwife will provide stability for the woman and reduce her experiences of anxiety or fear, enabling her to develop confidence in herself.

For a relationship to develop or establish, three components are required:

• trust

• respect

• communication.

Trust

All adults realize that an individual can betray them; therefore, trust does not exist overnight in any relationship and has to be earned. It has long been recognized that if we have similar traits to another person then we are more likely to like that person, relax in their company and be influenced by them (Cialdini 2001). Women also expect a midwife to ‘look after them’ or act in their best interest, thus to advocate for them (Fraser 1999). Advocacy goes hand in hand with trust, and this means that midwives need to trust and believe in a woman’s ability to be pregnant and give birth so that the woman will believe in her own ability to be pregnant and give birth.

However, in today’s maternity services, risk management is an important aspect that influences the ways in which midwives practice. In a hospital setting, midwives respond to the influences of senior practitioners and will change their behaviour to obey or conform to their senior’s wishes (Hollins Martin & Bull 2008). If a woman sees this, she may feel differently about her midwife, perceiving that if the midwife conforms, the woman herself may consider the need to conform. If she conforms, she is seen as a ‘good’ patient. If she does not conform, she may be considered to be a ‘problem’ patient.

Women may prefer to be seen as the good patient, because the fantasy is that care will be kinder or better. However, the decision to change her behaviour and accept the care offered by a senior practitioner may result in the woman no longer feeling that she has choice, control or a voice to influence what happens to her during her pregnancy or labour. The trust she has in the midwife may be breached and may be irreparable. The woman may also feel angry with herself for not being stronger. She may consider herself weak and if she thinks this about herself, she may also think the same about the midwife.

A second aspect of trust is that if the midwife or student midwife is confident in her own ability to provide care to women and their partners, they, in turn, will have confidence in the midwife. The woman will feel safe. Often women are happy to be cared for by ‘brusque’ midwives because their behaviour displays confidence, whereas sometimes a very kind midwife can display behaviour which shows a lack of confidence, consequently the woman feels unsafe.

It is important for midwives to develop confidence and competence so that the care they offer to women provides feelings of safety to build trust. However, many students and midwives do not feel confident or competent at the point of registration (Donovan 2008). This perceived lack of confidence and competence will affect the woman/midwife relationship. During her student training, each midwife needs to be nurtured by a mentor who facilitates her practice, providing praise when it is due, encouraging the making of decisions when appropriate and discussing the decisions made (Currie 1999). Consequently, when students qualify and begin to work independently, they do not display or experience anxiety, thus women will feel safe in their care. As a result, an individual woman will be willing to tell the midwife her personal story, which will facilitate accurate history-taking and lead to the appropriate provision of care for the woman and her partner.

A third aspect of trust is compassion, which can also equate to un-possessive love. It is a challenge for midwives to remain compassionate when they are working under pressure. Midwives may work in a delivery ward where there are too few midwives to offer continuous support for women in labour. The pressures may lead to little or no time to comfort a midwife who has attended and been affected by a difficult birth. What happens is that the midwife becomes psychically numb. She switches off her empathy and compassion to protect herself and as a consequence she can be perceived and experienced by women as uncaring and unkind (Kings Fund 2008). The midwife no longer conveys the sense that she understands the experiences of the woman and wants to do something about it (Youngson 2008).

Respect

Respect for women is the foundation on which all meetings or interventions are built (Egan 2007). It is a way of seeing the woman as a unique individual and is based on maintaining a woman’s dignity. The midwife needs to convey in her way of being that she will not cause any harm and that she is skilled, competent and confident in her practice of midwifery. The midwife needs to convey to the woman that she is her advocate and will be with the woman on her journey. This does not mean though that the midwife would collude with the woman. If the woman is drinking more than the recommended amount of alcohol units per week, the midwife will point this out, because this behaviour needs to be challenged. The midwife works on an assumption that women wish to live healthily, so if the woman resists, she will also recognize and respect that it is her right so to do. It is important that midwives are able to suspend judgements; most people are their own worst critics, so women do not need other people to judge them as harshly as they may judge themselves. Respecting women is to keep them as the focus in order to provide woman-centred care.

Communication

This refers to proficient and appropriate use of specific skills. Many people believe that they are good communicators, yet when asked to identify which communication skills they are using, they are unable to do so. If an individual is unable to identify which skill they are using, they are often not using the skill most appropriate for the situation. Communication skills need to be practised and fine-tuned so that they are used every day. As midwives interact with women each one may require different skills in order for her to feel valued, listened to and understood.

When all three of the above aspects are present, a woman will experience a satisfying relationship that will enable her to cope with the changes which occur during pregnancy, labour and early motherhood.

The dynamics of communication processes

A simple explanation of communication is that one person speaks to another, who hears and understands what is said and responds to the speaker, as in Figure 12.1.

Figure 12.1 Representation of the communication process.

The diagram shown in Figure 12.1 is very simplistic and does not allow for the complexities surrounding human interaction. What are important to take into consideration are the factors that impede our ability to listen to ourself and others.

Figure 12.2 illustrates some of the factors that midwives, students and women may experience every day which will impede their ability to listen. The factors may be present in one or other or both parties.