Nursing Inquiry 2007; 14(2): 140–152

Feature

‘With woman’ philosophy: examining

Blackwell Publishing Ltd

the evidence, answering the questions

Mary Carolana,b and Ellen Hodnettb
aVictoria University, Melbourne, Australia, bUniversity
of Toronto, Toronto, Ontario, Canada

Accepted for publication 1 February 2007

CAROLAN M and HODNETT E. Nursing Inquiry 2007; 14: 140–152

‘With woman’ philosophy: examining the evidence, answering the questions
‘With woman’, ‘woman centred’ and ‘in partnership with women’ are new terms associated with midwifery care in Australia,
and the underlying philosophy has emerged both as an antidote to the medicalisation of pregnancy and in a bid to reacquaint
women with their natural capacity to give birth successfully and without intervention. A reorientation of midwifery services in
the 1990s, a shift towards midwifery-led care (MLC) and the subsequent introduction of direct entry midwifery programs all
contributed to this new direction. Central concepts are a focus on the childbearing woman and a valuing of women’s experi-
ences. While this philosophical re-alignment has been applauded by many midwives in terms of maternal empowerment and
improved autonomy for midwives, there are nonetheless some concerns that, with its emphasis on normality, midwifery-led care
is in danger of becoming an exclusionary model. Particular concerns include meeting the needs of a growing cohort of women,
those with ‘high risk’ pregnancies, and the educational adequacy of direct entry midwifery programs. To date, there has been
no thorough evaluation of this emerging midwifery philosophy in Australia. In order to open the debate, this paper aims to
initiate a discussion of ‘with woman’ midwifery care as it applies to Australian practice.
Key words: continuity of care, direct entry midwives, midwifery relationship, midwifery, woman centred.

Midwifery-led care emerged in the UK in the early 1990s in
response to government policy changes to maternity services
provision, which were outlined in the now famous Changing
childbirth report (Department of Health (UK) 1993; McCourt
et al. 1998). Changes were driven by both consumers and
professionals and followed widespread dissatisfaction with
existing maternity service provision. A variety of studies
conducted in Australia and in the UK found that women
giving birth at public hospitals were particularly unhappy.
Issues raised included a lack of continuity of care and carer
(Williamson and Thomson 1996), long waiting times in clinics
(Brown and Lumley 1994), a lack of information and involve-
ment in decision-making (Jacoby 1987; Brown and Lumley
1994, 1998; Garcia et al. 1998; Proctor 1998) and a lack of
respect and sensitivity among care-givers (Brown and
Correspondence: Dr Mary Carolan, School of Nursing and Midwifery, Victoria
University, PO Box 14428, Melbourne 8001, Australia.
E-mail: <mary.carolan@vu.edu.au>
Lumley 1994). Concerns such as fragmented care and
increasing medicalisation of pregnancy were common to
both women and midwives.
Subsequent government policy changes in the UK gave
rise to a new type of maternity service, variously called
midwifery-led care, one-to-one midwifery care or woman-
centred care. The principal difference with this type of care
was that midwives now assumed the role of primary care
giver, instead of the more usual physician-led care. Stated
aims included a ‘woman-centred’ focus, and an emphasis on
birth as a normal life event. It was anticipated that approxi-
mately 30% of British women would receive midwifery-led
care (McCourt et al. 1998) and it was hoped that this move
would go some way towards addressing dissatisfaction with
existing services. It might also reduce caesarean section
rates, help contain service costs (Myers-Ciecko 1999; Homer
et al. 2001; Page 2003) and increase the likelihood of a focus
on the woman’s individual needs (Pope, Graham and
Patel 2001). The advent of direct entry midwifery programs,

© 2007 The authors. Journal compilation © 2007 Blackwell Publishing Ltd


offering 3-year preregistration degree courses to non-nurses,
is also traceable to this time. This new form of midwifery
education was contingent upon and philosophically congruent
with the general shift within midwifery, and a growing
emphasis on ‘women empowerment’, and ‘woman-centred’
care (Lobo 2002).
Midwifery-led care has now been employed for more
than a decade in the UK and for almost the same amount of
time in Australia. Traditionally, it takes two forms. The first
approach is personal caseload, wherein a midwife has primary
responsibility for the maternity care of a group of women,
usually in the region of 40 cases per annum. A named mid-
wife provides antepartum, intrapartum, educational and
postpartum care and remains with the woman throughout
labour. Most personal caseload midwives work in partner-
ship with at least one other midwife in order to provide
cover for holiday and other leave. This model is commonly
employed in the UK. The second approach is team-led
midwifery care, where a group of as many as seven to eight
midwives provide a similar level of care to a shared caseload
of women (Biro et al. 2003). This is the form of midwifery-led
care most commonly employed in Australia.
This paper offers a discussion of ‘with woman’ midwifery
care, as currently endorsed in Australia. In the first instance,
a review of the central concepts of continuity of care, choice
and control is offered. Second, contingent issues of mid-
wifery education, normal birth and the midwife–woman
relationship are considered. Throughout, a series of ques-
tions are posed as midwives transit, from more traditional
models of maternity care, to an understanding and appreci-
ation of ‘with woman’ care.
