Fundamentals of Midwifery: A Textbook for Students (34 page)

emotional lids
’ on (Deery and Kirkham 2007, p81), women tend to take their cues from that and do the same (Edwards 2009) and the opportunity to achieve a balanced exchange (Hunter 2006) is inevitably lost.It is valuable to consider how and why meaningful relationships develop in some circum- stances and situations but not in others. A number of things come into play, such as individual personalities. We cannot all instantaneously build rapport with everyone; some relationships may take a little more emotion work and create the need to draw on communication skills.
Individuals are not all the same in their ability to communicate, and capacities for empathy and trust also vary (Deery and Hunter 2010). The model within which care is delivered may also facilitate or restrict the development of relationships (for examples see McCourt and Stevens 2009; Dykes 2009; Kirkham 2010). Unfortunately, research evidence continually suggests that communication within maternity care is an area of dissatisfaction for women (Edwards 2004;‌76 Jomeen 2010; Jomeen and Redshaw 2012) and something we could ‘do’ better.
Activity 4.2 Can you think of situations in clinical practice where you have engaged in emotional labour?

How did your behaviour affect the women you were caring for?

How did your behaviour affect you?

What might you have done differently?
Initiating, building and maintaining relationships
So if the key is the potential to create a meaningful relationship, we might ask: How this can be achieved?Central to any relationship is effective communication. Communication is complex and about more than just the imparting of information. Essentially communication falls into two groups; verbal and non-verbal, but we communicate in three ways, through the content of our speech, our body language and the tone of our voice.
Verbal communication:
Refers to using speech and writing to share thoughts, feelings and ideas with other people.
Non-verbal communication:
Includes all other ways that people share their thoughts, feelings and ideas:

facial expressions

touch

gestures such as nods of the head

silence

the way people sit or stand

the space they maintain between them. (Arnold and Boggs 2007; Sully and Dallas 2010)
First impressions
The context within which midwives and women meet for the first time will inevitably have an impact on the initiation of the relationship. Early impressions, especially those gleaned from non-verbal communication are often the most influential and enduring and can be nega- tive or positive. Initial inferences (non-verbal or verbal) can be corrected, but require greater emotional work on behalf of both parties and sometimes may not be remedied (Raynor and England 2010).
Building and/or maintaining a woman–midwife relationship‌
Once an impression has been formed people look for evidence that reinforces their initial con- clusions. Women have highlighted the characteristics of midwives that shape either close or distant relationships. Nicholls and Webb (2006) state the attributes of a ‘good’ midwife that are important to women. These are midwives who are: friendly, kind, smiling, caring, approachable,non-judgmental, have time, are respectful, provide support and companionship and are good
⁷⁷
communicators. ‘Good’ midwives establish rapport and create a relationship of a social nature (Bharj and Chesney 2010). ‘Bad’ midwives are unhelpful, insensitive, abrupt, officious, fail to listen and lack concern (Nicholls and Webb 2006), fail to respond to women’s support needs and are perceived as disrespectful and insensitive, leaving women feeling disempowered (Jomeen and Redshaw 2012).Midwives themselves recognise that they are not always able to form an emotional relation- ship with a woman; in these cases they form a professional relationship through which they attend to the physical aspects of care (McCrea and Crute 1991). Whilst women have profiled ‘bad’ midwives this is most often based on the midwife’s attitude, attributes and the lack of a relationship, rather than a failure to provide physical care (Bharj and Chesney 2010). What this demonstrates is how valuable the midwife–woman relationship is in women’s experiences of care. A combination of verbal and non-verbal communication behaviours underpin women’s assessments of a midwife’s attributes. Poor communication when described by women is con- sistently linked to the behaviours and characteristics that midwives display (Jomeen and Redshaw 2012).There will be levels of communication which range from superficial to deep which are per- fectly normal and a functional part of human relating (Raynor and England 2010). Even if there is no strong sense of connection, midwives can still draw on communication skills to create rapport (Deery and Hunter 2010). Sometimes, for example, women adopt aggressive or passive communication styles, which can result in a strong temptation for the midwife to pull away. Raynor and England (2010) argue that this is a mistake because ‘
it nurtures a psychological void
’ (p. 91) and believe such behaviour actually requires sustained contact, continuity and assertive communication, which facilitates the midwife to express appropriate thoughts in a transparent and authentic way, that does not result in psychological expense to the woman.
Concepts that underpin effective communication and the woman– midwife relationship
Listening
It is fundamental in any relationship to be heard (Kirkham 2010), yet listening is a difficult skill to develop because it takes time (Raynor and England 2010). This is affected by several elements:

Women do not like to ask because midwives are busy.

