Introduction

This paper aims to examine midwifery practices and education from Foucauldian perspectives. A Foucauldian analysis may be viewed under the umbrella of post modernism, seeking multiple realities of truth, experience and objectivity. Thus postmodernism takes nothing for granted, not even its basic principles and assumptions (Hoy 1986). Foucault (1972) used “archaeology” of knowledge, to show the “truth” claimed by history. The search for “truth” or “reality” of midwifery practices and education of today, will not simple uncover events, but will actively shape and create them within a social and political context.

Through this post-modern approach, an examination of Foucault's philosophies (1972) and his thoughts around construction of “regimes” of truth, power and knowledge in relation to midwifery practices and education is presented. “Truths” about human practices and society change with time and are motivated by a will to power. Therefore, Foucault (1980) believed that the shifting patterns of power are related to societal needs and the perception of the empowered “self”, through systemised knowledge. These philosophies can be applied to midwifery education and practice.

It is primarily in understanding the relationship between empowerment of practitioners and the notions of power and knowledge, which will guide this paper. It will be difficult to discover which form of practice, within midwifery culture and its education, is more empowering and for whom, but an examination of events through a Foucauldian archaeological and genealogical perspective will give some direction. Foucault is also appropriate in aiding this examination because of his thoughts on power in relation to health. In addition, to support the discussion on Foucauldian perspectives. other literature will be referred to throughout.

It must be remembered, that knowledge is not universal and is constantly shifting, as is midwifery “reality”, which changes within the context of its cultural production. Expert knowledge is created through dialogue and interaction, it is not ingested by students or bestowed by tutors and mentors. It is not a definitive but a creation of possibilities and interpreted through language, spoken or written. Beck (1993) believes that words are not tied to fixed concepts, and systems of speech, change over time within their culture and context. . It is through some of these underlying principles, within midwifery curricula, which reconstruct knowledge through interactive process and reflective practices. In using Foucault's work to examine existing systems of education and practice, not only will pre-existing “realities” and “truths” be unveiled but may be useful in structuring new “realities” and “truths” for future curricula and practices.

The Medicalisation of Midwifery

Through examining the development of midwifery education over the years, a picture of what defines present midwifery curricula, and the “reality or truth” of its nature can be traced through competing political and social forces which resulted in the changes that occurred. An examination of the history of midwifery education uncovers how those in the past were taught the art and science of midwifery, and what significance this may have to the teaching and learning strategies of present curricula. However, to bring this narrative to the present, midwifery education has to be traced through time, and describe the historic presuppositions of its systemic development; its archaeology. Whilst tracing these historic processes of descent and emergence, through an examination of what political and social factors propelled and transformed these changes, is a genealogical approach (Olssen 1999). In other words an archaeological approach will give details of parameters and conditions under which these changes have occurred and a genealogical approach will examine the different stages of the development of curricula and their particular relationship between past and present. Papps & Olssen (1997 :26) suggest that in using Foucault's post-structuralist approach “genealogy is building upon and extending archaeology” and are useful as strategies in terms of examining midwifery education, its culture and history. Olssen (2003) suggests that genealogy puts an emphasis on power rather than knowledge and practices rather than language (in midwifery), and post-structuralism is more concerned with the politics of its discourse. In Olssen's words (2003: 7), Foucault's approach is not just a critique of its discourse but “an account of how discourse is shaped and how discourse shapes everyday existence”.

