A metasynthesis of midwives' experience of hospital practice in publicly funded settings: compliance, resistance and authenticity

Worldwide, increasing percentages of women are giving birth in centralized hospitals in the belief that this maximizes safety for themselves and their babies. In parallel, there is international recognition that the number of birth interventions used in the routine care of labouring women is rising. This is fuelling concern about iatrogenesis, and, particularly, maternal and infant morbidity and mortality. It also has an adverse impact on the economics of health care. National and international policy characterizes midwives as the guardians of normal childbirth. This guardianship appears to be failing. The objective of this metasynthesis is to explore midwives' perceptions of hospital midwifery with a focus on labour ward practice to examine professional discourses around midwifery work in the current modernist, risk averse and consumerist childbirth context. Based on an iterative search strategy, 14 studies were selected for the metasynthesis. Three overarching themes were identified: 'power and control'; 'compliance with cultural norms'; and 'attempting to normalize birth'. Most midwives aimed to provide what they characterized as 'real midwifery' but this intention was often overwhelmed with heavy workloads and the normative pressure to provide equitable care to all women. This raises questions of authenticity, both in terms of midwives living out their beliefs, and in terms of acknowledgement of the power to resist. The theoretical insights generated by the metasynthesis could have resonance for other professional and occupational groups who wish to offer autonomous individualized services in an increasingly risk-averse target driven global society.