Midwives working in fragmented, busy environments may see little point in listening towomen who they are never going to meet again.

Midwives focus on tasks not women, which prevents them from hearing women.

Midwives are more concerned with giving information and advice, because they knowbetter.Being heard is important to a woman, it means she is being taken seriously and her thoughts and feelings matter. Care can be ‘smiley’ but if it is still formulaic (Kirkham 2010), it prevents midwives listening, inhibits the woman who might wish to express her wishes and promote herdecisions and hence prevents the development of an effective relationship (Kirkham 2010; Raynor and England 2010).‌‌
Listening is more than just letting someone talk; it is an active activity. The listener must pay attention, concentrate on what the woman has to say and be present. Empathy, for example, requires listening skills to understand others’ feelings of anxiety and self-doubt. This in turn then
⁷⁸
requires ‘
an emotional shift
’ (Raynor and England, p. 94) from thinking to feeling, where themidwife then is able to communicate a sincere non-judgmental understanding of the woman’s experience.
Presence
The offering of presence and time is a powerful form of psychosocial support. Presence is ‘being with’ rather than ‘doing to’ and can be particularly valuable when words become redundant (Raynor and England 2010).
Trust
Trust rests on common value, not necessarily on common viewpoints, but the midwife must have respect for the woman’s values and priorities (Kirkham 2010). When a mother feels safe in her relationship with her midwife, a positive relationship is much more likely to develop because the mother feels acknowledged and valued. This is in direct opposition to a midwife who exerts authority, offers choice but then proffers personal opinions, either through her verbal or non- verbal communication, or gate-keeping through the withholding of information. The notion of choice and the woman as an active decision-maker then becomes largely illusory, which can have implications for women’s psychological health (Jomeen 2010).
Summary
Women clearly believe that good relationships with their midwives are central to their experi- ences of childbirth; many midwives hold similar beliefs. Verbal and non-verbal cues are critical in first impressions and establishing and maintaining relationships. Good relationships are built on trust, mutuality and empathy. All of these aspects require an active not passive approach and can be emotionally demanding, but when achieved are also immensely rewarding for both parties. Awareness that the development and establishment of relationships can be both challenging and emotionally demanding, and attentiveness to barriers, both real and perceived, are critical to ensure that both women and midwives do not suffer negative emotional consequences.
Bonding and attachment
Bonding and attachment are vital for the maternal–child relationship and the wellbeing of theinfant. It is important to differentiate between ‘bonding’ and ‘attachment’ as the terms are often used interchangeably (Redshaw and Martin 2013). The origins of attachment are predominantly based on Bowlby’s development of Attachment Theory (Bowlby 1969).
Defining bonding and attachment
Bonding
describes the
maternal–infant relationshi
p, that is, the
mother’s
relationship with her infant.
Attachment
describes the
infant–maternalrelationship
– the
infant’s
connection with its mother/ caregiver.Attachment theory has informed our understanding of the importance of the infant–maternal bond, the ‘secure base’ (Bowlby 1988), for the psychological and physiological wellbeing of the
neonate. Attachment, as stated above, is used to define the infant’s connection with a caregiver. Bonding, as described by Altaweli & Roberts (2010) is a complex phenomenon which defines a deep, enduring emotional attachment between mother and fetus in utero, which progresses to bonding with the neonate post-birth. However, there is a lack of conceptual clarity regarding the maternal–fetal relationship during pregnancy, and whether bonding is an appropriate term‌in this context (Redshaw and Martin 2013). 79
Further reading activityFor further reading on the antenatal maternal–fetal relationship, see Walsh, J., Hepper, E.G., Bagge,