(p. 225) The Contribution of Psycho-Analysis to Midwifery
It should be remembered that it is the midwife’s skill, based on a scientific knowledge of the physical phenomena, that gives her patients the confidence in her that they need. Without this basic skill on the physical side she may study psychology in vain, because she will not be able to substitute psychological insight for knowing what to do when a placenta praevia complicates the birth process. However, given the requisite knowledge and skill, there is no doubt that the midwife can add greatly to her value by acquiring also an understanding of her patient as a human being.
Place of Psychoanalysis
How does psychoanalysis come into the subject of midwifery? In the first place, through its minute study of detail in long and arduous treatments of individual people. Psychoanalysis is beginning to throw light on all sorts of abnormality such as menorrhagia, repeated abortion, morning sickness, primary uterine inertia; and many other physical states can sometimes have as part of their cause a conflict in the unconscious emotional life of the patient. Much has been written about these psychosomatic disorders. Here, however, I am concerned with another aspect of the psychoanalytic contribution: I will try to indicate, in general terms, the effect of psychoanalytic theories on the (p. 226) relationships between the doctor, the nurse, and the patient, with reference to the situation of childbirth.
Psychoanalysis has already led to a very big change in emphasis which shows itself in the attitude of midwives today compared with those of twenty years ago. It is now accepted that the midwife wants to add to her essential basic skill some assessment of the patient as a person—a person who was born, was once an infant, has played at mothers and fathers, has been scared of the developments that come at puberty, has experimented with new-found adolescent urges, has taken the plunge and has married (perhaps), and has either by design or by accident fallen with child.
If the patient is in hospital she is concerned about the home to which she will return, and in any case there is the change which the birth of the baby will make to her personal life, to her relationship with her husband, and to the parents of both herself and her husband. Often, also, complications are to be expected in her relationship to her other children, and in the feelings of the children towards each other.
If we all become persons in our work, then the work becomes much more interesting and rewarding. We have, in this situation, four persons to consider, and four points of view. First there is the woman, who is in a very special state which is like an illness, except that it is normal. The father, to some extent, is in a similar state, and if he is left out the result is a great impoverishment. The infant at birth is already a person, and there is all the difference between good and bad management from the infant’s point of view. And then the midwife. She is not only a technician, she is also human; she has feelings and moods, excitements and disappointments; perhaps she would like to be the mother, or the baby, or the father, or all in turn. Usually she is pleased and sometimes she feels frustrated to be the midwife.
Essentially Natural Process
One general idea goes right through what I have to say: that is, that there are natural processes which underlie all that is taking place; and we do good work as doctors and nurses only if we respect and facilitate these natural processes.
Mothers had babies for thousands of years before midwives appeared on the scene, and it is likely that midwives first came to deal with superstition. The modern way of dealing with superstition is the adoption of a scientific attitude, science being based on objective observation. Modern training, based on science, equips the midwife to ward off superstitious practices. What about fathers? Fathers had a definite function before doctors and the welfare state took it over: they not only felt themselves the feelings of their women, and went through some of the agony, but also they took part, warding off external and unpredictable impingements, and enabling the mother (p. 227) to become preoccupied, to have but one concern, the care of the baby that is there in her body or in her arms.
Change in Attitude to the Infant
There has been an evolution of attitude with regard to the infant. I suppose that throughout the ages parents have assumed that the infant was a person, seeing in the infant much more than was there—a little man or woman. Science at first rejected this, pointing out that the infant is not just a little adult, and for a long time infants were regarded by objective observers as scarcely human till they started to talk. Recently, however, it has been found that infants are indeed human, though appropriately infantile. Psychoanalysis has been gradually showing that even the birth process is not lost on the infant, and that there can be a normal or an abnormal birth from the infant’s point of view. Possibly every detail of the birth (as felt by the infant) is recorded in the infant’s mind, and normally this shows in the pleasure that people get in games that symbolize the various phenomena that the infant experienced—turning over, falling, sensations belonging to the change from being bathed in fluid to being on dry land, from being at one temperature to being forced to adjust to temperature change, from being supplied by pipeline to being dependent for air and food on personal effort.
The Healthy Mother
One of the difficulties that is encountered with regard to the midwife’s attitude to the mother ranges round the problem of diagnosis. (Here I do not mean the diagnosis of the bodily state, which must be left to the nurse and the doctor, nor will I refer to bodily abnormality; I am concerned with the healthy and the unhealthy in the psychiatric sense.) Let us start with the normal end of the problem.
At the healthy extreme the patient is not a patient, but is a perfectly healthy and mature person, quite capable of making her own decisions on major matters, and perhaps more grown-up than the midwife who attends her. She happens to be in a dependent state because of her condition. Temporarily she puts herself in the nurse’s hands, and to be able to do that in itself implies health and maturity. In this case the nurse respects the mother’s independence for as long as possible, and even throughout the labour if the confinement is easy and normal. In the same way, she accepts the complete dependency of the many mothers who can go through the experience of childbirth only by handing over all control to the person in attendance.
