safe and fulfilling birth experience (Halfdansdottir et al. 2015). In addition, Hall et al. (2018) indicate that women's dynamic experience of birth is influenced by the confidence felt in the belief that one's body is able to give birth, whilst drawing on emotional and physical support to cope with the experience and a sense of control over pain and pain relief to ensure comfort and increased relaxation.
The relational model also considers relational continuity which enables professionals to provide holistic care through their presence whilst providing emotional support in the woman–midwife relationship. Quality and content of care is perceived by women to be important in enabling a positive birthing experience (Dahlberg and Aune 2013), aided by the nurturing presence of the midwife as her advocate and companion. The concept of the ‘ritual companion’ has been explored from an Australian perspective and concludes that two contrasting types of midwifery practice were being facilitated: that of the ‘rites of passage’ during childbirth, in which the woman–midwife relationship is enabling and empowering and, the ‘rites of protection’ in which labour is perceived to be a time of danger and requires monitoring and assessment to provide a sense of control over the childbirth process (Reed et al. 2016).
Earlier literature advocates for a ‘caring presence’ in the true sense of ‘with woman’ that involves a personal connection between woman and midwife placing the woman at the centre of the relationship and creating an environment of security and trust (Pembroke and Pembroke 2008). With this commitment by midwives to positively enhance the birth experience, the authors suggest that the spirituality of midwifery is played out through the concepts of responsiveness and availability. It is viewed sensitivity and respects the uniqueness of each woman. As identified in the study by Brown (2012), midwives are ‘with woman’ when they are perceptive enough to read the situation and are responsive to her needs and values. This requires the midwife to be available as a ready listener and include herself in the protective sphere that women retreat to when in labour. In addition, it needs the midwife to understand and be actively involved in providing the information and skills to enable the woman to make the right decisions.
Women and midwives are generally in agreement about the need to achieve a positive outcome for every birthing experience. This agreement is based on shared values of solidarity which promote and champion physiological birth through social and mutual support and minimum intervention (Brown and Gallagher 2015). The concept of solidarity as applied to bioethics results in cohesion and integration connected through similar aspirations (Prainsack and Buyx 2011) of mother and midwife in an interdependent relationship to achieve a safe and effective birth outcome. An integration of solidarity with an ethos of midwifery practice can only be achieved through reciprocity of information, transparency and honesty between childbearing women and the health professional to maintain the ‘with woman’ concept (Dann 2007). In making rational choices, the midwife and woman must justify their decisions by considering the value that is placed on the birthing experience. This shared solidarity is demonstrated through mutually shared responsibility between mother and midwife who take on personal accountability for choices and decisions made.
Advocacy
Making decisions is challenging and complex, especially within midwifery practice, and has an impact on the type and standard of care that is provided (Smith 2016). Reasoned and safe choices based on evidence and intuition can be achieved through this partnership with women (Daemers et al. 2017). A sympathetic and empathetic approach to decisions is perceived by women to result in a more positive birth experience (Boyle et al. 2016). However, pain during childbirth is one aspect that can hinder the decision‐making process (Whitburn et al. 2019) and requires midwives to exercise the concept of relational autonomy to protect the woman when she cannot make reasoned decisions (Brown and Salmon 2018). In this respect, autonomy (discussed earlier in this chapter) ‘is a key concept in understanding advocacy’ (Cole et al. 2014, p. 576).
Advocacy has had an important role in professional/service user relationships. One of the ‘key messages’ in ‘Midwifery 2020: Delivering expectations’ is in the section ‘Developing the midwife's role in public health and reducing inequalities’ which states:
Midwives should use their advocacy role for influencing and improving the health and wellbeing of women, children, and families. This will include making the economic case for committing resources so that the midwife can deliver public health messages in the antenatal and postnatal periods and ensuring that there is a midwifery contribution at policy, strategic, political, and international level (p. 7).
Working alongside women, midwives exercise what has been referred to as ‘skilled companionship’ (Dierckx de Casterlé 2015) as they journey ‘with women’ through the birth and postnatally. Through this concept, midwives integrate skills and companionship and bring together the scientific and moral aspects of care. This requires midwives to be committed to provide an empathic presence during childbirth events. Women thus feel accompanied and supported. However, ethical challenges may arise should women make choices which are considered detrimental to the health of themselves, their baby or the midwife (Jenkinson et al. 2017). In such situations, midwives may experience ethical uncertainty or, perhaps, unpreparedness to respond ethically to women's needs and preferences. There may, for example, be a conflict of principles between respect for autonomy and beneficence/non‐maleficence and justice. The midwife should use her advocacy role by taking the lead to facilitate making decisions for the woman and meeting her holistic needs and interests through empathetic, intuitive and sensitive support and ‘companionship’.
Empathy, Intuition and Sensitivity
A definition of empathy is the action of understanding, being aware of, being sensitive to and vicariously experiencing the feelings, thoughts and experience of another (Medical Dictionary 2019). Both empathy and intuitive knowledge are integral components of what is perceived by experts as creating competence and is expressed through touch and physical closeness or emotionally through spiritual oneness ‘with woman’. Facilitative or cathartic interventions enable emotional and supportive approaches to acknowledge the woman's worth and demonstrate mutual respect. Sensitivity to women's needs is another aspect of the ‘with woman’ concept and is illustrated below. In addition, a midwife who makes an effort to be compassionate demonstrates empathy and intuition as spiritual care (Linhares 2012, Crowther and Hall 2015), as documented by Moloney and Gair (2015).
Observation that the nature of midwifery practice changes in an environment in which the midwife is engaged in being ‘with woman’ rather than doing, concurs with Brown's (2012) findings of watching and waiting and not just doing. Leap's publication in 2000 remains at the centre of this midwifery philosophy and was perceptive in suggesting that midwives give when they do less (Leap 2000). A key element of ensuring midwives and healthcare professionals are ‘with woman’ in their daily contact with childbearing women is well‐developed communication skills. In this respect, Gibbons (2010) suggests that communication goes beyond just words into the environment which is created in order to encourage comfort and privacy and promote unspoken dialogue. Positive first impressions created by midwives influence the quality of rapport and the relationship that is grown between woman and midwife (NHS England 2016). Raynor and England (2010) suggest that attitudes of acceptance and warmth, sharing a genuineness of transparent thoughts and feelings demonstrated in empathetic understanding by the midwife placing herself in the woman's position, are a humanistic approach to therapeutic verbal and non‐verbal communication.
The ‘Good’ Midwife
The concept of being a ‘good midwife’, as explored in systematic reviews by both Nicholls and Webb (2006) and Byrom and Downe (2010), identifies well‐developed communication skills, compassion, kindness, knowledge and midwifery skills as key elements. Attitudes and feelings together with midwifery knowledge create clinical competence to fulfil being ‘with woman’ (Carolan 2011). Halldorsdottir and Karlsdottir (2011) debate the primacy of the midwife's professionalism as central to the role of the