CONTINUITY OF CARE
Although the term ‘continuity of care’ is not well defined
(Green, Renfrew and Curtis 1999; Hodnett 2000), it is
generally taken to mean fewer carers during pregnancy (van
Teijlingen et al. 2003) and the presence of a known midwife
in labour (Page 2003). There is little doubt that midwifery-led
care that endorses this sort of continuity benefits childbear-
ing women in terms of satisfaction and support (McCourt
et al. 1998; Biro et al. 2003; Page 2003). Indeed, it is associated
with a whole range of benefits including less clinical inter-
vention during labour (Gagnon, Waghorn and Covrell 1997;
Page et al. 2001), shorter second stage of labour (Page et al.
1999), less intrapartum analgesia (Page et al. 1999; Hodnett
2000), fewer caesarean sections (Gagnon and Waghorn 1999)
and fewer episiotomies (Page et al. 1999; Hodnett 2000),
although Hodnett’s systematic review suggests a higher
incidence of perineal tears. Women receiving midwifery-led
© 2007 The authors. Journal compilation © 2007 Blackwell Publishing Ltd
‘With woman’ philosophy
care are also likely to experience shorter waiting times to
antenatal appointments (Waters et al. 2004), and to feel
prepared for childbirth and well supported in labour
(Hodnett 2000). Other benefits, such as greater satisfaction
with care among ethnic minority groups (McCourt and
Pearce 2000), are posited. Although it is clear that women
value supportive care centred on their needs, what is less
clear is the importance women accord to being cared for in
labour by a known midwife. Several critiques suggest that
‘ethos of care’, consistent information and involvement in
decision-making are of greater importance to women than
having met their midwife previously (Morgan et al. 1998;
Green, Renfrew and Curtis 1999, 77). In addition, Green,
Coupland and Kitzinger (1990) found that, although women
‘wanted consistent care from carers they trusted’ they did
not value ‘continuity for its own sake’ (186). Similarly,
Waldenstrom (1998), who conducted a birth centre study,
found that continuity of carer was less important to women
than philosophy of care. Hundley, Ryan and Graham (2001)
found that women considered that continuity, which was
‘achieved at the expense of decreasing the availability of
pain relief’, was an unacceptable choice (254). Overall, the
weight of evidence suggests that while women value continuity
of care they consider philosophy and consistency of care to
be of greater importance.
CHOICE AND CONTROL
Choice and control are described as central concepts of
woman-focused care. Nonetheless, these concepts are not
well defined in the literature, although it would seem here
that choice refers to women’s decisions about models of
maternity care, types of carers and decisions within particu-
lar models of care. Within midwifery-led care, concepts of
choice and control include providing women with sufficient
information to enable them to make care decisions in partner-
ship with midwives. Within this model, midwives tailor
care to the individual woman’s requirements (Pope, Graham
and Patel 2001), which is a central recommendation of the
Changing childbirth report (Department of Health 1993).
In Australia, choice for pregnant women seems to be
principally affected by three factors: the knowledge women
possess about care models, local availability of services and
perceptions of risk. Sociodemographics may also play a part.
Overall, the knowledge Australian women possess about
pregnancy care seems to be highly variable, although a var-
iety of resources are available both at a community level and
on the Internet. Pamphlets and information sheets in
several key languages are available at doctors’ surgeries,
community centres and maternal and child centres.
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M Carolan and E Hodnett
Websites outlining current thoughts about ‘woman-centred
care’ and offering advice and information on differing models
of maternity care are common. Examples include http://
www.nsw.gov.au/life.asp; http://www.health.vic.gov.au/
maternitycare; and http://www.service.sa.gov.au/. None-
theless, it seems likely that this information is accessed prin-
cipally by well-educated and well-resourced individuals
and this tendency is widely reported elsewhere. For example,
studies by Benigeri and Pluye (2003), Eng et al. (1998) and
Brodie et al. (2000) have all demonstrated that individuals
of lower socioeconomic circumstance and reduced social
resources are unlikely to access health-related Internet
services. It also seems likely that Internet information about
birthing options may be beyond the reach of a percentage of
childbearing women.
Additionally, although midwifery-led care is both strongly
advised and suggestive of excellent results in terms of maternal
satisfaction and measurable clinical outcomes, there is some
suggestion that childbearing women actually know little
about midwifery-led care or the role of the midwife in
general. Colleagues working in antenatal services at a major
metropolitan hospital in Melbourne, Australia, confirm this
premise, as do some recent Australian studies (Zadoroznyj
2002; Leen Ooi Boon 2004). For example, Zadoroznyj
found that ‘women’s main source of information about
midwife care is developed through the actual experience of
it’ (177). Leen Ooi Boon found that, although women generally
understood that the midwife was appropriately trained to
provide care during pregnancy and normal birth, most expected
a doctor to be present at their vaginal births. They also con-
sidered that the doctor should perform perineal suturing.