(p. 228) Relationship of Mother, Doctor, and Nurse
I suggest that it is because the healthy mother is mature or adult that she cannot hand over the controls to a nurse and a doctor whom she does not know. She gets to know them first, and this is the important thing of the period leading up to the time of the confinement. She either trusts them, in which case she will forgive them even if they make a mistake; or else she does not trust them, in which case the whole experience is spoiled for her; she fears to hand over, and attempts to manage herself, or actually fears her condition; and she will blame them for whatever goes wrong whether it is their fault or not. And rightly so, if they failed to let her get to know them.
I put first and foremost this matter of the mother and the doctor and nurse getting to know each other, and of continuity of contact, if possible, throughout the pregnancy. If this cannot be achieved, then at least there must be a very definite contact with the person who is to attend the actual confinement, well before the expected date of the confinement.
A hospital set-up which does not make it possible for a woman to know in advance who will be her doctor and her nurse at the time of the confinement is no good, even if it be the most modern, well-equipped, sterile, chromium-plated clinic in the country. It is this sort of thing that makes mothers decide to have their babies at home, with the family practitioner in charge, and with hospital facilities available only in case of serious emergency. I personally think that mothers should be fully supported in their idea when they want a home confinement, and that it would be a bad thing if in the attempt to provide ideal physical care there should come a time when the home confinement would not be practicable.
A full explanation of the process of labour and childbirth should be given to the mother by the person to whom she has given her confidence, and this goes a long way towards dispelling such frightening and incorrect information as may have come her way. It is the healthy woman who most needs this and who can make best use of the true facts.
Is it not true that when a healthy and mature woman who is in a healthy relation to her husband and family reaches the moment of childbirth, she is in need of all the immense skill that the nurse has acquired? She is in need of the nurse’s presence, and of her power to help in the right way and at the right moment, should something go wrong. But all the same she is in the grip of natural forces and of a process that is as automatic as ingestion, digestion, and elimination, and the more it can be left to nature to get on with it the better it is for the woman and the baby.
One of my patients, who has had two children, and who is now gradually, so it seems, coming through a very difficult treatment in which she herself had to start again—in order to free herself from the influences on her early development of her difficult mother—wrote as follows: ‘… even allowing for (p. 229) the woman to be fairly emotionally mature, the whole process of labour and childbirth breaks down so many controls that one wants all the care, consideration, encouragement and familiarity of the one person looking after you, as a child needs a mother to see it through (each) one of the new and big experiences encountered in its development’.
Nevertheless, with reference to the natural process of childbirth one thing can seldom be forgotten, the fact that the human infant has an absurdly big head.
The Unhealthy Mother
In contrast to the healthy, mature woman who comes under the midwife’s care there is the woman who is ill, that is, emotionally immature, or not orientated to the part the woman plays in nature’s comic opera; or who is perhaps depressed, anxious, suspicious, or just muddled. In such cases, the nurse must be able to make a diagnosis, and here is another reason why she needs to know her patient before she gets into the special and uncomfortable state that belongs to late pregnancy. The midwife certainly needs special training in the diagnosis of psychiatrically ill adults, so that she may be free to treat as healthy those who are healthy. Naturally the immature or otherwise unhealthy mother needs help in some special way from the person who has charge of her case: where the normal woman needs instruction, the ill one needs reassurance; the ill mother may test the nurse’s tolerance and make herself a positive nuisance, and perhaps she may need to be restrained if she should become maniacal. But this is rather a matter of common sense, of meeting need with appropriate action, or studied inaction.
In the case of the healthy mother and father, the ordinary case, the midwife is the employee, and she has the satisfaction of being able to give the help that she is employed to give. In the case of the mother who is in some way ill, who is unable to be fully adult, the midwife is the nurse acting with the doctor in the management of a patient—her employer is the agency, the hospital service. It would be terrible if this adaptation to ill health should ever swamp a natural procedure adapted not to illness but to life.
Of course many patients come in between the two extremes I have devised for descriptive purposes. What I wish to emphasize is that the observation that many mothers are hysterical or fussy or self-destructive should not make midwives fail to give health its due and emotional maturity its place; should not lead them to class all their patients as childish, when in fact the majority are fully capable except in the actual matters which they must be able to leave to the nurse. For the best are healthy; it is the healthy women who are the (p. 230) mothers and wives (and midwives) who add richness to mere efficiency, add the positive gain to the routine that is successful merely because it is without mishap.
Management of the Mother with Her Baby
Let us now consider the management of the mother after the birth, in her first relationship to the newborn baby. How is it that when we give mothers a chance to speak freely and to remember back we so often come across a comment of the following kind? (I quote from a case description given by a colleague, but time after time I myself have been told the same.)
‘He had a normal birth and his parents wanted him. Apparently he sucked well immediately after delivery but was not actually put to the breast for thirty-six hours. He was then difficult and sleepy, and for the next fortnight the feeding situation was most unsatisfactory. Mother felt that the nurses were unsympathetic, that they didn’t leave her long enough with the baby. She says that they forced his mouth onto the breast, held his chin to make him suck, and pinched his nose to take him off the breast. When she had him at home she felt that she established normal breast-feeding without any difficulty’.
