ACTIVE MANAGEMENT OF LABOUR - A FEMINIST CRITIQUE

FIRST PREPARED AS PART OF A BSC (HONS) IN MIDWIFERY AT THAMES VALLEY UNIVERSITY LONDON





ABSTRACT


The principles of the protocol of Active Management of Labour, first conceived of by O'Driscoll et al (1969) form part of current midwifery practice. The protocol was aimed at preventing prolonged labour in women having their first babies, and involved: prenatal instruction; strict diagnosis of labour onset; early amniotomy; and early use of oxytocin by intravenous infusion. A time limit was placed on labour duration. Despite all of these interventions being routinely employed within midwifery care today, the research basis for these practices is weak and what research there is is medicalised and reductionist. For this project, the available research is examined and evaluated, looking at the protocol as a whole in its original form, and at subsequent research on both the whole package and its component parts.

Feminist theory is used as the standpoint from which to critique the use of these essentially medical interventions, and to point out the shortfalls in the protocol when considering labour from a more holistic, woman-centred position. Feminist midwifery research is suggested as a possible means of redressing the balance by providing a sound research base and a more holistic perspective on the issue.


INTRODUCTION

Modern midwifery care of the labouring woman predominantly takes place within the hospital setting. The standard care 'package' involves a plethora of medical interventions which are seen as a normal part of midwifery care, including early artificial rupture of the membranes, early use of oxytocin intravenously to accelerate labour and rigid monitoring of labour in relation to an obstetric model of 'normal', involving the use of the partogram (see Appendix 1). This dissertation is aimed at presenting a critical examination of certain current practices in maternity care, based on the concept of active management of labour, a phrase first coined by O'Driscoll et al (1969), by examining the research basis of the concept, and whether the role of the midwife in active management is appropriate.

It is the author's contention that all care during labour, particularly hospital based labour care (that is, the majority of labour care in this country), takes on and is defined by the active management protocol, especially in diagnosis of labour, early rupture of membranes, and placing a strict time limit on labour duration, defining labour length and progress as normal or abnormal.

The broader aim of this project is to analyse and discuss the place of active management of labour within midwifery care today, utilising a feminist perspective to place the issue within the context of women's experience, allowing the author to examine the sociological basis of active management of labour, along with its medical basis. By necessity, the feminist voice within this essay is equated to the viewpoint of Oakley (1981), equating women's experiences of pregnancy and motherhood with women's life experiences, status and power; it is the voice of someone working within the system in order to raise awareness, rather than that of radical feminism, which may call for radical change, which is not possible if the health service is to continue to function. This perspective as a starting point for analysis will look at the relationship of the Active Management of Labour to the gendered divisions of role and status within the insititutionalised setting of modern maternity care, focusing in particular on power, patriarchy and women's position within the system.

The essay will postulate that active management is part of a wider concept - that is the medicalisation of childbirth, and is both a symptom and a product of the medical control of women's bodies. Through a review of literature and research, the argument should show the drawbacks of interventionist practices during a very normal process, and highlight what is seen to be good practice, hopefully from a midwifery perspective. It will be emphasised that the role of the midwife is in care of uncomplicated labour, and that obstetricians have a role only when labour becomes dysfunctional, presenting a risk to mother and fetus. The place of Active Management of Labour within this role will be critically examined, taking into account the context of modern-day maternity care and the history of Active Management of Labour as a concept.

The issue has already been raised in current literature, summarised in one question -is childbirth defined only by a medical model or do we take the different perspectives of childbirth into account when providing care for childbearing women (Waldenstrom, 1996). The author would further like to question the validity of the whole active management protocol by reviewing the research basis of the process, and evaluating its safety and efficacy. A feminist midwifery perspective is used as the basis for the discussion. By placing childbirth within a social, psychological and cultural context, it is hoped to illustrate the deficiencies of the medical model and the need for a more multi-dimensional conceptual basis for maternity care of the labouring woman.

It is assumed that the reader is fully cognisant of the current pattern and structure of the modern maternity care setting, and is aware of the hierarchy of power, role and status within the hospital environment in which almost all maternity care takes place or is co-ordinated. It is also assumed that the reader is aware of the normal physiological process of parturition, whereby the fetus is expelled from the uterus by the action of the hormone oxytocin, causing cervical dilatation and uterine contraction, accompanied by maternal effort.



FEMINISM - DEFINITIONS AND DISCUSSION


To set the scene, it is necessary to define the term feminism in relation to the standpoint taken in this essay. Many would agree that, at the very least, a feminist is someone who holds that women suffer discrimination because of their sex, that they have specific needs which remain negated and unsatisfied, and that the satisfaction of these needs would require a radical change in the social, political and economic order (Mitchell & Oakley, 1986). On the other hand, feminism, in the broadest sense, can be defined as a world view which places women at the centre of analysis and social action; it involves an ideological commitment to fostering the well-being of women both as individuals and as a social broup in all spheres of life (Ruzek, 1986). Some writers feel that midwifery and feminism are synonymous (Kirkham, 1986). This is not the appropriate place to be discussing the history and development of feminism, but to briefly give an overview of certain perspectives.

Horey (1995) splits feminism into liberal feminism, radical feminism and socialist feminism. Liberal feminism appears to be concerned with the achievement of equal rights for women, legally, politically and socially (Humm, 1992; in Horey, 1995). Radical feminism in Horey (1995)'s terms seems to agree that the oppression of women is the most entrenched form of oppression and the analysis of attempts to control women's bodies by men is a common theme. Radical feminists believe that women need to reconstruct their sexuality to serve the needs of women, not men. (Tong, 1989; in Horey, 1995). They believe that women are essentially different to men and that their behaviour and needs are biologically, rather than socially determined (Horey, 1995). Socialist feminism, however, looks at the links between capitalism and patriarchy, and theoretically has concentrated on issues such as the sexual division of labour, identifying men's control over the labour of women as the material base of capitalism, where women have restricted access to important economic resources that leads to their lack of control of female sexuality and reproductive capacities (Tong, 1989; in Horey, 1995).

Hall and Stevens (1991: in Draper, 1997) identify three basic principles of feminisms:

a valuing of women and their experiences, ideas and needs; a recognition of the ideological, structural and interpersonal conditions that oppress women; and a desire to bring about change. Oakley (1981) sums up the whole issue of the relation of feminism to midwifery in one statement. She says that reproduction is inseparable from women's lives and how reproduction is managed and controlled is inseparable from how women are managed and controlled. This, in essence, is the basis of the feminist perspective in this discussion.



MEDICALISATION AND ACTIVE MANAGEMENT OF LABOUR AN INTRODUCTION TO THE CONCEPTS

Medicalisation refers to the process by which human experiences are redefined as medical problems (Becker and Nachtignall, 1992 in Young, 1995). Nowhere is this more evident than in active management of labour, where normal labour in women having their first babies is regarded as needing preventative intervention. Active management of labour is a means of accelerating labour, ~ definition of the ideal duration of Jabour based on the obstetricians limits, not on the woman's or the baby's. Women's concern about unnecessary and dangerous intervention in childbirth is no new phenomenon: historically it has always been associated with the conduct of childbirth by doctors (Kitzinger, 1988, 1992: in Young, 1995). However, modern day obstetrics assumes superiority and ultimate knowledge of childbirth, and fosters the belief that hospital birth, under indirect supervision by obstetricians, is safest.



KIERAN O'DRISCOLL AND THE NATIONAL MATERNITY HOSPITAL, DUBLIN
 In the 1960's, the term Active Management of Labour was coined by an obstetrician, Kieran O'Driscoll, to describe a process which was aimed at preventing prolonged labour (O'Driscoll et al, 1969). Thornton (1996) summarises the active management 'package' as including: special classes preparing women for labour; strict criteria for determining the onset of labour; psychological support; regular supervision of the delivery area by senior staff (obstetricians); routine amniotomy; early recourse to high doses of oxytocin under supervision of a midwife to accelerate slow labours; and an undertaking that labour would never last more than 12 hours. (O'Driscoll et al, 1969, originally stated that every woman would be delivered within 24 hours.) The conceptual basis for the original paper describing this process was that prolonged labour was a harrowing experience that mothers should not be forced to undergo, and that the interventions described would not only prevent this but had the result of coincidentally producing a comparatively low caesarean section rate (O'Driscoll et al, 1969). Subsequent research suggests that the package of active management reduces the rate of operative interventions for delivery. However, the true consequences of this package, for both the woman and the labour experience, as well as the implications for midwifery care, do not seem to have been fully appreciated.

There seem to be two main viewpoints about the Active Management of Labour. The first is that it is a safe, research-based and effective way of reducing caesarean section rates by preventing 'dystocia' (that is, arrest of labour or labour being longer than the defined norm). The second viewpoint is that active management of labour is an invasive and interventionist procedure, which does not take into account the woman's experience of labour or the wider context of labour and delivery. The latter argument leans to the side of the feminist debate within this discussion, and questions the nature and reason for such interventions. Because of the very nature of society, the argument is by definition related to gender. We live in a world which is gendered male and this pervades all organisations and policy making (Davies, C., 1995)

However, the unfortunate situation is that the first viewpoint can be backed up by a wealth of scientific literature and some clinical research, which despite its questionable validity, lends it more power and status within the medical world, whereas the latter argument can be less well proved or validated. A detailed analysis of the research and literature should illuminate the rather murky waters that cloud this debate.