In Foucault's thesis Archaeology of Knowledge, on power and knowledge (1972), power can only be within a context and therefore subjective and can be understood in relation to the kind of power that constitutes it. An example of this is through a review of the history of women healers or midwives by Ehrenreich & English (1973). The authors suggest that by the twelfth century, the Roman Catholic Church had become extremely powerful in Western Europe and was concerned with improving sexual morality. In this context, the midwife became a powerful law enforcer and was empowered through the Church. However, if such women performed services not within the teachings of the Church, they were often feared for their superior knowledge of herbs and potions and were seen to possess mystical powers. They were often accused of witchcraft and punished accordingly, either by excommunication from the Church or death by various nefarious means. Hoy (1986) argues that empowerment through superior knowledge, without liberation, is useless. Although midwives possessed the art and knowledge of their profession, were expert and technically competent, their knowledge was not neutral or disinterested. Were they empowered because of their knowledge or suppressed because of it? The Church clearly became the dominant power at this point, regardless of the superior knowledge of these healers. Empowerment of healers remained within the dominant forces of the all, empowering Church. At this time the underlying power driving midwives, was the Church, mainly to prevent witchcraft and contain their activities (Thomas 1973). In Foucault's earlier work (1972), he stops at empowerment for its own sake, whilst the shifting elements from one era to another, from one dominant social group to another, or from one context to the next are not considered. However, in Foucault's latter writings on Discipline and Punishment (1977) and The History of Sexuality Vol 1 (1978), power is seen to be from many sources and diverse in its forms. As such, individual experiences of empowerment, are derived from the collective experiences of its practitioners, and are socially generated.

The tradition of midwifery, in the past, has been a skill passed on from mother to daughter, and on examining historic evidence it seems that up to this stage, the midwife was an important member of society where childbearing was concerned (Webster 1979). However, new developments around the middle fifteen hundreds were to have implications for the future of the midwife. For the time being, knowledge by midwives had ensured empowerment. Things were soon to change and the quest for knowledge was to empower another ruling class: men. Men involved in other areas of medicine and surgery, were beginning to show an interest in the childbearing process (Donnison 1988). Using texts to understand or find clues to social practices gives an understanding of what motivates dominant groups. When reflecting back, on the shifts between dominant discourses, it is evident that men had gradually changed the importance of women, as venerated “knowers” of childbearing to a status of “non-discourse” and the total subjugation of women within childbearing practices. Foucault (1980) suggests that man may be driven by desire for power and resistance to it by competing groups, in order that history is shaped. In such terms, Foucault (1979) represents power as a “multiplicity of force relations” and presents an alternative concept of power, which moves away from the Marxist teachings of hierarchical direction of power. He focuses on the discursive systems of power, knowledge and domination and the interplay between them and suggests that power is exercised rather than possessed, both repressive and productive and emerges from the bottom up. (Olssen 1999).

A post-modern belief is that health professions tend to place male dominance over that of female, but such discursive assumptions as “reality”, need to be explored from a cultural and political perspective ie their genealogy. Motives and motivation need to be explored to understand how knowledge is value laden, culturally orientated and shifting constantly. In examining midwifery practice and its education, through philosophical principles, theoretical understanding may not explain practice but is integral to it. There is some evidence suggest that at this time, midwives had approached the King for a charter to form their own society to better control the standards of midwifery practice. However the Church continued to grant a licence whilst the Royal College of Physicians petitioned for all midwives to be examined and approved by the college before granting a licence (Donnison 1988). Power here is contested, and in examining historic evidence, one needs to understand the context of society at this time to understand dominant power. This long struggle for domination of midwifery practice, between the medical profession and midwives, has a long history.

Foucault (2001) believed in the exercise of power as determined by individual groups and not by the structure of social systems as a source and consequence of this power. Midwives were restricted within a cultural system in what they could do, but their practices could not be restricted if society at the time gave them scope for change. The position of male midwives enhanced their control over childbirth with the onset of instrumental deliveries to shorten labour and save both mother and baby from certain death. However, in retrospect this may have been the cause of more foetal and maternal morbidity and mortality (Page 1995). Hence, midwifery as an art form and skill taught, learnt and practised by female midwives was soon on its way to a rapid decline. Knowledge, whether it was “true or false”, was not relevant to these practices, but became part of midwifery culture. Foucault (1972) maintained that “truth” is linked to a system of power, which produce and sustain it, and which in turn gives rise to possibilities of practices, which then become inherent to that culture.

Hoy (1986) suggests that it is not how power appears to be but how it came to be and the culture involved which needs to be examined. He states that it may be difficult to determine precisely what Foucault (1979) was attempting to achieve in his explanations of power relationship within societal reform, but the process of “subjection” needs to be understood. Midwives “conformed” but what caused midwives to “conform” to current practices? During the following centuries, most male midwives or obstetricians as they were being called, continued to grow in importance, not because they were superior to midwives or were more competent, but because they frightened women into believing that they would be safer delivered and cared for by them. