The labouring woman shakes her head, a worried look now on her face. She indicates she’s not sure she can push again. The midwife kneels beside her to check the dilation with her fingers “You can. The baby is moving down. You’re doing exactly what you need to and I know you still have strength in you. What do you need?’ Another contraction comes and the woman cries out, her body tensing ‘I just want it to be over.’‘What do you need?’, asks the midwife again. ‘The hospital, now!’
The midwife calls the ambulance.
During this interaction that unfolds before my eyes, the midwife is in a constant state of alertness, using all her senses in watchful attendance[1]. The word ‘attendance’ is about being there for the birthing mother and her individual needs, which is evident by the midwife’s repeated question, ‘what do you need?’ It is equally about being very present and connected to what is happening moment by moment. By responding to the labouring woman’s need to call the ambulance, the midwife hands over control and respects her autonomy.
What is my role through this process? I am a part of a team composed of midwives and ethnographers who are collaborating to investigate the lived experiences of midwives and birthing women. Midwives practice watchful attendance at every moment during birthing, even when they have retired to a corner of the room to knit, read a novel, check emails or joke with the partner of the woman in labour. They may consciously adopt such behaviours because they see that their continuous presence may hinder the to-be mother in giving herself over to the process.
Immeasurable value
So far, midwives are largely seen as facilitating ‘natural’ births as opposed to ‘medicalized’ ones by (mostly male) obstetricians. Our study goes beyond these poles and what lies in between them and recognizes watchful attendance as woman centred support in the hands of a skilled professional exercising clinical alertness. When a woman is in the middle of the arduous task of giving birth she is referred to as being in ‘labour’. We see the midwife’s work as one of ‘emotional labour’[2]. She is monitoring the medical condition of the birthing mother – her blood pressure, dilation and so on and she is simultaneously engaged in coaching her. Midwives often engage in an internal dialogue: ‘I am performing a clinical task right now – monitoring how dilated the birthing mother is. Once I have done that, I need to support her emotionally….’ There’s a tension between the medical expert and the coach; between safety and autonomy; between facilitating a normal birth and preventing risk. We focus on the ‘emotional labour’ midwives perform.
In doing so, we help future midwives to connect their medical and coaching roles. Besides this, the mother gets to express ‘what helped me when I was pushing the baby out…what worked, what didn’t…how did I feel supported in a way that I wouldn’t feel in a hospital with doctors surrounding me’. In maternal health there is an increasing impulse to measure, to control, to prevent mistakes, knowing full well that the aspect of midwives’ work which is about providing ‘emotional labour’ is almost impossible to measure. In a society that is insurance driven and risk averse, this kind of work midwives are performing tends to go unseen. Our research brings the immeasurable value of their work into light. The midwives we worked with felt that a collaboration with anthropology would reveal the unexpected aspects of midwives’ own experiences in providing watchful attendance.
Flipping the question
I am interested in how diverse groups negotiate definitions, values, roles and responsibilities around a shared concern. Some years ago, I worked with donor organizations in Africa. Statistics show that the amount of money migrants send home as remittances largely outsmarts the money spent on international development. Funding schemes by well-meaning donor organizations saw the benefits of teaming up with African migrants to scale up their own initiatives. However, as insights from my research revealed, these did not match the kind of activities migrants were engaging in. For instance, migrant initiatives included gatherings to meet others, network and mobilize in ‘in-migration’ countries and not the countries they had migrated out of. So, Somali refugees who have associations that are located in different countries could not get access to funding that would support activities in those places, and not exclusively in Somalia. By helping donors flip the question to, ‘what are migrants strengths and how can we tap into them?’ the organization I was collaborating with responded by changing the funding scheme to allow for access on both ends of the migration trail – country of origin and immigration. This is a bottom-up response to the spontaneous initiatives of migrants.
The Outsider Insider
My work in the field could take the form of shadowing or tagging along with my interlocutors. It’s precisely because I came from Mars—in the sense that I knew nothing about healthcare—that I was able to bring out the implicit or automatic ways of doing things, for instance among midwives. I ask questions, sometimes critical ones; the kind that make some people feel ethnographers are nosey and have the nasty habit of popping up and following them around.
At the moment, my focus is on transnational collaboration in biomedical HIV cure research. As with other fields I have researched, this one is not one I knew much about. By shadowing, observing, asking unusual questions, the potential of ethnographic insights can be powerful tools to shape change in a people centred way. This, in my case is as true for migrant involvement in development as it is for health, care and cure. In doing so, my aim is to bridge the gap between academic research and practice to create impact through collaboration, be it with organizations in the development field, or with practitioners in healthcare. As with other fields, in the field of HIV cure too, I find my ‘outsider’ position strengthens my ethnographic practice as a builder of bridges. The critical questions I ask could contribute to the tweaking that is necessary for my interlocutors to take decisions that facilitate a future cure that is equitable, global, and just.
And this is what makes my heart beat about the work I do.
[1] The expression watchful attendance has been introduced by midwifery scientists, including Netherlands based Prof. Ank de Jonge, to describe this state of alertness.
[2] The term ‘emotional labour’ by sociologist Arlie Hochschild indicates the display of certain emotions to meet one’s job requirements.