The starting point must be O'Driscoll et al (1969)'s first report on this subject, which summarised their supposed rationale for the introduction of this series of interventions, and also gives purported 'results' which demonstrate their efficacy and safety. The statement that summarises their standpoint, being the explanation or background to the process is that prolonged labour presents a picture of mental anguish and physical morbidity which often leads to surgical intervention and may produce a permanent revulsion to childbirth (O'Driscoll et al, 1969). This rather emotive and dramatic statement paints the picture of the authors (obstetricians) as benevolent learned men intervening to alleviate the suffering of prolonged labour. They go on to say:

"the harrowing experience is shared by relatives, and by doctors and nurses to the extent that few complications so tarnish the image of obstetrics" (O'Driscoll et al, 1969: 477).

 This further emphasises the paternalistic 'we know better than you' attitude which pervades the paper, whilst at the same time implying that obstetrics has failed so far to alleviate this suffering, as if all suffering can and should be alleviated by science. By making such statements the authors disclose their position and their viewpoint as controllers of childbirth.

It is necessary to examine in detail the way in which this study was performed and reported. To begin with, this was not a randomised, controlled trial, but 'a prospective study of 1,000 consecutive primigravid deliveries.' (O'Driscoll et al, 1969: 477). The hypothesis appears the be summarised in the following sentence:

"the purpose of this paper is to show that prolonged labour can be prevented by effective stimulation" (O'Driscoll et al, 1969: 477).

 Obviously, this conclusion has already by reached by the author when writing the article,. The basis of the research question seems to be based on an arbitrary definition of prolonged labour:

"The progress of labour should be regulated to ensure that every woman is delivered within 24 hours." (O'Driscoll et al, 1969: 479).

 There is no rationale given for this time limit. Instead, this need to be delivered within a set period is qualified by a statement that would seem to reinforce the paternalistic, medicalised standpoint already mentioned, taking control of an essentially natural process:

"The results obtained in the present series of 1.000 consecutive primigravidae show that this can be achieved provided the obstetrician assumes direct responsibility and forsakes the role of passive observer for that of active director, controlling the course of labour, instead of waiting in the hope that is may conclude within a reasonable period of time." (O'Driscoll et al, 1969: 479) (Project author's italics).

 Reasonable for the obstetrician, the understaffed hospital, or the woman? This appears to cast doubts on the validity of the research, because the primary attitude is interventionist, and all labours are seen as requiring active management to prevent them continuing for too long. In this study, there is no control group, so no comparison of outcomes can be made. The differentiation between primigravid and multigravid labours implies that first labours are inherently problematic, requiring intervention.

O'Driscoll et al (1969) do mention what is called the clinical syndrome of prolonged labour (supposedly what they are trying to avoid by intervention). One woman, in labour for more than 24 hours, was dehydrated, exhausted, ketotic, retained urine and vomited (O'Driscoll et al, 1969). However, the prevention of this syndrome might be related to other factors, such as the restriction of food and fluids in labour. (It might be more appropriate to prevent ketosis in labour by allowing free access to food and drink than to correct its alleged influence on labour progress with uterine stimulants and intravenous glucose infusions. Keirse, 1989)

O'Driscoll et al (1969)'s description of active management very definitely places all power within the hands of the obstetricians, thus removing power and control from the woman, the mother actually undergoing this experience. The whole process becomes a medical one. The obstetrician diagnoses labour:

"In adopting an active role the first duty of the obstetrician is to decide whether or not a woman is in labour." (O'Driscoll et al, 1969: 479)

 Thus the woman has no say in the matter - the length of time of labour is based on this diagnosis:

"This decision must not be surrendered to the mother, assuming she is in labour simply because she says so." (O'Driscoll, et al, 1969: 479).

 The dismissive attitude of the authors towards the women they care for is evident:

"It must be recognised that a primigravida, particularly with scant knowledge and no experience, is not qualified to make the clinical decision on which subsequent management depends." (O'Driscoll et al, 1969: 479).

 From their supposedly superior position as doctors, the authors demonstrate that the only form of knowing that is valid within the institution is rational, scientific and objective.

The process described is characterised by rigid obstetric control. There are definite unwavering criteria to be met, and a firm protocol of monitoring, control and intervention which must be adhered to. The description of the process seems to have some flaws:

"The membranes should be ruptured at an early stage if dilatation of the cervix is not progressive." (O'Driscoll et al, 1969: 479).

 No definition of progressive dilatation is given, making the evaluation of progress without a frame of reference difficult.

"An intravenous infusion of oxytocin should be started if progress is not satisfactory after rupture of the membranes." (O'Driscoll et al, 1959).

 Satisfaction is a vague term of reference (Rees, 1996) and no explanation or detailed rationale for what is considered satisfactory is given. Although it is stated that progress should be measured by dilatation of the cervix, no details of the rate or the clinical basis of a satisfactory rate are given.

The role and experience of the woman to which all this is happening is further belittled throughout the discussion:

"Too often women are given to understand that not only are they expected to diagnose the onset but also to interpret the progress of labour. To subordinate the rate of infusion to the reaction of the patient is to allow her to control the drip." (O'Driscoll et al, 1969: 479).

 The author of this project is not advocating that women know everything about labour, whether it be onset, progress or outcome, but that their presence here is being disregarded, that their present experience and reactions are being stressed as unimportant. Women are supposed to adopt a passive role as if their labour has nothing to do with them at all, a truly patriarchal and paternalistic attitude. This demonstrates very definitely the way in which language controls interpersonal relationships, creating and maintaining power differentials (Shirley and Mander, 1996). This manner of wielding power and control through the use of scientific knowledge and language is what feminist theory seeks to challenge and address.

The other main problem with this piece of research is that a large number of possible factors in the process are not taken into account (or if they are, not mentioned). These could include reasons for prolonged labour, other than malposition and cephalopelvic disproportion, including positions adopted by the women, aumbulation in labour, the effect of transfer from home to hospital, the woman's own preparations for and reactions to labour, and the natural progress and length of labour.

However many flaws, shortfalls and discrepancies are evident in the article, certain issues should be taken into account. The first is the age of the article, which was published in 1969. There has been significant development in the area of research since then, with more knowledge being generated about what affects labour experience, length and procgress. The standard for reliable research now is the randomised controlled trial. Also, the culture of the time and the location should be appreciated - the study took place in Dublin, serving a particular clientele, within a very distinctive culture, where perhaps medicalisation is the norm, and probably where a concept such as feminism and women's rights to control over their own bodies was not an issue.

The main reason for the opinion that the article is biased is that it is written by the obstetricians who pioneered this project, taking as their proof of success certain outcomes which are not examined in a wider context, nor are the implications of the change in labour management taken into account, especially for the women concerned.

Whatever the problems associated with this piece of research, there are two definite relationships between active management of labour and outcomes: the prevention of prolonged labour and the reduction in the rate of caesarean section~ However, what is actually having this effect is questionable. As Gibbs (1994) states, study results show overwhelmingly that something in the active management protocol is successful in reducing the number of caesareans, but what that is remains to be seen. Despite this, the practice of active management is now such a part of hospital labour care that some midwives don't even realise that their practice is based on it. Automatic time restrictions on all three stages of labour, routine artificial rupture of membranes and automatic use of an oxytocin infusion when cervial dilatation falls behind one centimetre per hour are as much a part of midwifery care as support and comfort from the midwife. These obstetric practices, based on obstetric research, do need to be questioned.



ACTIVE MANAGEMENT OF LABOUR – CURRENT LITERATURE AND RESEARCH

O'Driscoll et al (1969)'s success in preventing prolonged labour and subsequently maintaining a lower than average caesarean section rate led to a surge of interest in his protocol and methods, and since that initial study other obstetric units have attempted, through research of the implementation of the procedures, to duplicate the results found in Dublin: active management of labour being used as a means to reduce caesarean section rates (Frigoletto et al, 1995), as well as prevent prolonged labour.

Despite all the apparent drawbacks to the research by O'Driscoll et al (1969), and all the negative connotations of active management of labour in relation to women's experiences of autonomy in labour and delivery, a reduced caesarean section rate is essentially a good thing, for the women, for the midwives, and the obstetricians and accountants. A review of subsequent research should indicate whether active management itself (that is, the whole protocol) does have this effect, and how else it affects labour and delivery.

To begin with, it should be noted that the original Dublin study and protocol was not aimed at reducing caesarean section rates, but was designed to show that the protocol reduced the length of labour in women having their first babies, and that the use of oxytocin at higher than usual doses was safe and effective (O'Driscoll et al, 1969). The reduction in the rate of caesarean section was a phenomenon noted subsequently in relation to the study outcomes.

However, other studies have examined this consequence of active management. Frigoletto et al (1995) report on a randomised trial to evaluate the efficacy of active management in lowering the rate of caesarean section in this one group of women considered to be more at risk of undergoing the procedure (that is, primigravidae). With a good sized sample population controlled at initial selection and again to exclude women who developed complications which affected their suitability for the protocol, the study set out to test the package as described by O'Driscoll et a (1969). Data was analysed both for the group originally randomised and for the subsequent protocol eligible subgroup. This particular study appears quite reliable; the authors have tried to address or at least discuss factors that could possibly affect or influence the results, by, for example, attempting to prevent 'pollution' of the non-active-management group by physically separating the two groups, the active management goup being allocated to a separate unit. The authors also take into account the possibility that the Hawthorne Effect (Roethlisberger and Dickenson, 1939; in Frigoletto et al, 1995) affected the results; that is that because the study focusedon rates of caesarean section, the rate in the usual-care group (the control) was lowered. However, a comparison of the usual-care group with similarly typified women during the six months before the trial supports the validity of the data.

The results showed that active management of labour did not reduce the rate of caesarean section in nulliparous women. However, the data also showed that labour was shorter (the median duration of labour being shortened by 2.7 hours.) The other observed result was a reduced incidence of maternal fever. So this study supports the findings of O'Driscoll et al (1969) in a more modern (and therefore more relevant) maternity care setting, lending weight to the effectiveness of the protocol in achieving its original aim, the reduction of the duration of labour in women supposedly at risk of prolonged labour.

Drawbacks to this particular study include the fact that it is an American study, which means that the American culture and care setting will have had some effect on the outcomes, and that certain factors from the Dublin study can never be truly duplicated, for example, the special antenatal classes for the experimental group. The kind of knowledge that women have now about childbirth and maternity care, as well as the very nature of the care practice, is bound to be different to that of the women in the original study, and the kind of information and instruction they are given are bound to be vastly different. Evaluation of antenatal classes is fraught with difficulty, not least the differing attitudes conveyed in classes, the quality of instruction, and the different techniques and philosophies expounded. Also this study takes into account no other factors than the clinical outcomes, being essentially a random ised trial to attempt to duplicate a low caesarean section rate. Other factors that a midwifery or feminist perspective might include are short, medium and long-term effects on maternal morbidity, including psychological morbidity, incidence of operative vaginal delivery, maternal satisfaction, and the relationship between the midwives and the mothers. The piece is a typical example of medical research.

It would be appropriate to point out at this stage that researching this particular protocol of intervention is fraught with difficulty. As Fraser (1993) suggests, evaluation through clinical trials is a methodologic challenge, since active management of labour is not one, but a complex series of interventions. Researching the whole package is far from easy:

"Consider a hypothetical trial in which women in one group are allocated to receive the entire active managernent package, while those~in the control group are provided standard care. Suppose the study finds the caesarean section rate to be substantially lower in the active management group. The design would not allow one to determine whether it was the augmented professional social support, the early administration of oxytocin, a combination of both, or some other aspect that was responsible for this effect." (Fraser, 1993:155)

 Thus all trials that merely look at the whole package can be questioned, because no one really knows just what is having the effect. It is difficult to evaluate the appropriateness of the protocol from a purely clinical point of view because of this fact.

However, not all 'medical' literature on the subject of Active Management of Labour is as narrow in viewpoint or as exclusive in nature as the two pfeces already mentioned. As stressed earlier, the whole package and its effects need to be seen from a wider view than merely medical intervention leading to measurable clinical outcomes. As Liston (1995) emphasises, despite the paucity of the research on the whole protocol as applied outside the Dublin setting, the facts would tend to suggest that the success of active management does not lie in oxytocin alone, as stressed by proponents of the Dublin philosophy. Liston (1995) also places stress on something other than 'management':-

"Skilful handling of labour will result in the safe birth of a healthy newborn baby with a minimum of intervention." (Liston, 1995: 768)

 Liston (1995) highlights the important and useful factors of the active management protocol, including the importance of appropriate, effective and timely intervention, not only to keep women informed of the progress of labour and of the options available to them, but to determine their specific wishes.

The significant fact which arises from the literature discussed so far, and further on in this essay, is that it is all, in nature, obstetric, scientific and rational, written in the language of science, embodying only one way of knowing, and really only one viewpoint - the medical one. This is due to the nature of our society as a whole. As Davies (1995) says, the patriarchal societies in which our ways of knowing have developed have emphasised scientific ways of knowing, while other ways such as intuition and embodied knowledge receive little acknowledgement. The result of this is that the scientific field, predominantly male in membership, presents only one narrow, restricted viewpoint, circumscribed by their own rules (See Table One, p.20).

In the case of active management, the research obviously falls short of providing adequate reliable evidence on which to base midwifery practice. As can be seen from Table One, there are few randomised controlled trials available, specifically evaluating active management. The masculinist nature of the literature is evident, as is the complete lack of midwifery research into this subject. This shortfall, surprising but not totally unexpected, leads the author to doubt both the quality and the nature of clinical practice when based on such poor foundations.




TABLE ONE

A FEMINIST CRITIQUE OF THE LITERATURE AND RESEARCH ON ACTIVE MANAGEMENT OF LABOUR

All the literature specifically evaluating active management of labour that was available to be used for this project is summarised below under a series of headings



 

FEMINIST

OBSTETRIC

RESEARCHED BY MEN

RESEARCHED BY WOMEN

MIDWIFERY

RCT

O'Driscoll et al, 1969

NO

YES

YES

1 woman in team

NO

NO

Akouryetal, 1988

NO

YES

YES

NO

NO

NO

Hogston&Noble, 1993

NO

YES

1 man

1 woman

NO

NO

Thornton, 1996

NO

YES

YES

NO

NO

NO

Thornton&Lilford, 1994

NO

YES

YES

NO

NO

NO

Turneretal, 1991

NO

YES

YES

NO

NO

NO

Gerhardstein et al, 1995

NO

YES

YES

NO

NO

NO

Peaceman et al, 1993

NO

YES

YES

NO

NO

NO

O'Herlihy, 1993

NO

YES

YES

NO

NO

NO

Borges, 1991

NO

YES

YES

NO

NO

NO

Turner et al, 1988

NO

YES

YES

NO

NO

NO

Walkinshaw, 1994

NO

YES

Unknown

Unknown

NO

NO

Liston, 1995

NO

YES

YES

NO

NO

NO

Malone et al, 1996

NO

YES

YES

1 woman in team

NO

NO

Lopez-zeno et al, 1992

NO

YES

YES

NO

NO

YES

Henderson, 1996

Not really

NO

NO

YES

YES

NO

Frigoletto et al, 1995

NO

YES

YES

NO

NO

YES

Cammu/V'Eeckhout l996

NO

YES

YES

NO

NO

YES

TABLE ONE CONTINUED


 

QUANTITATIVE

SEXIST LANGUAGE

HOLISTIC REDUCTIONIST

META-ANALYSIS

RESULTS/ METHODOLOLGY VALID

O'Driscoll et al, 1969

YES

YES

NO

NO

NO

Akouryetal, 1988

YES

YES

NO

NO

NO

Hogston&Noble, 1993

YES

YES

NO

NO

NO

Thornton, 1996

NO

YES

NO

NO

Descriptive

Thornton&Lilford, 1994

YES

YES

NO

YES

Descriptive

Turner et a, 1991

YES

YES

NO

NO

Descriptive

Gerhardstein et al, 1995

YES

YES

NO

NO

YES

Peaceman, et al, 1993

YES

YES

NO

NO

YES

O'Herlihy, 1993

YES

YES

NO

NO

Descriptive

Borges, 1991

YES

YES

NO

NO

Descriptive

Turneretal, 1988

YES

YES

NO

NO

YES

Walkinshaw, 1994

YES

Not always

NO

NO

Descriptive

Lislon, 1995

YES

Not always

NO

NO

Descriptive

Malone et al, 1996

YES

YES

NO

NO

YES

Lopez-zeno et al, 1992

YES

YES

NO

NO

NO

Henderson, 1996

NO

NO

NO

NO

Descriptive

Frigoletto et al, 1995

YES

YES

NO

NO

YES

Cammu/V'Eeckhout l996

YES

YES

NO

NO

YES


Interestingly, the three randomised controlled trials described in the literature are somewhat less than useful. Lopez-zeno et al (1 992)'s study was shown to have bias, caused by the Hawthorne effect (Olah and Gee, 1996). Frigoletto et al (1995) and Cammu and Van Eeckhout (1996) show a modest reduction in the duration of labour, but no differences in neonatal outcome or reduction in operative delivery rates (Olah and Gee, 1996). This begs the question of how much benefit active management of labour really is, which is turn questions current midwifery practice.



THE ACTIVE MANAGEMENT OF LABOUR - A MORE DETAILED ANALYSIS

By necessity the remainder ot the analysis of active management as a protocol is based on the obstetric research and literature available, and the clinical basis and effects of the interventions employed. A more detailed exploration of Active Management breaks the protocol down into its component parts.



ANTENATAL INSTRUCTION
 The first, antenatal instruction, has already been mentioned above. Although antenatal classes have not always been popular, the literature does point to a number of beneficial effects, including reduction in the use or need for pain medication during labour (Timm, 1979; in Liston, 1995).



DIAGNOSIS OF LABOUR
 A key factor in determining the 'normality' or not of labour is the first crucial diagnosis of labour. O'Driscoll et al (1969) emphasised this feature of active management and took into account the fact that estimates of the duration of labour were subject to personal interpretation because of the lack of a precise definition of when ~bour begins. O'Driscoll et a (1969) stressed the use of objective evidence, giving a group of clinically recordable features as his criteria for defining labour onset: painful contractions, accompanied by a show, spontaneous rupture of the membranes or dilatation of the cervix. Liston (1995) highlights the fact that diagnoses of non-progressive labour are still made erroneously, labour never having been established in the first place. Other authors further refine the definition of labour commencement:

"A diagnosis of the active phase of labour should not be made in nullipara without regular uterine contractions plus complete cervical effacement with at least 3 cms dilation." (Consensus Conference Report, 1986: in Liston, 1995:769).

 Turner et al (1988) also use these criteria. However, other authors deny something so fundamental as the latent phase of labour, adhering to the above criteria but with only one centimetre of cervical dilatation (Hogston and Noble, 1993). This issue of the latent phase casts doubt on the validity of the time limit set on labour duration. In denying the existence of the latent phase, or early labour, and diagnosing labour at such an early stage, it is not surprising that some labours progress beyond 12 hours (Axten, 1995). The duration of the latent phase varies so greatly from woman to woman that a normal range is virtually impossible to define (Keirse, 1989). It may not always be appropriate to define labours lasting longer than 12 hours as abnormal (Axten, 1995). The validity of progress measured in centres per hour can be challenged (Axten, 1995). Many women who show slower rates of cervical dilatation proceed to a normal delivery (Flint, 1987).

To take it to a more clinical level, as O'Herlihy (1993) shows, active management was brought into being by O'Driscoll et al (1969) for the early recognition of inefficient myometrial activity. However, as Keirse (1993) points out, neither O'Herlihy (1993) or O'Driscoll et al (1969) made it clear that they arrived at this concept without ever quantifying myometrial activity. The active management concept arose from a series of beliefs and assumptions (Keirse, 1993). And yet it is this activity which is intertered with as part of the active management protocol, specifically by the use of intravenous oxytocin.

The issue of diagnosing labour onset appears to be a product of the medicalisation of childbirth, in that women now expect to be told when they are in labour, or to have their own beliefs confirmed by professional opinion and examination, leading to an official diagnosis. Women no longer have the trust in or the control over their own bodies to recognise true labour for themselves, and to cope with early labour without medical involvement, instead having been encouraged to come into hospital as soon as they feel they are having contractions. Perhaps this is because of a lack of belief that they are doing this themselves, or a fear that without doctors and midwives around, they are not safe and their baby is at some sort of risk, a reason for the minimal rate of home birth in this country. However, an accurate diagnosis for these women can be a positive thing. If labour is misdiagnosed, the woman may be more likely to undergo intervention, particularly the use of oxytocin intravenously, in order to accelerate labour. Within the parameters of active management, this stage is vital, but it is the first of many limitations and controls placed on the woman and the labour.



CONTINUAL PROFESSIONAL SUPPORT
 The next aspect of the active management protocol to be examined is the issue of providing continual professional support for each labouring woman. O'Driscoll et al (1969) described this as a situation in which no patient is left unattended and skilled nursing attention and medical supervision are always at hand. In Frigoletto et al (1995)'s study, this was described as one4o-one nursing care, where a nurse (who changed only with shifts) remained with the patient throughout labour. Thornton and Lilford(1994) state that the labour companion can be qualified or unqualified. In O'Driscoll et al's (1969) approach, support, aimed at establishing a strong sense of rapport, is provided by the professionals also responsible for clinical care. Liston (1995) also suggests that support can also be provided by professionals who are there to be supportive rather than deliver clinical care, support being defined as including physical contact, conversation, and the constant presence of a companion. Thornton and Lilford (1994) present a meta-analysis of 10 randomised trials, including 3336 women, examining this issue, which supports the idea that psychological support has positive beneficial effects on labour, including reducing analgesic requirements, lowering the incidence of caesarian section and operative vaginal delivery, and improving fetal outcome (Hodnett, 1993: in Thornton and Lilford, 1994). Meta analysis of the effects of social support on caesarean section rates yields promising results outcome (Hodnett, 1993: in Thornton and Liltord, 1994; Fraser, 1993), yet the generalisability of the studies is seen as limited (Fraser, 1993).

Of all of the interventions of active management of labour, support appears to be the most useful and most relevant when labour experience is evaluated from a feminist midwifery perspective. Research suggests that during labour the main source of emotional support is the midwife (Tarkka and Paunonen, 1996). This piece of research showed that a significant association was found between the emotional support provided by midwives and mother's experiences of childbirth (Tarkka and Paunonen, 1996). As Gotlieb and Mendelson (1995) state, support must fit mothers' needs, and listening carefully to mothers enables midwives to determine the kind of support needed. This issue of supprt highlights the individual and personal nature of midwifery care, and thus contradicts the active management protocol, as it is applied across the board to primigravidae. It would seem to be the one area of active management which can be seen as true midwifery care, if this care is based on need rather than routine.



ARTIFICIAL RUPTURE OF THE MEMBRANES
 This leads us to the next intervention in the protocol, that of artificial rupture of the membranes, as early as physically possible in labour, in order to speed up labour progress. The physiological basis for this concept is that artificial rupture of the membranes releases prostaglandins which stimulate uterine activity and facilitate cervical effacement and dilatation, and also that once the protective cushioning of the forewaters is removed, the presenting part is applied with more force to the cervix, stimulating the Henderson reflex, which also augments the mechanism of labour (Mitchell et al, 1997, Sellers et al, 1984: in Keirse, 1989;Goff, 1993; Sweet and Tiran, 1997).

Borges (1991) summarises the purpose of artificial rupture of the membranes as threefold: 1) To see the colour of the liquor; 2) To see the amount of liquor; 3) To accelerate labour. He further qualifies this by stating that artificial rupture of the membranes is done in order to select the fetus that is compromised at the onset of labour, the intention being that a compromised fetus (having meconium stained liquor or reduced liquor volume, both clinical signs of less-than-ideal fetal status) could have a scalp ph done and monitoring via scalp electrode, so that any signs of fetal compromise would exclude this case from active management. Borges (1991) further believes that there are no convincing reasons for having intact membranes in labour, and that the risk of cord prolapse, the most obvious risk associated with amniotomy, is minimal.

This would all seem to make perfect sense, as it has always been seen important to exclude from active management any woman whose pregnancy or fetus displays some level of deviation from the norm, such as a complication or pathological condition (O'Driscoll et al, 1969; O'Herlihy, 1993)

However, data from random ised trials summarised by Thornton and Lilford (1994) show that early amniotomy is associated with a small decrease in the duration of labour, but does not lower the rate of caesarean section or operative vaginal delivery. Meta analysis of six studies described as relatively unbiased, including two multi-centre studies from Canada and the United Kingdom with over 2000 participants, shows little diflerence in maternal and fetal outcomes (Thornton and Lilford, 1994).



OXYTOCIN
In the context of active management, synthetic oxytocin as an intravenous infusion is employed when cervical dilatation proceeds at less than the regulated one centimetre per hour. As O'Driscoll and Meagher (1986) state, the therapeutic effect of oxytocin is to cause the cervix to dilate during the first stage of labour and the baby's head to descend during the second stage.

The dosage of oxytocin employed varies from researcher to researcher. The dose used by O'Driscoll et al (1969) and ODriscoll and Meagher (1986) is 10 units of oxytocin in one litre of 5% dextrose, while Hogston and Noble (1993) use 20units of oxytocin in 500 ml or dextrose. The standard at the author's place of work is 10 units of oxytocin in 500 ml of dextrose saline. This is administered intravenously according to a strict regime. For example, again at the author's place of work, the initial dose, regulated electronically, is six millilitres per hour, the amount doubling every thirty minutes to a maximum of 92 millilitres per hour, in the attempt to achieve 3-4 contractions in 10 minutes. This mirrors O'Driscoll and Meagher's (1986) process, where they state that evidence of fetal distress is the only absolute bar to this step-by-step method of progression.

Much of the research literature implies that the use of oxytocin is safe, and that hyperstimulation is rare (Akoury et al, 1988; Hogston and Noble, 1993). However, much of the data available is not from randomised controlled trials. Meta analysis of the available randomised clinical trials on the components of active management show that oxytocin augmentation does not improve caesarean section rates, operative vaginal delivery rates or neonatal outcome, but it does increase hyperstimulation and the amount of pain experienced by the mother (Thornton and Lilford, 1994; Olah and Gee, 1996). keirse (1989) states that from the research data available, it does not appear that liberal use of oxytocin augmentation in labour is of benefit to the women and babies so treated.

Fraser (1993) however, highlights the difficulty in assessing active management by this research method, because of the high number of variables involved which may influence the results. A low or non-existent rate of hyperstimulation is probably because of the rigid monitoring of uterine activity by use of cardiotocography continuously once the infusion is in place, and close monitoring by a midwife. However, evaluation of the effect of oxytocin administration is far from easy in the context of clinical research. Although regarded as a single, discrete component of active management, in reality oxytocin administration is a complex intervention that requires such continuous electronic fetal monitoring and necessitates the continuous presence of a health professional (Fraser, 1993). These new variables have a bearing on research outcomes when evaluating active management of labour. This belies the accepted simplistic belief that oxytocin equals increased uterine activity equals reduced labour duration. Such is the complexity of the issue needing research, that even the use of randomised controlled trials could be called into question (Fraser, 1993).

Perhaps the different components of active management of labour cannot be truly evaluated as individual entities, and what is more important is the basis and the consequences of the package as a whole, when viewed from the point of view of the women subjected to it.



ACTIVE MANAGEMENT OF LABOUR - COUNTER ARGUMENTS

Despite the prevalence of acceptance of the principles of Active Management, and the implicit and explicit adoption of its practices, a counter argument exists. Henderson (1996) suggests that the National Maternity Hospital in Dublin (the setting for O'Driscoll's work) has not reduced its caesarean section rate, but merely maintained its lower rate. Factors other than the use of Active Management of Labour could account for this; for example, the way in which the National Maternity hospital avoided many of the innovations seen in most obstetric units during the 1970's (Henderson, 1996). This includes: a low rate of induction of labour, which avoids the concurrent rise in caesarean section rates due to failed induction and high induction rates; the low use of electronic fetal monitoring, also avoiding the escalation of caesarean section rates due to fetal distress; and the use of peer review and audit (Henderson, 1996).

The opposite camp in this conflict, as it were, presents the argument that technological and obstetric involvement in normal labour is unnecessary, unhelpful and even harmful. Ultimately, this argument takes on more than the single-dimensional concept of good outcome at any cost, and demonstrates the multi-dimensional aspects of childbirth and maternity care. By the very nature of society, this argument is labelled as 'alternative'.

"The project of obstetrics as obstetricians originally defined it was the pathology of childbirth, but the continued existence of obstetricians depended on their ability to capture childbirth, all of it, treat it and hold it firmly as part of their project." (Arney 1982: in Hancock, 1996: 7)

 Arney (1982: In Hancock, 1996) is not the first to question the role of obstetrics in normal birth; other have previously done this, highlighting the plight of childbearing women in the modern technocratic world, and daring to suggest different approaches to childbirth. Leboyer (1974: in Hancock, 1996) saw birth from the point of view of the fetus or baby, controversially suggesting that birth was the 'torture of an innocent'. Significant change was called for as far back as 1984 when another controversial opinion, that of Michel Odent, seeing no limit to the mechanical invasion of the delivery room, called for a condemnation of the present conditions of birth in industrialised societies. (Odent 1984 & 1985: in Hancock, 1996).

It is suggested that in this technological era women are led to believe having a baby is a complicated and dangerous affair, and this has encouraged dependence and undermined their confidence in themselves as reproducers (Huntingford, 1985, Kitzinger, 1992, Levin and Oleson, 1985, Oakely, 1981, Odent 1993: in Young, 1995). There is some evidence that women whose labours involve particular obstetric procedures are more likely to experience depressed mood than other women (Jacoby, 1987). Such effects are still not truly recognised in the context of medical research.

The main problem in the counter-argument is that it has hifle validity.in the scientific field, this field being the accepted norm for defining what is reliable and valid. Much of what is written, whilst providing excellent opinion, thought and descriptive evidence, is not based on sound' research evidence, found through randomised controlled trials. The assimilation of this standard into midwifery care was achieved by Enkin, Keirse and Chalmers of the Oxford Pregnancy Database (Hancock, 1996). The problem in validating the 'alternative' viewpoint is the lack of such 'hard data' with which to meet this standard, as much of the research employed in illustrating the multi-dimensional nature of midwifery care and maternal need, is descriptive, experiential or qualitative. However, alternatives to certain of the principles of active management of labour are not necessarily from an alternative research base or paradigm. Randomised trials of ambulation in labour, for example, have demonstrated a lower use of oxytocics for augmentation of labour (Flynn et al, 1978; McManus and Calder; 1978, Williams et al, 1980; Hemminki and Saarikoski 1983: in K6irse, 1989). Despite this, ambulation, while encouraged, is not seen as a valid alternative to the use of oxytocin.

Examples of different structures of maternity care demonstrate the underlying principle of non-medicalised maternity care; that in normal pregnancies uncomplicated by pathology, non-interventionist care is best. Such is the case in the Netherlands, where over one-third of babies are born at home under the care of the midwife (Silverton, 1993). The low-technology care given by midwives in the home and to a lesser extent in hospital results in significantly lower perinatal mortality than the interventionist medical care (Silverton, 1993). Dutch perinatal mortality statistics demonstrate that midwives achieve better outcomes for all births after 32 weeks of gestation for all levels of risk assessment than either general practitioners or obstetricians (Tew and Damstra-Wijmenga, 1991, in Silverton, 1993).

However, the concepts of patriarchy and medicalisation are rejected by some authors as the possible bases for explaining the differences between the Dutch and British organisation of maternity care (Van Teulingen, 1994). Perhaps it is a cultural issue, more deeply entrenched than oversimplified concepts of sexism and medicalisation. The values and attitudes in the wider society towards birth, motherhood, women, families, midwives, the medical profession and other factors will have an influence on maternity care and services (Bryar, 1995). The structures within the organisation - for example, the relationships between the different professional groups involved in the care of the childbearing woman: midwives, obstetricians, physiotherapists and others, and the management systems, whether these hierarchical or collegial - will also affect the activities of midwives and the care of women (Bryar, 1995). Essentially, the issue is complex and multifactorial, but certain basic factors can be highlighted as significant.

The same kind of emphasis on midwives as the main carers for women with uncomplicated pregnancies can be seen in Sweden, where such women are cared for in local mothercare centres, small maternity units which are run by midwives who are employed by the state (Benoit, 1992 in Bryar, 1995). As already mentioned, statistics show the success of such care in terms of outcomes. However, the main problem remains, that the lack of research evidence makes it difficult to prove our point within the medicalised paradigm.

It could be argued that there is no need to prove such a point, that attempting to gain equal footing for midwifery care by utilising and subscribing to the standards of the scientific world is a futile exercise at best, and at worst a form of treason against the underlying principles of midwifery care. As already stated, scientific knowledge is still the dominant influence within medical institutions.

Midwives and feminists would argue that other, more holistic forms of knowledge are as important as the scientific, if not more so. However, we work within a scientific arena, and that is unlikely to change radically in the near future, so it might be that we have to find some footing within that arena in order to gain any validation of our status as midwives.

The two opposing arguments, medical versus midwifery, typically fall into a gendered dichotomy - male medical establishment versus female midwifery carers. Murphy-Lawless (1991) describes Flint's (1987) account of the relationship between women and midwives which emphasises the nonmedical, feeling and intuitive elements which it is argued midwives can bring to the birth process. This strong, feminist voice typifies the standpoint which the medical establishment find it so difficult to stomach:

"Midwives and women are intertwined, whatever affects women atfects midwives and vice-versa - we are interrelated and interwoven. When midwives are strong, women are able to labour safely and without interference. When midwives are weak women's bodies are taken over and the birth process is interfered with often to the detriment of women (Flint, 1987 p viii in Murphy-Lawless, 1991:199.)

 In such a situation, midwives then have to contend with an inner conflict, a form of cognitive dissonance, knowing one way is best, but being forced to act in another. A division of loyalties results, the midwife as employee versus the midwife as supporter of women (Davies, 1996). In the scenario where the midwife knows that the active management protocol is not sound, evidence-based practice, but where she is still forced to work within its parameters, she must then compromise both her own ideals and those of the mother. However, if midwives utilised research effectively, this could change.

Research shows that while it is possible to identify midwifery ideals and goals, and mothers' ideals and goals, achieving this elusive concept of satisfaction for both parties is far from easy. Data from one small study suggests that the shared goals between women and midwives postulated within the model of woman-controlled childbirth are, in reality, difficult to achieve (Murphy-Lawless, 1991)



THE FUTURE - FEMINIST MIDWIFERY RESEARCH?

If midwives are to collectively and individually challenge and improve the current status of maternity care services, it would appear that research is the key to opening the door to change and evolution. Midwives as both research users and as research innovators could have an enormous impact on the future satisfaction of women undergoing pregnancy and childbirth, as well as highlighting and reinforcing the status of the profession. Midwifery must have its own body of professional knowledge, developed by midwives, for midwives, to be used by midwives (Hicks, 1992). Therefore, it is imperative that a prevailing research culture is fostered within the profession (Hicks, 1992). However, the parameters of this research pose the challenge, for it must be tailored to meet a broad range of needs.

Particularly there is a need to support research into the active management of labour, and also for parents, doctors and midwives to co-operate in investigating other ways of normalising and facilitating birth (Klein, 1993). However, first midwives need to become aware of their own shortcomings and the ways of thinking which define their actions and attitudes towards research and practice. In one study, it was found that midwives undervalue research they believe to have been undertaken by a midwife as compared with that believed to have been undertaken by an obstetrician (Hicks, 1992). This finding is partly explained in terms of the gender influences that operate in midwifery where research by obstetricians is given more validity (Hicks, 1992). This underlying value system is fostered and perpetuated by the same socialisation process that leads midwives to continue to employ active management of labour because it is 'the norm', despite the inadequacy of its research basis and principles.

The question is, what kind of research into active management of labour is needed to be undertaken in order to evaluate its appropriateness, its effectiveness and its place within midwifery care. The obvious answer would be quantitative research. A quantitative approach is interested in the accurate measurement of results which have a numeric value (Rees, 1996). Quantitative approaches include descriptive studies such as surveys; studies which try to establish a correlation or association between factors; experimental studies; and quasi-experimental studies (Carter, 1991: in Rees, 1996). The most significant issue here, when attempting to discover research methods that will provide more detailed information about such a multi-faceted area is descriptive research, which can be included under the heading of quantitative research where the results are mainly in the form of numbers (Rees, 1996). Perhaps this is a starting point for midwifery research, in that numbers and statistics may be generated from research other than the randomised controlled trial, which, as already demonstrated, may be less than adequate as a research tool for this particular subject.

Bortin et al (1994) recommend the employment of qualitative research with a feminist perspective as a method to elucidate concepts in the midwifery care framework, and suggest that future research should explore the recognition and validation of the woman and her experiences, appropriate use of technology, and the influences of the birth environment. Feminist research methods would provide an alternative to the mainstream, obstetrically dominated research arena.

Feminist research is about making women and their experiences visible (Draper, 1997). It is concerned with not only making women visible, but with theoretical and methodological issues, with problems of sexual division in the research team, with the language of the research findings and the ways in which these are used when they are published (Roberts, 1981: in Draper, 1997). Feminists see mainstream 'masculinist' research as inadequate. The scientific method is based on male conceptualisation and values (Harding, 1987: in Denny, 1991) and functions in support of the status quo (Denny, 1991). The challenge to the mainstream is that masculinist knowledge is often considered neutral or value-free because it pervades all sciences and is 'taken for granted' (Denny, 1991). It emphasises the domain of cognitive and objective rationality, reductionism and a sex-dichotomised positioning of the social and natural worlds (Denny, 1991). However, feminist knowledge includes caring, sharing, co-operation and solidarity (Sydie, 1987).

Feminist approaches grew out of a dissatisfaction with existing research philosophies (Draper, 1997) and seek a new approach which will develop theory firmly rooted in women's experience (Wilkinson, 1986: in Draper, 1997. See also table 1 above). Seibold et al (1994: in Draper, 1997) propose a set of guiding principles for feminist research which are: that women's experiences are the major object of the investigation; that the researcher attempts to see the world from the point of view of the women; that the researcher is active in trying to improve the lot of women. The main issue is that feminist methodologies should be used (Draper, 1997). For example, non-hierarchical research relationships and reciprocity, where the power between the researched and the researcher is equal (Draper, 1997).

This then would entail the research into the active management of labour being carried out by midwives who believe themselves to be truly 'with woman', with the aim accurately assessing the affects on women and their babies from every angle, including but not emphasising clinical outcomes. The next step would be putting the findings of the research into practice, using the theory generated by the research in order to change and improve the active management protocol.

This is obviously a huge chltlenge, involving a lot of time, input, effort and reflection on behalf of the midwives and the women involved. It involves challenging not only the 'norm of active management and the everyday practices of hospital-based midwifery care during labour, but extending that challenge and changing the fundamental ways of thinking, the language and power structure and attitudes that pervade the research arena today. It involves taking on the whole obstetric institution, not by merely fighting it on its own ground, in the terms of the randomised controlled trial and the clinical outcome, but by validating other forms of evidence and attempting to find a common ground where the scientific and the subjective meet. Perhaps then the true picture of the effects of active management will at last be painted, and the whole concept can be evaluated, allowing midwives the autonomy and power to provide the best care possible, utilising the obstetric and the feminist contribution to practice.

Feminist approaches grew out of a dissatisfaction with existing research philosophies (Draper, 1997) and seek a new approach which will develop theory firmly rooted in women's experience (Wilkinson, 1986: in Draper, 1997. See also table 1 above). Seibold et al (1994:

In Draper (1997) propose a set of guiding principles for feminist research which are: that women's experiences are the major object of the investigation; that the researcher attempts to see the world from the point of view of the women; that the researcher is active in trying to improve the lot of women. The main issue is that feminist methodologies should be used (Draper, 1997). For example, non-hierarchical research relationships and reciprocity, where the power between the researched and the researcher is equal (Draper, 1997).

This then would entail the research into the active management of labour being carried out by midwives who believe themselves to be truly 'with woman', with the aim accurately assessing the affects on women and their babies from every angle, including but not emphasising clinical outcomes. The next step would be putting the findings of the research into practice, using the theory generated by the research in order to change and improve the active management protocol.

This is obviously a huge challenge, involving a lot of time, input, effort and reflection on behalf of the midwives and the women involved. It involves challenging not only the 'norm of active management and the everyday practices of hospital-based midwifery care during labour, but extending that challenge and changing the fundamental ways of thinking, the language and power structure and attitudes that pervade the research arena today. It involves taking on the whole obstetric institution, not by merely fighting it on its own ground, in the terms of the randomised controlled trial and the clinical outcome, but by validating other forms of evidence and attempting to find a common ground where the scientific and the subjective meet. Perhaps then the true picture of the effects of active management will at last be painted, and the whole concept can be evaluated, allowing midwives the autonomy and power to provide the best care possible, utilising the obstetric and the feminist contribution to practice.



CONCLUSION

As has been demonstrated in the above discussion, the protocol of active management of labour forms a part of current midwifery practice. However, while the research base for the components of active management shows some validity, the research base for the protocol as a whole is weak and, in the author's opinion, not an adequate basis for practice. Despite this fact, no midwifery research on the protocol appears to exist, which means that midwifery care at present is far from the ideal of betng evidence based practice. What research exists is entirely obstetric, and as such subject to the constraints of the medical paradigm, which for the most part is restricted to clinical outcomes, and is far from holistic or woman-centred.


If midwives are to truly be 'with woman', then the primary focus of care should be the woman and her baby, and the research performed on this very important aspect of labour care should reflect this. From the literature available for review in the above discussion, it would appear the feminist midwifery research would be ideal. The author, however, has some reservations about the applicability of such research, and its validity in what is still a medically-dominated arena. There is the possibility that midwifery research, taking the woman as the focus, might be incompatible with the ideal if the randomised controlled trial, as this kind of research involves concepts such as 'satisfaction' and 'experience' , which are difficult to quantify. Perhaps instead midwives should employ both kinds of research to such issues, concurrently, utilising both qualitative and quantitative methods. Or indeed it might be that the time has come to shift the focus of midwifery care away from reductionist concepts such as the hard data produced by random ised controlled trials, and instead follow the radical lead into a midwifery arena where obstetrics does not exist.

Unfortunately, the latter argument will never be viable. Everyone, midwives obstetricians and mothers alike, is concerned with the same outcome - a live, healthy baby and mother with the minimum of complications and intervention. Until nature can guarantee every pregnancy will proceed without complication, and every birth will be perfect, midwives, obstetricians and mothers will remain equally invested in ensuring that everything goes as well as possible. This is the place for feminist midwifery research then, to incorporate the findings of the medical establishment into their own, holistic, woman-centred research and knowledge.

In the case of active management of labour, as has been seen, much more reliable research is needed to accurately understand the protocol and its components, and the true benefits and drawbacks to its use. Research is also needed into the more elusive area of women's experience of labour being actively managed, to create a better picture of the effects of our intervention, and their appropriateness. Whatever the results may be, evolution of the active management protocol can only be a good thing, and hopefully, in the future this evolution will have a sound research base, providing everyone concerned with a more thorough knowledge of what they are doing and why they are doing it.

Shooting at the moon? Perhaps, but if we did not constantly strive for improvement, we would not have the low perinatal mortality rates that we have, and midwifery as a profession would still have no status or recognition. Feminism still receives a bad press in mainstream political thought, but if feminist midwifery research, in whatever form, can bring us that better knowledge base about active management of labour, then it must be a good way to move forward.




BIBLIOGRAPHY

AKOURY, H.A. et al. (1988) Active management of labour and operative delivery in nulliparous women. American Journal of Obstetrics and Gvnaecolociv 158 (2) February 255-258.

ANNANDALE, E. & CLARK, J. (1996) What is gender? Feminist theory and the sociology of human reproduction. Sociologv of Health and Illness 18 (1)17-44.

ANONYMOUS (1993) Birth Practices - ten things you may not have known. Empowerment 2 (2) 4-7.

ARNEY, W. (1982) Power and the Drofession of obstetrics London: University of Chicago Press. In: HANCOCK, H. (1996 ) Women and birth - Triumph or travesty? Birth Issues 5(2)5-10.

AXTEN, 5. (1995) Is active management always necessary? Modern Midwife 5 (5) May 18-20.

BARTON, D.P.J. et al (1992) Prolonged spontaneous labour in primigravidae whose labour was actively managed: results of an audit. Journal of Obstetrics and Gynecology. 12 304-308.

BECKER, G. & NACHTIGNALL, R.D. (1992) Eager for medicalisation: the social produdtion of infertility as a disease. Sociology of Health and Illness 14 (4) 456-471. In: YOUNG, J. (1995) The medicalisation of childbirth: a cause for concern. Midwifery 3 (1) Spring. 9-16

BEECH, B.L. Is obstetrics good for your health? In: BEECH, B,L (ed) (1996) Waterbirth Unplugged: proceedings of the first International Waterbirth Conference. Hale, Cheshire: Books for Midwives Press.

BENOIT, C. (1992) Midwives in comparative perspective: professionalism in small organisations. Current Research on Occupations and Professions 7 203-220. In: BRYAR, R.M. (1995) Theorv for Midwiferv Practice Basingstoke: Macmillan.

BLUFF, R. (1997) Evaluating qualitative research. British Journal of Midwifery 5 (4) April 232-235

BOER, D. (1993) The birth of intervention. International Journal of Childbirth Education 8 (3) August/September 35-36.

BORGES, S. (1991) The importance of Artificial rupture of membranes in early labour as part of active management of labour Obstetrics and Gynaecology Product News Autumn 19-21.

BORTIN, S. et al. (1994) A f~nist perspective on the study of home birth. Applications of a midwifery care framework. Journal of Nurse-Midwiferv 39 (3) May/June 142-149.

BRYAR, R.M. (1995) Theorv for Midwiferv Practice Basingstoke: Macmillan.

BYRNE, B.M., KEANE, D. BOYLAN, P. & STRONGE, J.M (1993) Intra-uterine pressure and the active management of labour Journal of Obstetrics and GvnaecoIo~v 13 433-436.

CAMMU, H. & VAN EECKHOUT, E. (1996) A randomised controlled trial of early versus delayed use of amniotomy and oxytocin infusion in nulliparous labour British Journal of Obstetrics and Gynaecology. 313-318 In: OLAH, KS. & GEE, H. (1996) The active mismanagement of labour. British Journal of Obstetrics aand Gvnaecolociv 103 August. 729-731

CARTER, D. (1991) Quantitative research. In: CORMACK, D. (ed.) (1991) The Research Process in Nursing Oxford: Blackwell. In: REES. C (1996) Quantitative and qualitative approaches to research. British Journal of Midwiferv 4 (7) July. 374-377

CONSENSUS CONFERENCE REPORT (1986) Indications for Caesarean Section: Final Statement of the Panel of the National Consensus Conference on Aspects of Caesarean Birth Canadian Medical Association Journal 134.1348-52.

COREA, G (1988) The Mother Machine London: The Women's Press.

DAVIES, C. (1995) Gender and the Drofessional Dredicament in nursinci Buckingham: Open University Press.

DAVIES, R.M. (1995) Introduction to ethnographic research in midwifery. British Journal of Midwifery 3 (4) April 223-227.

DAVIES, 5. (1996) Divided loyalities: the problem of normality. British Journal of Midwifery. 4 (6) June. 285-286.

DAVIES-FLOYD, B. (1994) C~ture and Birth: the technocratic imperative. International Journal of Childbirth Education 9 (2) 6-7.

DRAPER,J. (1997) Potential and problems: the value of feminist approaches to research. British Journal of Midwifery 5 (10) October 597-600.

DENNY, E. (1991) Feminist research methods in nursing. Senior Nurse 11(6) November/December. 38-40.

EDWARDS, G. (1994) Jobs for the boys: male domination within nursing and midwifery. British Journal of Midwifery 2 (10) October. 504-506.

ERICSON, D.L. (1991) Territorialism in the Health Care Professions. International Journal of Childbirth Education August. 30-31.

FIELD, P.A. & MORSE, J.M. (1985) Nursing Research: The Application of Qualitative Approaches London: Groom Helm.

FLINT, C. (1987) Sensitive Midwifery London: Heinemann. In: Murphy-Lawless, J. (1991) Piggy in the middle: the midwife's role in achieving woman-controlled childbirth. The Irish Journal of Psychology 12 (2)198-215.

FLYNN, A.M. et al. (1978) Ambulation in labour. British Medical Journal 2 591-593. In: KEIRSE, M.J.N.C. (1989) Augmentation of Labour. In: ENKIN, M., CHALMERS, I & KEIRSE, M.J.N.C. (Eds.) (1989) Effective Care in Pregnancy and Childbirth Volume 2. Oxford: Oxford University Press. Chapter 58, 951-968.

FRASER, W. (1993) Methodologic issues in assessing the active management of labour. Birth 20 (3)155-156.

FRIEND J.R. (1995) Respect for women's choice. Maternal and Child Health 202-206.

FRIGOLETTO, F.D. et al (1995) A clinical trial of active management of labour. The New England Journal of Medicine 333 (12) 745-750.

GERHARDSTEIN, L.P et al. (1995) Reduction in the rate of cesarean birth with active management of labour and intermediate dose oxytocin Journal of Reproductive medicine 40 (1) January 4-8.

GIBBS, 5. (1994) Two paths toward reducing cesareans Midwifery Todav 30. Summer 16-18

GOFF, K.J. (1993) Initiation of parturition American Journal of Maternal Child Nursing 18 (Suppl.) Sept'Oct. 23-30.

GOTTLIEB, L.N. & MENDELSON, M.J. (1995) Mothers' moods and social support when a second child is born. Maternal Child Nursing Journal 23 (1) Jan-March. 3-14.

HAGELL, E.I. (1993) Reproductive technologies and court-ordered obstetric interventions: the need for a feminist voice in nursing. Health Care for Women International 14.77-86.

HALL, J.M & STEVENS, P.E. (1991) Rigor and feminist research Advances in Nursing Science. 13 (3)16-29 In: DRAPER, J. (1997) Potential and problems: the value of feminist approaches to research. British Journal of Midwifery 5 (10) October 597-600.

HANCOCK, A. (1994) How effective is antenatal education? Modern Midwife 14 (5) 13-15.

HANCOCK, H. (1996 ) Women and birth - Triumph or travesty? Birth Issues 5 (2) 5-10.

HARDING, S. (ed.) (1987) Feminism and Methodology Milton Keynes: Open University Press. In: DENNY, E. (1991) Feminist research methods in nursing. Senior Nurse 11(6) November/December. 38-40.

HEMMINKI, E. & SAARIKOSKI, 5. (1983) Ambulation and delayed amniotomy in the first stage of labour. European Journal of Obstetrics. Gynaecology and Reproductive Biology 15 129-139.In: KEIRSE, M.J.N.C. (1989) Augmentation of Labour. In: ENKIN, M., CHALMERS, I &KEIRSE, M.J.N.C. (Eds.) (1989) Effective Care in Pregnancv and Childbirth Volume 2. Oxford: Oxford University Press. Chapter 58, 951-968.

HENDERSON J. (1996) Active management of labour and caesarean section rates. British Journal of Midwifery 4 (3) 132-149

HICKS, C. (1992) Research in midwifery: are midwives their own worst enemies? Midwifery 8 (1) March 2-18.

HICKS, N.R. & MANT, J. (1997) Using the evidence: putting the research into practice. British Journal of Midwifery 5 (7) July 396-399.

HODNETT, E.D. (1993) Support from caregivers during at risk pregnancy. In: ENKIN, M.W., KEIRSE, M.J.N.C., RENFREW, M.J. & NEILSON J.D. (Eds.) Pregnancy and Childbirth Module. Cochrane Database of Svstematic Reviews Review 041.69. Oxford: Cochrane Updates, Update Software. In: THORNTON, J.G. & LILFORD, R.J. (1994) Active management of labour: current knowledge and research issues British Medical Journal 309 6 August 366-369.

HOGSTON, P. & NOBLE, W. (1993) Active Management of Labour - the Portsmouth experience. Journal of Obstetrics and Gynaecology 13 (5) 340-342.

HOREY, D. (1995) Feminism and homebirth. Homebirth Australia Newsletter 40. August 15-18.

HOUSTON, S.M. (1996) Designing a questionnaire for a midwifery research project. British Journal of Midwifery 4 (12) December. 629-632

HUMM, M. (ed.) (1992) Feminisms: A Reader Hempstead: Harvester Wheatsheaf. In: HOREY, D. (1995) Feminism and homebirth. Homebirth Australia Newsletter 40. August 15-18

HUNDLEY, V. & GRAHAM, W. (1997) Research and audit in midwifery: does the difference matter? British Journal of Midwifery 5 (11) November 664-668.

HUNT, S. & SYMONDS, A. (1995) The Social Meaning of Midwifery Basingstoke: Macmillan.

HUNTINGFORD, P. (1985) Birthright: The Parents' Choice London: British Broadcasting corporation. In: YOUNG, J. (1995) The medicalisation of childbirth: a cause for concern. Midwifery 3 (1) Spring. 9-16.

JACOBY, A. (1987) Women's preferences for and satisfaction with current procedures in childbirth - findings from a national study. Midwifery 13 (3) September. 117-124.

KAUFMAN, K.J. (1993) Effective control or eflective care? Birth 20 (3)156-158

KEIRSE, M.J.N.C. (1993) A final comment... managing the uterus, the woman, or whom? Birth 20 (3)159-161

KEIRSE, M.J.N.C. (1989) Augmentation of Labour. In: ENKIN, M., CHALMERS, I & KEIRSE, M.J.N.C. (Eds.) (1989) Effective Care in Pregnancy and Childbirth Volume 2. Oxford: Oxford University Press. Chapter 58, 951-968.

KING, C.K. (1992) The Ideological and Technological Shaping of Motherhood. Women and Health 19(2/3)1-12

KIRKHAM, M.J. (1994) Using research skills in midwifery practice. British Journal of Midwifery 2 (8) August 390-392.

KIRKHAM, M.J (1986) A feminist perspective in midwifery In: Webb, C. (ed.) Feminist Practice in Women's Health Care Chichester: John Wiley.

KITZINGER, S. (1992) Ourselves as mothers: the universal exDerience of motherhood Toronto: Bantam Books. In: YOUNG, J. (1995) The medicalisation of childbirth: a cause for concern. Midwifery 3 (1) Spring. 9-16

KITZINGER, S. (ed.) 1988) The Midwife Challenge London: Pandora Press. In: YOUNG, J. (1995) The medicalisation of childbirth: a cause for concern. Midwifery 3 (1) Spring. 9-16

KLEIN, M (1993) The active management of labour: whose agenda? Birth 20 (2) June 97-99.

LEBOYER, F. (1974) Birth without Violence Australia: Rigby. In: HANCOCK, H. (1996) Women and birth -Triumph or travesty? Birth Issues 5(2)5-10.

LEVIN, E. & OLESON, V. (eds.) (1985) Women. Health and Healing: Toward a New Perspective London: Tavistock Publications. In: YOUNG, J. (1995) The medicalisation of childbirth: a cause for concern. Midwifery 3 (1) Spring. 9-16.

LIDEGARD, O., JENSEN, L.M. & WEBER, T. (1994) Technology use, cesarean section rates and prenatal mortality at Danish maternity wards. Acta Obstetrica Gynaecologica Scandinavia 73.24-245.

LISTON, R.M. (1995) Active Management ot Labour. Journal SOGC 17 August. 767-774.

LOCICERO, A.K. (1993) Explaining excessive rates of caesareans and other childbirth interventions: contributions from contemporary theories of gender and psychosocial development. Social Science and Medicine 37 (10) November. 1261-1269.

LOPEZ-ZENO, J.A. et a (1992) A controlled trial of a program for the active management of labour. New England Journal of Medicine 326 450-454. In: OLAH, KS. & GEE, H. (1996) The active mismanagement of labour. British Journal of Obstetrics and Gynaecology 103 August. 729-731.

MALONE, F.D. et al (1996) Prolonged labour in nulliparas: lessons from the active management of labour. Obstetrics and Gynaecology. 88 (2) August. 211-215.

MCCOOL, W.F. & MCCOOL, S. (1989) Feminism and Nurse-Midwifery - Historical overview and current issues. Journal of Nurse-Midwifery 34 (6) November/December 323 - 334.

MCLEAN, MT. (1995) The medicalisation of the second stage of labour. Midwifery Today 33 March 36.

MCLEAN, M.T. (1994) Personal autonomy versus active management of labour Midwifery Today 3O Summer 18.

MCMANUS, T.J. & CALDER, A.A. (1978) Upright posture and the efficiency of labour. The Lancet 1 72-74. In: KEIRSE, M.J.N.C. (1989) Augmentation of Labour. In: ENKIN, M.,CHALMERS, I & KEIRSE, M.J.N.C. (Eds.) (1989) Effective Care in Pregnancy and Childbirth Volume 2. Oxford: Oxford University Press. Chapter 58, 951-968.

MITCHELL, J. & OAKLEY, A. (eds.) (1986) What is feminism? Oxford: Blackwell.

MITCHELL, M.D. et al. (1977) Evidence for a local control of prostaglandins within the pregnant human uterus. British Journal of Obstetrics and Gynecology 84 35-38. In: KEIRSE, M.J.N.C. (1989) Augmentation of Labour. In: ENKIN, M., CHALMERS, I & KEIRSE, M.J.N.C. (Eds.) (1989) Effective Care in Precinancv and Childbirth Volume 2. Oxford: Oxford University Press. Chapter 58, 951-968.

MURPHY-LAWLESS, J. (1991) Piggy in the middle: the midwife's role in achieving woman-controlled childbirth. The Irish Journal of Psvcholociv 12 (2)198-215.

NEWBURN, M., & HUTTON, E. (1996) Women and Midwives, turning the tide. IN: KNOLL, D. (ed.) Midwifery Care for the future: meeting the challenge. London: Balliere Tindall.

OAKLEY, A. (1981) Women confined: Toward a Sociology of Childbirth. Oxford: Martin Robertson.

OAKLEY, A., & RAJAN, L. (1990) Obstetric technology and maternal emotional well-being -a further research note. Journal of ReDroductive and Infant Psychology 8.45-55.

ODENT, M. (1996) Knitting needles, cameras and electronic fetal monitors. Midwifery Today 14-15.

ODENT, M (1993) Midwives are better than electronics. MIDIRS Midwifery Digest 3 (3) September. 265-267.

ODENT, M. (1985) Birth Reborn London: Fontana. In: HANCOCK, H. (1996 ) Women and birth - Triumph or travesty? Birth Issues 5 (2) 5-10.

ODENT, M. (1984) The De-medicalisation of Childbirth London: Marian Boyars. In: HANCOCK, H. (1996) Women and birth - Triumph or travesty? Birth Issues 5 (2) 5-10.

O'DRISCOLL, K., JACKSON, R.J.A. & GALLAGHER, J.T. (1969) Prevention of prolonged labour. British Medical Journal. 2.477-480.

O'DRISCOLL, K. & MEAGHER, D. (1986) Active Management of Labour - The Dublin Experience. (2nd . Ed.) London: Balliere Tindall.

O'HERLIHY, C. (1993) Active management: a continuing benefit in nulliparous labour Birth 20 (2) 95-97.

OLAH, KS. & GEE, H. (1996) The active mismanagement of labour. British Journal of Obstetrics and Gynaecology 103 August. 729-731

OLAH, K.S., HENDERSON, C., & BIRKBECK, J. (1993) Assessment of uterine contractions: midwife or monitor? British Journal of Midwifery 1(3) July/August 111-118.

PEACEMAN, A.M. & SOCOL, M.L. (1996) Active management Qf labour. American Journal of Obstetrics and Gynecology 175 (2) August 363-368.

PELKA, F. (1992) Electronic fetal monitoring. Mothering Fall. 71-75.

PHILLIPS, R. & DAVIES, R. (1995) Using diaries in qualitative research. British Journal of Midwifery 3 (9) September 473-476

PRENDIVILLE, W.J. et al (1988) The Bristol third stage trial: active versus physiological management of the third stage of labour. British Medical Journal 297. 19 November. 1295-1300.

REES. C (1996) Quantitative and qualitative approaches to research. British Journal of Midwifery 4 (7) July. 374-377

REES, C. (1995a) Questionnaire design in midwifery. British Journal of Midwifery 3 (10) October 549-552.

REES, C. (1995b) Evaluating a research article. British Journal of Midwifery 2 (12) December 596-601.

ROBERTS, H. (1981) Doing Feminist Research London: Routledge. In: DRAPER, J. (1997) Potential and problems: the value of feminist approaches to research. British Journal of Midwifery 5 (10) October 597-600.

ROBERTS, Y. (1992) Mad About Women London: Virago.

ROCKENSCHAUB, A. (1990) Avoiding medical technology in Obstetrics. AIMS Quarterly Journal 4 (2)13-14.

ROETHLISBERG ER, F.J. & DICKENSON, W.J. (1939) Management and the worker: an account of a research prog ram conducted bv the western Electric Companv. Cambridge, Mass.: Harvard University Press. In: FRIGOLETTO, F.D. et al (1995) A clinical trial of active management of labour. The New Enaland Journal of Medicine 333 (12) 745-750

ROMITO, P. & HOVELAQUE, F. (1987) Changing approaches in women's health: new insights and new pitfalls in prenatal preventive care. International Journal of Health Services 17 (2) 241-258.

ROTHMAN, B.K. (1993) The active management of physicians. Birth 20 (3)158-159.

ROTHWELL, H. (1995). Medicalisation of Childbearing British Journal of Midwifery 3 (6) June. 318-322.

RUZEK, S. (1986) Feminist visions of health: an international perspective. In: MITCHELL, J. & OAKLEY, A. (eds.) (1986) What is feminism? Oxford: Blackwell.

SEIBOLD, C., RICHARDS, L., SIMON, D. (1994) Feminist method and qualitative research about midlife Journal of Advanced Nursing 19394-402 In: DRAPER, J. (1997) Potential and problems: the value of feminist approaches to research. British Journal of Midwifery 5 (10) October 597-600.

SELLERS, S.M. et al. (1984) The influence of spontaneous and induced labour on the rise in prostaglandins at amniotomy. British Journal of Obstetrics and Gvnaecolociv 91 849-852. In:

KEIRSE, M.J.N.C. (1989) Augmentation of Labour. In: ENKIN, M., CHALMERS, I & KEIRSE,

M.J.N.C. (Eds.) (1989) Effective Care in Pregnancv and Childbirth Volume 2. Oxford: Oxford University Press. Chapter 58, 951-968.

SHIRLEY, K.E. & MANDER, R. (1996) The power of language. British Journal of Midwifery 4 (6) June 298-300.

SILVERTON, L. (1993) The Art and Science of Midwifery Hemel Hempstead: Prentice Hall.

STUMPF, V. (1993) Do medical interventions impede or enhance the labour process? International Journal of Childbirth Education 8 (3) 32.

SUTTON, J. (1996) Birth: medical emergency or engineering miracle? MIDIRS Midwiferv Digest. 6 (2) June. 170-173.

SWEET, B.R. & TIRAN, D. (1997) Maves' Midwifery London: Balliere Tindafl.

SYDIE, R.A. (1987) Natural Women, Cultured Men Milton Keynes: Open University Press. In:

Denny, E. (1991) Feminist research methods in nursing. Senior Nurse 11(6)November/December. 38-40.

TARKKA, M.T. & PAUNONEN, M. (1996) Social support and its impact on mothers' experiences of childbirth. Journal of Advanced Nursing 23 (1) January. 70-75.

TAYLOR M. (1981) Active management of labour in the National Hospital Dublin. Association of Radical Midwives Newsletter 10 June 8-9

TEW, M. & DAMSTRA-WIJMENGA, S.M. (1991) Safest birth attendants: recent Dutch evidence. Midwifery 7 (2) 55. In: SILVERTON, L. (1993) The Art and Science of Midwifery Hemel Hempstead: Prentice Hall.

THOMSON, A. (1994) A feeling of being in two different worlds. Midwifery 10 123-124

THORNTON, J.G. (1996) Active Management of Labour. British Medical Journal 313.17 August. 378.

THORNTON, J.G. & LILFORD, R.J. (1994) Active management of labour: current knowledge and research issues British Medical Journal 309 6 August 366-3.69.

TIMM, M.M. (1979) Prenatal education evaluation. Nursing Research. 28 (6) 388-392. In: Liston, R.M. (1995) Active Management of Labour. Journal SOGC 17 August. 767-774.

TONG (1989) In: HOREY, D. (1995) Feminism and homebirth. Homebirth Australia Newsletter 40. August 15-18. (full reference for Tong, 1989 not published in Horey, 1995)

TOWLER, J & BRAMALL, J. (1986) Midwives in History and Society. London: Croom Helm.

TURNER, M.J., RASMUSSEN, M.J. and STRONGE, J.M. (1991) Active Management of Labour. Fetal Medicine Review 3 67-72

TURNER, M.J., BRASSIL, M., & GORDON, H. (1988) Active Management of Labour Associated with a decrease in the cesarean section rate in nulliparas. Obstetrics and Gynaecology 71(2) February 152-154

VAN TEIJLINGEN, E.R. (1994) A social or medical model of childbirth? Comparing the arguments in GramDian and the Netherlands. Aberdeen: University of Aberdeen.

WAGNER, M. (1993) Research shows medication of pain is not 'safe'. Caduceus 20 14-15.

WALDENSTROM, V. (1996) Modern maternity care: does safety have to take the meaning out of birth? Midwifery 12.165-173.

WALKINSHAW, S.A. (1994) Is routine active medical intervention in spontaneous labour beneficial? ContemDorary views in Obstetrics and Gynaecology 6. January. 13-17

WALSH, D. (1996) Evidence-based practice: whose evidence and on what basis? British Journal of Midwifery 4 (9) September 454-

WILKINSON, S. (ed.) (1986) Feminist Social Psychology: Developing Theory and Practice Milton Keynes: Oxford University Press. In: DRAPER, J. (1997) Potential and problems: the value of feminist approaches to research. British Journal of Midwifery 5 (10) October 597-600.

WILLIAMS, R.M. et al. (1980) A study of the benefits and acceptability of ambulation in spontaneous labour. British Journal of Obstetrics and Gynaecology 87 122-126. In: KEIRSE, M.J.N.C. (1989) Augmentation of Labour. In: ENKIN, M., CHALMERS, I & KEIRSE, M.J.N.C. (Eds.) (1989) Effective Care in Pregnancv and Childbirth Volume 2. Oxford: Oxford University Press. Chapter 58, 951-968.

YOUNG, J. (1995) The medicalisation of childbirth: a cause for concern. Midwifery 3 (1) Spring. 9-16

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