Introduction

This chapter will highlight the unique abilities of babies to communicate from birth, and how their optimal development relies on contingent responses, which are part of the parent–infant attachment process. These qualities in interpersonal skills are fundamental to building relationships, and the lessons from infancy influence our adult ability to communicate. Thus, by enhancing early relationships between parents and babies, midwives can reapply these principles in everyday communication. The common errors that inhibit midwifery communication will be outlined and skills of listening and empathy will be analysed.

Midwives are in a unique position to observe how humans learn to communicate. When time is taken to observe infants, it can be noticed that babies are ‘pre-programmed’ to interact with adults (Stern 1998). This is due to their preference for the sound, sight and movement of adults to other comparable stimuli and they are especially attracted to their mother. This interaction is probably a biological instinct, as humans depend on mother and other adults to care for them to ensure survival.

The work of MacFarlane (1977) clearly highlighted the ability of babies, and dispelled many myths around infants, such as the idea that babies cannot see. Not only can they see (and focus well at about 30 cm) but they like to look at contrast and contours found in the human face. They turn to sound, particularly the mother’s voice; they will turn to the smell of their own mother’s breast pad in preference to another. So they develop recognition of their mother very quickly through their senses, and communicate their needs through behaviours (RCM 1999). As adults, we also communicate through voice and behaviours.

The behaviours of a human baby are social and communicative; they mimic adults, most noticeably by facial changes. So if you smile, open your mouth wide or stick out your tongue, the baby will watch carefully and then copy (Murray & Andrews 2010), which is quite remarkable when you consider how they know that they even have a mouth. Indeed, this mimicking can be observed in the first hour after birth. This response to adults demonstrates babies turn taking in their non-verbal responses and vocalisations, provided the adult is sensitive to them (Brazelton et al. 1974).

Being sensitive to interaction in this dance of communication requires that the other is responding to that baby (or indeed an adult) and does not ignore or overwhelm with intrusive responses. The critical aspects of building relationships is engagement but its absence gives the message of indifference, which indicates lack of importance, and possibly feeling unwanted by the other or even a feeling of non-existence (McFarlane 2012). This indifference can readily be recognised when a mother is suffering with postnatal depression (RCM 2012). ‘Insensitive mothers’ may be overintrusive in communicating with their baby, and base their responses on their own needs and wishes, or general ideas about infants’ needs. The same dynamic is easily replicated by midwives when they have an agenda which differs from the client’s needs, for example during a booking history.

Midwifery wisdom

You cannot feel indifferent towards clients in your care. If you find yourself feeling this way, then think ‘how can I love this person?’. And ‘who can help me feel cared for?’.

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Care taking and our sensitivity to infants are normally based on how we were cared for as infants. If we formed a good enough attachment to our parents and they were in tune with our needs, if they were ‘baby centred’, then we become secure adults (Steele 2002) and naturally become ‘woman centred’ in midwifery care. Sensitivity also comes from our attitudes and behaviours. Thus, every time babies are changed in a loving way or sympathetically responded to when lonely, tired, hungry or frightened, they take in the experience of being loved in the quality of care received. For a baby, physical discomfort is the same as mental discomfort and vice versa (Stern 1998).

The key aspects of early parenting and building a sensitive relationship are described clearly in the RCM’s Maternal Emotional Wellbeing and Infant Development (RCM 2012). It is the parental attunement to the needs of the infant (which midwives have a role in fostering) that leads to loved individuals who do not become antisocial adults. Through our early relationships and communication from conception to 3 years of life, Sinclair (2007) suggests that we develop our emotional brain and our capacity for forming relationships. Fundamentally, human beings at any age respond and feel understood when an attuned warm, positive and sensitive other interacts with them. As a professional responding as a sensitive mother would, you too can communicate in this way with clients in your care, which can enhance how you build relationships and improve communication.

Sensitive responsiveness is one of the key constructs of attachment theory (Bowlby 1980, RCM 2012). The early infant–mother relationship has far-reaching consequences for the developing child’s later social and mental health. It is the underpinning theory in national agendas and frameworks interventions (e.g. DfES 2006, DH 2004, 2009, RCM 2012, Sinclair 2007), recommended for effective practice in the promotion of family health and parenting skills, which are now a priority politically and professionally.

The concept of sensitive responsiveness includes the ability to accurately perceive and respond to infant signals, with contingent responses because the person is able to see things from the baby’s point of view. These key concepts (in italics below), that mothers who are sensitively responsive seem to demonstrate, are fundamental to all our interactive relationships.

• An observer who listens and sees their strengths and helps them with their difficulties.
  
• Warm and responsive interactions with caretakers. The mother’s task is to respond empathically – to mind read. The baby has no control or bad intent; they learn that they can self-regulate through maternal containment. They then learn to self-soothe, for example, by sucking.
  
• Structure and routine, flexible,and age appropriate, that give boundaries. Providing psychological and physical holding; holding also relieves anxiety the baby feels ‘held together’.
  
• Maintains interest by providing things to look at and do through play and touch, but in tune, e.g. recognises that a yawn means ‘leave me to sleep’.
  
• Vocalisation reinforced by response-dialogue. Hearing and being heard – responds to familiar parent voice, giving a sense of security. Babies need to hear talking in order to develop speech (DfES 2006, DH 2004, Paavola 2006, Ponsford 2006, RCM 2012).

Sensitive responsiveness can be facilitated, and when mothers’ sensitivity and responsiveness are enhanced, this results in dramatic increases in secure attachments with fussy infants (Steele 2002).

Our infant–parent attachment patterns are largely acquired, rather than determined by genetic or biological make-up (Steele 2002), so with support we can all improve our ability to relate to others. For midwives, this means relating to clients and colleagues but also facilitating parent–infant relationships. This can be done by praising the sensitivity you observe in the parents, and helping them see and understand their baby. Using the questions in Box 1.1 with parents might enable them to realise that they can understand their baby. The RCM’s Maternal Emotional Wellbeing and Infant Development (RCM 2012) also has many suggestions to develop your skills in this area.

The basic methods of improving relationships are those that mothers ideally use with their infants. This is primarily non-verbal so it is not surprising that over 65% of our communication is non-verbal (Pease & Pease 2006), observing bodily and facial cues, and being in touch with what the person might be feeling. This is truly listening and being with another person, and because we are listening and empathising, we provide a safe environment. Sometimes midwives demonstrate this by holding women physically, which seems to help contain the labouring women in their pain, and at birth by encouraging skin-to-skin contact, thus giving the baby safe framework after having been contained in the womb. But we also provide holding psychologically, by being with women and trying to understand what the experience is like for them; this is demonstrating empathy. When we reflect back what the client says and feels, by our actions, sometimes by touch or words, then the client feels held and heard.

Humans become socialised, and learn that they should not say this or that or that they should not upset another person or that they should not argue. We often learn to hide our feelings and not say clearly what we mean, which in turn leads to a lack of communication. Dissatisfaction in midwifery care and family life is often due to lack of communication. It is recognised that communication is one of the key elements for a compassionate workforce.

Communication is central to successful caring relationships and to effective team working. Listening is as important as what we say and do and essential for “no decision about me without me”. Communication is the key to a good workplace with benefits for those in our care and staff alike.

(Commissioning Board Chief Nursing Officer and DH Chief Nursing Adviser 2012)

Our early skills in relation to communication become fixed into patterns, and the stamped foot of a temper tantrum in a toddler can still be apparent in the adult. Nichols (2009) summarises the four early stages of the development of self, described by Stern (1998), which helps inform us of how we adopt patterns of acting and reacting that become unconscious responses in adult life. This partly explains why, when we are in an anxious state, we cannot find the words to describe it because we have returned to a developmental stage which was preverbal.

Effective communication can be hard to achieve. Sometimes it seems that no matter how carefully we try to phrase the things we say, the listener either doesn’t understand us or they misunderstand us. In verbal communication, we often add emphasis through body language or the intonation of our voice. We may adopt defensive or intimidating postures to reinforce the intended messages and, of course, we may raise or lower our voices. These techniques are used subconsciously, having developed through our socialisation from childhood.

Some common problems in communication

Bolton (1997) suggests that there are six common problems of human communication. These are mainly to do with understanding and listening:

The first problem is poor understanding, which is often due to an unclear message or unclear words, because words can have different meanings for different people. As Ralston (1998) points out, terms such as ‘incompetent cervix’ or ‘inadequate pelvis’ are open to very different interpretation for the non-professional listener. But even a straightforward term, such as ‘mayonnaise’ when it is not differentiated into ‘home made’ (with raw eggs, to be avoided in pregnancy) and the commercial product, can lead to women misunderstanding the information given (Stapleton et al. 2002).

When the message is ‘coded’, the real meaning is masked; for example, the client asks you to put her flowers in water but she could really be asking you to keep her company. It can also often be observed that clients present with one agenda but really have a different problem; for example, they present with backache but they are really concerned that the pregnancy is normal. Midwives also miss conversational codes for more information from clients (Kirkham et al. 2002a). ‘I don’t know’ and ‘What would you do?’ are both tactics women use to elicit more information, which unfortunately are generally not very successful.

The way a sentence is spoken can also indicate an underlying message. Most speech has an obvious and a hidden meaning (Kagan et al. 1989). For example, ‘What did you say?’ has the obvious meaning of ‘please say that again’ but the hidden meaning could be ‘you are so boring, I was not listening’. But if we said what was meant, we may hurt someone’s feelings so we try to act in a professional way, thus creating barriers to communication, because we are not clear in our message. Indeed, as professionals there are times when we are acutely aware of appropriate interactions and needing to maintain a professional face. For example, it is inappropriate to look cheerful or go into a long explanation of care during life-threatening emergencies (Mapp and Hudson 2005).

Clients also do not hear or take in what we say because they are distracted, by the environment or physical symptoms. The disruption of a child needing attention during a conversation is an example of distraction, or a client may be in pain and can consequently miss the information given. However, what is tragic is that midwives often miss the non-verbal cues and often carry on with their own conversation, neglecting the woman. This could end up with the midwife thinking ‘I know I have given the information’, even if the client ‘could not hear’. It is interesting to observe that mothers will say ‘look at me when I am talking to you’ when addressing their children, thus ensuring the non-verbal feedback that tells us we are being heard (Yearwood-Grazette 1978). Midwives need to ensure that they respond to non-verbal cues with their clients, particularly eye contact.

Midwifery wisdom

Reflect on your interactions with clients. If you are doing most of the talking, then you are not listening, and the client probably has switched off too!

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Midwives and clients often filter information because of perception, emotions or simply hearing what they wish to hear. A midwife may say ‘you can go home after the paediatrician has discharged the baby’ but the client hears only the ‘go home’ part and so phones her partner to collect her immediately. Midwives filter information by avoiding discussion. They may emphasise physical tasks, giving the message that discussion, particularly on how women feel, is less important. Indeed, discussion if often avoided, for example by filling the time with asking for urine samples and ignoring possible anxiety, even when the last pregnancy was a stillbirth (Kirkham et al. 2002a). In essence, filters become blocks to communication.

Another block to communication is the phrase ‘don’t worry’, used frequently to reassure (Stapleton et al. 2002). However, it has the effect of causing anxiety. The client is denied expression of how they really feel, and as such the words ‘don’t worry’ should be avoided (Mapp and Hudson 2005) as this blocks the client from disclosing further concerns or feelings (Stapleton et al. 2002). A smile and touch are more helpful in allowing the client to feel human and reassured (Mapp and Hudson 2005).

It is not just what we say and do; it is also how we listen. It is rare for midwives to explore topics such as what foods a client eats, to invite discussion (Stapleton et al. 2002). This would enable the client to say what they know, but the midwife then needs to listen for the relevant missing information. This is harder work, so instead there is a tendency to tell clients what to do, things they often already know, such as the advantages and disadvantages of breastfeeding, but not what the client is seeking, for example how it feels to breastfeed (Stapleton et al. 2002).

Finally, people who have difficulty with emotional issues may deny their emotions or become blinded by them (Bolton 1997). Blinded because anxiety and fear or any high levels of emotional arousal lock the brain into one-dimensional thinking (Griffin & Tyrrell 2004). Our emotions are then affecting our physiology, hijacking the brain’s capacity for rational thinking. This inhibits our ability to rationalise or entertain different perspectives, because these traumatic and distressing experiences, big and small, cause imbalance in the nervous system, thus creating a block or incomplete information processing. This is why it is difficult to take in medical or other information or advice when upset, frightened, angry or in pain. This dysfunctional information is then stored in its unprocessed state both in the mind (neural networks) and in the body (cellular memory) (Pert 1999). Certainly, during emergencies poor communication can compound the stress. Careful sensitive communication that is congruent, i.e. the non-verbal matches the verbal communication, is what is required (Mapp and Hudson 2005).

Non-emergency situations can also involve high emotional states. Emotional arousal, for example, as a consequence of a power struggle, will evoke a defensive response. The thinking part of the brain becomes inhibited in emotional arousal, so it follows that learning and taking in information cannot be effective when the client feels conflict or stress (Griffin & Tyrrell 2004). When a midwife says ‘I want to tell you about breastfeeding’, the emotional arousal in the client may come from the unsaid ‘who are you to tell me how to bring up my family?’. It would be more useful to first reduce the emotional arousal, and reframe or present the information another way: ‘It’s good you have decided on your method of feeding and I would like to hear more about how you are going to feed your baby’. Nichols (2009) points out that ‘It isn’t exuberance or any other emotion that conveys loving appreciation; it’s being noticed, understood and taken seriously’.

However, midwives may perceive that the use of open questions in this way will take up too much time. When information becomes blocked, then misunderstanding is increased which leads to spending more time correcting the problem at a later date. Midwives also limit their emotional effort, and they may stereotype in order to increase control over work situations (Kirkham et al. 2002b), although if they were able to increase their sensitive responsiveness, clients would be able to find out the information they need, understand and feel understood.

Midwives need to give emotional care to their clients, particularly those in labour, and this is draining for them. Many midwives realise they do not have time for their own emotional feelings so they pull down the shutters to look calm. It is this that can give the impression of ‘aloofness’, whereas others are perceived as naturally friendly (John & Parsons 2005). As John and Parsons (2005) suggest, support mechanisms need to be developed and implemented in order to reduce stress in practice. According to Nichols (2009): ‘If you see a parent with blunted emotions ignoring a bright-eyed baby, you’re witnessing the beginning of a long, sad process by which unresponsive parents wither the enthusiasm of their children like unwatered flowers’.