Availability of services is also likely to impact on women’s
choices and, in Australia, service provision is affected by
geographical location. Rural services, for example, cater for
fewer women, and thus offer less variety and less choice than
urban services (Department of Human Services 2004). Not
all centres offer more than one model of care and this is
dependent on the size of the hospital and available funding
(Department of Human Services 2003, 2004). This finding
is not uniquely Australian and similar restrictions to choice
in maternity care are seen in other countries. For example,
Hundley et al. (2000), who conducted a survey as part of a
national audit of maternity services in Scotland (n = 1137),
found that as few as one-third of women surveyed felt they
had a choice about antenatal care. Although several women
in Hundley et al.’s study felt they had a choice about where
they gave birth, most felt that home birth or early discharge
with domiciliary care was not possible. Recommendations
by professionals are also likely to inform decisions, and
Hundley and Ryan (2004), who solicited information from
142 © 2007 The authors. Journal compilation © 2007 Blackwell Publishing Ltd
a sample of 301 childbearing women from three geographical
areas in England, present a case in point. In this study, a dif-
ferent system of maternity care was offered in each area and
the authors suggest that women’s choices were influenced by
the ‘systems of care on offer’ (550). They found that women
in the area with least continuity rated this aspect of care sig-
nificantly lower than did women in other areas (P = 0.007).
These authors considered this finding to relate to a lesser
expectation/valuing of the concept.
Perceptions of risk are seen to impact on care options for
childbearing women in Australia and women considered
‘at risk’ for pregnancy complications are usually referred to
a medical or shared model of care at a larger centre. Women
deemed at low risk may be allocated to, or offered a choice
of, midwifery-led care or standard care (Department of
Human Services 2004). This trend of referral of women at
risk to medical or shared models of care is also reported in
many studies evaluating midwifery-led care. Most include
phrases indicating the allocation of ‘high risk’ women to
traditional care models (McCourt et al. 1998; Spurgeon,
Hicks and Barwell 2001; Rogers 2002; Page 2003). Biro
et al.’s (2003) study presents one exception to this trend,
and discusses how 1000 high and low risk women were
randomly allocated to standard or midwifery-led care in a
tertiary level hospital in metropolitan Melbourne.
Sociodemographics seem to impact on the choices women
make about maternity care in Australia and several varia-
tions in maternity service usage are noted. For example, in
Victoria, women from the more affluent suburbs of Eastern
Melbourne are generally older (65.5% over 30 years) than
those in rural areas such as Gippsland (42.6% over 30 years)
(Victorian Perinatal Data Collection Unit 2003). This in
turn gives rise to a constellation of other factors. Women
aged 30–45 years are more likely to be financially secure and
to subscribe to private health insurance and women with pri-
vate insurance often choose maternity care led by a private
obstetrician (Victorian Perinatal Data Collection Unit 2001,
2003) and give birth in private hospitals. In 2002, this group
accounted for approximately 30% of women giving birth in
Victoria (Victorian Perinatal Data Collection Unit 2003).
In a different direction, Richards (1982) provides some
sociopolitical insights into the constraints of choice for
childbearing women. In his seminal paper ‘The trouble with
“choice” in childbirth’, he discusses the very notion of
choice as problematic. Although this paper is more than
20 years old, many of the central arguments still resonate
today. For example, Richards discusses the notion of choice
as implying a ‘comprehensive set of options to choose from’
similar to a menu. Within this notion, the chooser is in a
position to ‘freely exercise choice in an informed way’ (253).

In fact, within healthcare systems, this level of choice is
seldom available and even available choices may not be at
the discretion of the childbearing woman. Lupton (1999)
concurs with this notion and questions how much choice
women really have in childbearing matters. She suggests that
the ‘the pregnant woman is positioned in a web of surveil-
lance, monitoring, measurement and expert advice that
requires constant work on her part’ but also that the woman
embraces the discourse willingly and ‘chooses’ prenatal test-
ing in a bid to maximise her baby’s health (90).
Richards meanwhile suggests that resistance to change
in hospitals denies women of choice, and is related to power
relations within the hierarchical and bureaucratic fashion in
which institutions function (254). Although a managerial
approach provides for maximum efficiency of the organisa-
tion, it may have a negative effect on the power individuals
have to shape practice, which may in turn give rise to a ‘rule
following and avoidance of responsibility’ approach (Rich-
ards 1982, 256). Subsequent denials of maternal requests are
recast as something not in the best interest of mother or
infant (254). Chalmers (1986) also considers defensive prac-
tices employed by healthcare workers and suggests that the
burden of proof required by perinatal authorities, prior to
instituting change, is often far in excess of the ‘evidence pro-
vided in substantiation of their own claims’ (153).
Thus, to return to the earlier argument, we can see that
many factors impact on the ‘choices’ women make about
maternity care and place of birth, including knowledge of
services, availability of services and extenuating medical
circumstances. For women choosing to opt for, or who are
referred to midwifery-led care, choice and collaboration are
an expected part of the philosophy of care. This situation is
congruent with consumer movements and an increasing
midwifery emphasis on childbearing as a normal life event.