I do not know whether nurses know that this is how women complain. Perhaps they are never in the position to hear their remarks, and of course mothers are not likely to complain to the nurse to whom they certainly owe much. Also, I must not believe that what mothers say to me gives an accurate picture. I must be prepared to find the imagination at work, as indeed it ought to be, since we are not just bundles of facts; and what our experiences feel like to us and the way they get interwoven with our dreams is all part of the total thing called life, and individual experience.
Sensitive Post-natal State
In our specialized psychoanalytic work we do find that the mother who has just had a baby is in a very sensitive state, and that she is very liable for a week or two to believe in the existence of a woman who is a persecutor. I believe there is a corresponding tendency that we must allow for in the midwife, who can easily at this time slip over into becoming a dominating figure. Certainly it often happens that the two things meet: a mother who feels persecuted and a monthly nurse who drives on as if actuated by fear rather than by love.
This complex state of affairs is often resolved at home by the mother’s dismissal of the nurse, a painful procedure for all concerned. Worse than that is the alternative by which the nurse wins, so to speak: the mother sinks back (p. 231) into hopeless compliance, and the relationship between the mother and the baby fails to establish itself.
I cannot find words to express what big forces are at work at this critical point, but I can try to explain something of what is going on. There is a most curious thing happening: the mother who is perhaps physically exhausted, and perhaps incontinent, and who is dependent on the nurse and the doctor for skilled attention in many and various ways, is at the same time the one person who can properly introduce the world to the baby in a way that makes sense to the baby. She knows how to do this, not through any training and not through being clever, but just because she is the natural mother. But her natural instincts cannot evolve if she is scared, or if she does not see her baby when it is born, or if the baby is brought to her only at stated times thought by the authorities to be suitable for feeding purposes. It just does not work that way. The mother’s milk does not flow like an excretion; it is a response to a stimulus, and the stimulus is the sight and smell and feel of her baby, and the sound of the baby’s cry that indicates need. It is all one thing, the mother’s care of her baby and the periodic feeding that develops as if it were a means of communication between the two—a song without words.
Two Opposed Properties
Here then we have on the one hand a highly dependent person, the mother, and at the same time and in the same person, the expert in that delicate process, the initiation of breast-feeding, and in the whole bustle and fuss of infant care. It is difficult for some nurses to allow for these two opposed properties of the mother, and the result is that they try to bring about the feeding relationship as they would bring about a defecation in the case of loaded rectum. They are attempting the impossible. Very many feeding inhibitions are started in this way; or even when feeding by bottle is eventually instituted this remains a separate thing happening to the infant, and not properly joined up with the total process that is called infant care. In my work I am constantly trying to alter this sort of fault, which in some cases is actually started off in the first days and weeks by a nurse who did not see that though she is an expert in her job, her job does not include making an infant and a mother’s breast become related to one another.
Besides, the midwife has feelings, as I have said, and she may find it difficult to stand and watch an infant wasting time at the breast. She feels like shoving the breast into the baby’s mouth, or shoving the baby’s mouth into the breast, and the baby responds by withdrawing.
There is another point: this is that, almost universally, the mother feels a little, or a lot, that she has stolen her baby from her own mother. This derives from her playing at mothers and fathers, and from her dreams that belong to the time when she was quite a little girl, and her father was her beau ideal. (p. 232) And so she may easily feel, and in some cases she must feel, that the nurse is the revengeful mother who has come to take the baby away. The nurse need not do anything about this, but it is very helpful if she avoids actually taking the infant away—depriving the mother of that contact which is natural—and, in fact, only presenting the infant to the mother, wrapped in a shawl, at feedtime. This last is not modern practice, but it was common practice till recently.
The dreams and imaginations and the playing that lie behind these problems remain even when the nurse acts in such a way that the mother has a chance to recover her sense of reality, which she naturally does within a few days or weeks. Very occasionally, then, the nurse must expect to be thought to be a persecuting figure, even when she is not so, and even when she is exceptionally understanding and tolerant. It is part of her job to tolerate this fact. In the end the mother will recover, usually, and will come to see the nurse as she is, as a nurse who tries to understand, but who is human and, therefore, not without a limit to her tolerance.
Another point is that the mother, especially if she be somewhat immature herself, or a bit of a deprived child in her own early history, finds it very hard to give up the nurse’s care of her, and to be left alone to care for her infant in the very way that she herself needs to be treated. In this way the loss of the support of a good nurse can bring about very real difficulties in the next phase, when the mother leaves the nurse, or the nurse leaves her.
In these ways psychoanalysis, as I see it, brings to midwifery, and to all work involving human relationships, an increase in the respect that individuals feel for each other and for individual rights. Society needs technicians even in medical and nursing care, but where people and not machines are concerned the technician needs to study the way in which people live and imagine and grow on experience.