However, although undeniably in the mothers’ interest, for
existing midwives, schooled in more traditional models of
care, transition to this new model may not be so seamless.
TRANSITION
For myself (first author), a midwife educated in the medical
model of physician-led care, I first became aware of a shift
towards ‘woman-centred’ philosophy at midwifery confer-
ences I attended in Australia in the mid-1990s. At this point
a shift in emphasis to the midwife–woman relationship, as
important in terms of creating an environment of trust and
complicity. The central message was that this was the type
of maternity care women wanted and which all midwives
should aspire to deliver. It was a particularly powerful and
motivating message. However, for many of us working in
© 2007 The authors. Journal compilation © 2007 Blackwell Publishing Ltd
‘With woman’ philosophy
what was now known as fragmented care within tertiary
referral hospitals, this move seemed exclusionary and alarm-
ing. Many of the women we cared for were at serious risk of
life-threatening disorders and foetal loss. A considerable
number suffered from pre-existing maternal disease such as
diabetes, blood coagulation disorders, hypertension and
cardiac disease. Others suffered from pregnancy-related dis-
orders such as pre-eclampsia, placenta praevia and twin to twin
transfusion. Several had multiple comorbidities and, as one
colleague noted, ‘needed all their strength to get out of it
alive’. Many had availed of reproductive technology to conceive.
At the same time, changes to midwifery education in the
UK, Australia and Canada meant that it was no longer a
requirement for midwives to have completed nursing studies
before studying midwifery. A new emphasis on birth as a
normal life event was evident and normal births were no
longer considered to require additional nursing skills.
Although this move towards promotion of birth as normal,
and midwives as the specialists of normal birth, is a positive
one and a view endorsed by both authors, it nonetheless
gives rise to several concerns and questions. For example:
• Do non-nurse midwives have sufficient clinical skills to
care for pregnant women with serious comorbidities?
• Is it possible to focus on normal and yet still be acutely
sensitive to early indications of complications?
• Does an emphasis on normal birth as primary goal:
• detract from the experience of women who do not have
normal births?
• lend itself to a different form of authoritarianism where
women are ‘persuaded’ to birth in a certain way?
As this review progressed three areas of concern became
evident. The first relates to educational issues and questions
whether direct entry midwifery education is sufficient to
equip new midwives to care for pregnant women with sig-
nificant comorbidities. The second issue relates to the creation
of a hegemony, in which normal birth is the ideal and any
other form of birth is a potential source of disappointment,
guilt and/or failure. This understanding has the potential to
detract from the experiences of women who have medical
interventions. The third and final concern relates to a pro-
motion of the midwife–woman relationship as all-important.
EDUCATIONAL ISSUES
The principal aim of the move to direct entry/bachelor of
midwifery programs was to effect a division from the illness
orientation of nursing and to move towards greater profes-
sionalisation and autonomy for midwives. It was anticipated
that this approach would go some way towards addressing
dissatisfaction with existing midwifery services and would
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M Carolan and E Hodnett
also produce a new type of reflective midwife, who would
be congruent with the move towards ‘woman-centred’ care
(Lobo 2002). This ‘knowledgeable doer’ (Lobo 2002, 60;
May et al. 1997) would share a commitment to women
empowerment and to evidence-based practice.
In Australia, direct entry midwifery education is a very
recent innovation and the first graduates are now just enter-
ing clinical practice. Therefore there is, as yet, a dearth of
evaluative research available on the program. What litera-
ture is available stems from British practice, which has
employed midwifery degree programs for a slightly longer
period. Much of this literature indicates an initial level of
distrust among British doctors and nurse midwives towards
direct entry midwives (DEMs) related to concerns about the
clinical competence of non-nurse midwives (Radford and
Thomson 1994; Leap 1999; Duffin 2001). Similar trends are
reported anecdotally in Australia, although as yet a support-
ive literature is not available. British researcher Lobo (2002)
presents a good example of prevailing opinion, and inter-
viewed nurse-midwives about their impressions of direct entry
midwives. She found that participants were initially critical
of this new group, describing DEMs as needing more sup-
port and mentoring; as tending to be task-orientated with
poor time management skills; and as being unable to cope
in busy birthing units. Many found the new graduates to be
confident and assertive but nonetheless found their confi-
dence misplaced. Several admitted to putting the newly
qualified midwife ‘in her place’ (61). Some Australian mid-
wifery students report similar antagonisms (Commisso 2004).
Although there is no clear consensus at this point on the
value of direct entry midwifery education in comparison to
earlier educational models, the weight of opinion seems to
support the premise that direct entry midwives are ad-
equately prepared for practice, despite earlier reservations
(Fraser, Murphy and Worth-Butler 1997; May et al. 1997;
Lobo 2002). For example, May et al. (1997) reported the
most students graduating from direct entry midwifery edu-
cation programs met with registration and fitness-to-practice
criteria. Additionally, Fraser, Murphy and Worth-Butler (1997)
found that, although initially some experienced nurse mid-
wives were reserved and prejudiced against new graduates,
the new midwives’ commitment to and enthusiasm for
woman-centred care impressed them. Most reviews agreed
that graduates required additional clinical support and
confidence building as newly qualified midwives (Fraser,
Murphy and Worth-Butler 1997; May et al. 1997; Lobo 2002)
and, indeed, Lobo (2002) made an interesting observation,
suggesting that perhaps too much was expected of new
graduates. Drawing on the work of Benner, Tanner and
Chesla (1999), Lobo suggests that new midwives should be
144 © 2007 The authors. Journal compilation © 2007 Blackwell Publishing Ltd
regarded as advanced beginners in need of some support
and development, rather than polished professionals. More-
over, Lobo suggests that, with time, and as more direct entry
midwives are absorbed into the system, little evidence of dif-
ference in midwifery skills is noted. Finally, although my
colleagues and I (first author) initially felt that a keen focus
on normal might lead the new or inexperienced midwife to
be dismissive or unaware of early subtle clinical changes that
could herald an emergency situation, there is little evidence
to support this premise. Of the studies reviewed, newly
qualified direct entry midwives are seen to be overcautious
if anything, and in need of support and reassurance rather
than likely to take chances when unsure (Fraser, Murphy
and Worth-Butler 1997; May et al. 1997; Lobo 2002).
VALUING OF NORMAL BIRTH
In general the championing of normal birth by midwives
is a positive move that has led to a reduction of clinical
interventions in labour and a reduction in the intrapartum
use of analgesia (Gagnon, Waghorn and Covrell 1997;
Page et al. 1999; Hodnett 2000). However, the term ‘normal
birth’ pervades midwifery literature and midwifery text-
books to such a degree that a struggle for hegemony is a
legitimate concern. Many publications suggest a contest
between medical intervention, paternalism and control on
the one hand, and the midwife providing ‘woman-centred’
care and acting as the woman’s advocate on the other (Purkiss
1998; Cahill 2001; Johanson, Newburn and MacFarlane
2002; Page 2003; Goldberg 2004; Parratt and Fahy 2004;
Shallow 2004). Several discuss ‘protecting’ normal childbirth
and reacquainting women with their natural propensity
to birth (Crenshaw 2004; Guiver 2004; Hotelling, Amis
and Green 2004; Lothian, Amis and Crenshaw 2004;
Hotelling and Humenick 2005; Romano 2005). Australia’s
leading maternity consumer group, the Maternity Coalition
(see the coalition’s journal Birth Matters) and the Australian
Society of Independent Midwives are particularly vocal in
their support of this view and many are keen advocates of
home birth. These groups are also active in lobbying for a
re-introduction of community midwifery services through-
out Australia. Similar emphasis is evident in the writings of
midwifery students and new graduates (Beckinsale 1996;
Newnham 2001; Bosanquet 2002). Throughout there is a
suggestion of competing forces: midwives as guardians of
vulnerable childbearing women vs. physicians wishing to take
over and medicalise pregnancy. The undergirding feminist
argument is akin to objections raised by Oakley (1984) in
The captured womb and Martin (1987) in The woman in the body.
This mood is redolent of the following quote from Oakley:

prevailing medical definitions of pregnancy and antenatal
care ... the reduction of the social and personal experience
of pregnancy, and the individuality of pregnant women, to
the mechanical image of womb housed in the body of
either a reluctant or compliant patient, and processed on
the principle that a no risk birth is only to be achieved by
exposing all wombs and their owners to an identical all-risk
monitoring process (249).
As a newly appointed midwifery lecturer, this adversarial
undergirding has been both a shock and a revelation to me
(first author). I had previously considered that we were
all on the same side, with the common aim of providing
best care for childbearing women. Moreover, the current
emphases within midwifery create an interesting paradox.
At the same time as a move towards women empowerment,
midwifery care and normalisation of birth, changing
demographics in Australia and globally show a growing trend
towards older maternity (ABS 2000, 2003; National Statistics
UK 2001; National Vital Statistics Report [US] 2001) and
an increasing demand, by women, for caesarean section
(Quinlivan, Petersen and Nichols 1999; Gamble, Heath and
Creedy 2000; Al-Mufti, McCarthy and Fisk 2001; Kerr-Wilson
2001; Hannah 2004; Lin and Xirasagar 2005). An interrela-
tion between advanced maternal age and increased caesar-
ean rates is posited (Dougherty and Jones 1988; Dildy et al.
1996; Howard 1999; Rosenthal 1999; Kullmer et al. 2000;
Yuan et al. 2000; Bell et al. 2001; Ataullaha and Freeman-
Wang 2005), which may in part relate to subscription to
private health insurance (Fisher, Smith and Astbury 1999).
In Births in Victoria (Department of Human Services 2003),
primiparous women aged more than 35 years and attending
a private hospital for care were almost twice as likely to have
a caesarean birth as a spontaneous cephalic birth (46 vs.
27%, respectively, compared to 41 vs. 37% of women receiving
public hospital care. Overall, childbearing women, consid-
ered to be ‘at risk’ for pregnancy and maternal complication,
are ever more likely to give birth surgically, and although the
‘at risk/high risk’ label is both ambiguous and misleading,
approximately 15–25% of pregnant women are currently
deemed to be at high risk for pregnancy complication in any
given year (Martin-Arafeh, Watson and Baird 1999; Giur-
gescu 2004). Additionally, there are many women having
babies today who could not have reasonably contemplated
pregnancy in the past. Examples include sufferers of dis-
eases such as cystic fibrosis and cardiac disorders, who are
now experiencing greater lifespans and better quality of life;
postmenopausal women; women with genetic aberrations
such as Turner’s syndrome and women with anatomical or
functional abnormalities of the reproductive tract. The
parameters of fertility technology are continually expanding
and offer hope of pregnancy to many women who would
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‘With woman’ philosophy
have previously been considered infertile (Cohen and Sauer
1998; Pal and Santoro 2003). For these women, a ‘normal’
birth may not be possible or particularly desirable.
In sum, it is reasonable to speculate that these three
events (increasing maternal age; greater numbers of women
considered to be at risk and advancing reproductive techno-
logies) will together give rise to even greater percentages of
caesarean delivery in the future. This dichotomy of increas-
ing technology and medicalisation on the one hand, and
midwifery moves to re-claim ‘normal birth’ on the other,
gives rise to some important questions. For example:
• Do ‘at risk’ women value natural childbirth or ‘women
empowerment’?
• Does the current emphasis on ‘normal birth’ disadvantage
women giving birth by caesarean, in terms of a lesser
valuing of their experiences?
Overall, it is difficult to determine whether women who are
deemed ‘at risk’ for pregnancy complications are particularly
interested in achieving normal birth and/or woman
empowerment. Increasing demand for caesarean section,
particularly among well-educated women (Fisher, Smith and
Astbury 1999), mothers over 35 years (Rosenthal 1999) and
health professionals (Al-Mufti, McCarthy and Fisk 2001;
Johanson et al. 2001), suggests that they may not be. Other
evidence suggests that many women over 35 years consider
their pregnancy to be an exceptional event (a miracle) and
are anxious not to jeopardise the perceivably vulnerable
pregnancy in any way (Payne 2002; Carolan, in press), and
this is especially true of women who use reproductive tech-
nology to conceive (Carolan 2005). Throughout the litera-
ture and in media reports, the general impression is that
this trend of increasing caesarean birth is driven as much by
women as by obstetricians (Mould et al. 1996; Quinlivan,
Petersen and Nichols 1999; Teutsch 2002) and relates to
litigation fears (Fisher, Smith and Astbury 1999; Smith,
Piland and Burchell 1999) and ‘anxiety in both the older
mother and the obstetrician’ (Freeman-Wang and Belski
2002, 41). However, closer scrutiny reveals that the situation
is not as clear cut as one might suppose. Thomas and Paran-
jothy (2001) who reported on data related to 152 413 births
in Britain, in the National Sentinel Caesarean Section Audit,
found that only 5.3% of mothers reported that they would
prefer to deliver by caesarean. Of women actually requesting
caesarean section, previous caesarean section, infants over
4000 g and multiple pregnancies were common antecedent
events. Almost all mothers expressed a wish to have a birth
that was ‘the safest option for their baby’. In a similar vein,
Hildingsson et al. (2002), in a study of 3283 Swedish women,
found that ‘few women wished to be delivered by caesarean
section’ (618), which is consistent with midwifery care as
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normal in Sweden. Therefore, although the caesarean rate
is increasing, it is really not clear whether or how women are
driving this increase.
The second question above is an important one in this
time of increasing surgical birth. At present the evidence
suggests that, although many women choose or concede to
caesarean birth, they also experience a variety of negative
feelings following caesarean delivery (Ernzen 1994; Wijma,
Ryding and Wijma 2002; Yokote 2004; Gamble and Creedy
2005). Unplanned or emergency caesarean section seems to
intensify the negative impact. Feelings of guilt (Ryding,
Wijma and Wijma 1998), frustration, psychological trauma
(Ryding et al. 2004; Gamble and Creedy 2005) and a sense
of failure (Mutryn 1993) are reported, and Park, Yeoum and
Choi (2005) suggest that the individual woman’s subjectivity
impacts on how she will respond psychologically to her
caesarean. Thus, it is difficult to determine in advance how
a particular woman will react. Altogether, it is clear that many
women already suffer considerable psychological distress
following caesarean birth and there is some evidence to sug-
gest that a percentage of women are acutely sensitive to even
minimal undervaluing of this mode of birth. For example, in
Carolan’s (2005) study, several participants described a dis-
tressingly limited discussion of caesarean section in prenatal
classes and an emphasis on vaginal birth as penultimate, and
as something most women ‘could achieve’. This understand-
ing led to later feelings of inadequacy and guilt. Therefore,
it would seem important that midwives do not inadvertently
add to women’s angst by even subconsciously undervaluing
this mode of birth.
MIDWIFE–WOMAN RELATIONSHIP
In the final part of this review the midwife–woman relation-
ship, as posited by the new midwifery philosophy, is exam-
ined. In the first instance, the midwife–woman relationship
is considered important in terms of allowing the woman to
feel safe and supported, both physically and psychologically
(Flint, Poulengeris and Grant 1989; Wilkins 2000; Parratt
and Fahy 2004). This relationship aims to facilitate confi-
dence building and to empower the woman to trust her own
body and to take some control of her baby’s birth (Kennedy
1995; Leap 2000; Sharpe 2004). Midwives often strive to
promote an atmosphere of ‘women working with women’
(Page 2003) and to foster a sense of belonging and continuity,
which harks back to earlier simpler times when, traditionally,
childbearing was the province of ‘wise women’ within a
community. As such, birthing knowledge, as the ‘property’
of women, was handed down from generation to generation
(Barclay, Andre and Glover 1989; Wesson 2005).
146
Today, the midwife–woman relationship is seen as the
cornerstone of ‘woman-centred’ care, which in turn is seen
as satisfying for women (McCourt et al. 1998; Hodnett 2000,
2002; Biro et al. 2003; Page 2003). Within midwifery writings,
the ‘with woman’ aspect of this relationship receives consider-
able attention (Rooks 1999; Siddiqui 1999; Kirkham 2000;
Wilkins 2000; Pairman 2002; Page 2003), and the partner-
ship between the midwife and woman is seen as crucial (Guil-
liland and Pairman 1995; Leap 2000; Kennedy et al. 2004).
Indeed, Page declares this relationship to be ‘the crux of
effective, sensitive, and autonomous care’ (119). Throughout,
an emphasis on intimacy, woman empowerment and indi-
vidually tailored, engaged care prevails. Although there is
little disputing the fact that care centred on the woman is
associated with good clinical outcomes and maternal satis-
faction, this review and familiarity with the rhetoric gives rise
to some questions. For example:
• Is this intimate midwife–woman relationship always
achievable?
• Is it what all or even most women want/need?
Is this intimate midwife–woman relationship
always achievable?
First, the midwife–woman relationship is portrayed as going
beyond more usual professional relationships in terms of
importance, intimacy and intensity. For example, Page
(2003) describes this relationship as not ‘just instrumental ...
to increase trust or confidence’, but ‘important in itself’
(119–22), while Kennedy et al. (2004) consider this relation-
ship to provide the very ‘foundation for the midwife to
orchestrate an environment of care to meet the woman’s
needs’ (18). Considerable emotional investment is required
of the midwife and, as Rooks (1999) suggests, ‘midwives
use their own physical and emotional energy to encourage,
support, and comfort women during birth’ (372). Kennedy
(1995) personalises the argument and suggests that the indi-
vidual nurse-midwife’s qualities and behaviours, ‘her con-
cern and caring and her respect for the woman, significantly
affect the woman’s experience of birth’ (410). In a similar
vein, Walsh (1999), discusses the midwife as a ‘friend’ and
tells of ‘expressions of delight and gratitude’, on the part of
women towards their midwives (169). James (1997), whose
doctoral work examined the midwife–woman relationship,
speaks of midwives being with women through the ‘physical
and emotional care they provide during pregnancy’ and
further suggests that ‘midwives and women experience birth
together’ (vii). Overall, working in partnership with women
is prominently advised and Bailes and Jackson (2000), whose
study focuses on home birth, discuss the ‘client and midwife
© 2007 The authors. Journal compilation © 2007 Blackwell Publishing Ltd

work[ing] together in partnership [to] create ... the process
of care’ (537).
Throughout, there is little suggestion that the formation
of this relationship is ever other than seamless and it is diffi-
cult to find studies that critique the bond. Fleming (1998)
offers one exception and has discussed the woman–midwifery
partnership as problematic, suggesting that the values
central to midwifery practice may not hold much sway for
birthing women (8). In this 3-year project, set in New
Zealand, Fleming researched the relationship from both
midwives’ and women’s points of views. She found that,
although midwives felt they were providing care that was dif-
ferent from medical services, in terms of supporting and
empowering women, many women, in fact, chose midwifery
care for the convenience of having a midwife visit them at
home. Several felt that the care provided by the midwife was
little different than previously received obstetric care and
many did not feel they needed emotional support from the
midwife, although midwives felt the provision of support was
important. Similarly, Sharpe (2004), who also critiqued the
relationship from the perspectives of both midwives and
women (n = 80), found that midwives and women did not
always concur on the meaning and function of the relation-
ship. Sharpe’s acknowledgement that the relationship was
most successful when the midwife and woman shared funda-
mental life philosophies and values seems to point to the
possibility that philosophical differences between parties might
negatively affect the developing relationship. Freeman, Tim-
perley and Adair (2004), also critiqued the midwife–woman
relationship and found that, although power was not shared
equally between women and midwives, this situation did not
necessarily affect the success of the partnership.
Factors inhibiting the relationship/partnership are
seldom discussed in the literature, although some possibilities
are posited here. For example:
• What provision is there for the woman who doesn’t want
to work in partnership with the midwife, but would prefer
to leave care decisions to the ‘expert’?
• Or for women who would prefer a more formal contrac-
tual form of relationship?
There is some evidence to suggest that women who
consider their pregnancy to be particularly vulnerable may
wish to leave decision-making to the ‘experts’. Carolan (2005),
for example, found that many women over 35 years were so
concerned with ‘not jeopardising’ their perceivably vulner-
able pregnancy that, although anxious to be informed, they
preferred to leave decision-making to obstetricians involved
in their care. Similarly, Harrison et al. (2003), researching
high risk pregnancy, found that ‘women facing health crises
used the process of trusting in the expertise of nurses and
© 2007 The authors. Journal compilation © 2007 Blackwell Publishing Ltd
‘With woman’ philosophy
physicians’ rather than being responsible for decisions (109).
Meanwhile, Bluff and Holloway (1994) found that a percent-
age of women preferred passive rather than active involve-
ment in care decisions, a finding supported by Harrison
et al. Other researchers have found that not all individuals
wish to participate actively in their care decisions. For exam-
ple, Waterworth and Luker (1990) describe some patients as
‘reluctant collaborators’ in their care and allude to patient
descriptions of ‘toeing the line’ (971). In pregnancy and
maternity literature, this trend is reported most frequently
in relation to ‘high risk’ pregnancy, although it is not a
universal finding (for counter examples, see Harris and
Stern 1986; Durham 1999). Overall, it would appear that
not all women desire to work in partnership with care
providers.
Is it what women want/need?
Although ‘with woman’ care, with the midwife–woman rela-
tionship as central, is prominently advised in contemporary
midwifery texts (Kirkham 2000; Page 2000), the evidence
suggests that what women particularly want is an opportunity
to participate in decision-making (Green, Coupland and
Kitzinger 1990; Brown and Lumley 1994; Garcia et al. 1998;
Morgan et al. 1998; Green, Renfrew and Curtis 1999; Vande-
Vusse 1999), and care that is consistent, respectful and inform-
ative (Green, Coupland and Kitzinger 1990; Brown and
Lumley 1994, 1998; Fowles 1998; Garcia et al. 1998; Morgan
et al. 1998; Fraser 1999; Green, Renfrew and Curtis 1999;
Van de Vusse 1999). As we have seen earlier, continuity of
carer, although important, does not appear to be as highly
regarded by women as ethos of care, consistency and
respectful engagement.
The support of the women’s male partner during the
childbearing period is considered important in terms of
maternal adjustment (Tarkka and Paunonen 1996; Green
and Kafetsios 1997; Tarkka 2003; Borjesson, Paperin and
Lindell 2004), although there is a danger that the midwife–
woman relationship, by virtue of its feminine complicity and
views of birth as ‘women’s business’, may exclude the woman’s
male partner. For example, the very term ‘woman centred’
is quite different to its antecedent ‘family-centred’ care and
seems to suggest that the woman’s partner is of lesser impor-
tance. In some writings, such as Pope, Graham and Patel
(2001), ‘the need for the woman (and her partner, if she
wishes) to be the focus of care’ (227) is discussed, which seems
to imply that the presence of the partner is optional. More-
over, the pro-femina calibre of many midwifery writings is
suggestive of an exclusion of men in general, and examples
of this leaning towards female gender abound. For example,
147
M Carolan and E Hodnett
Page (2003) speaks of ‘the roots of midwifery’ as being firmly
entrenched in the ‘support given by one woman to another
around the time of birth’ (119), and Fraser (1999) discusses
‘developing a “special” trusting relationship with a female
midwife’ as important to participants’ childbearing experi-
ence (99). Meanwhile, Kennedy (1995) declares that ‘mid-
wifery is a profession that does not provide care to women,
but provides care with women’ (410). Throughout, there is
an emphasis on women caring for women.
CONCLUSION
In Australia and elsewhere, the midwifery profession is
undergoing a process of change and redefinition and there
is considerable evidence to suggest that this change is
responsive to women’s needs and will also aid the advance-
ment of the profession. ‘With woman’ care is the cornerstone
of this new midwifery philosophy, and in this review care
centred on the childbearing woman is suggestive of excel-
lent clinical results and increased maternal satisfaction.
What is not quite so clear is the value of the midwife–woman
relationship, in terms of intimacy and complicity. Overall, it
seems likely that midwives attach greater significance to this
relationship than do childbearing women. Additionally,
many childbearing women seem to have little understand-
ing of the role of midwives and do not immediately value
‘women-centred’ care. In all, it would seem that greater effort
is required to educate and improve public understanding of
midwifery as a profession.
Earlier misgivings that I (first author) and many of my
colleagues shared around the adequacy of direct entry
midwifery programs, seem to have evaporated in the light of
the evidence reviewed. Only the emphasis on normal birth
in the face of increasing caesarean section remains problem-
atic and there is no immediate solution to this discordance.
However, the moderate championing of normal birth is a
good and positive move in this direction and, once it is
attended with sufficient sensitivity to allow for a valuing of
birth, by whatever mode, it may, with the right public atten-
tion, assist women to make choices to maximise their health
and minimise childbearing risk.
Finally, during this review the myriad questions we have
asked have all shown that there is little comparison between
rhetoric and evidence when it comes to evaluating women-
centred care.
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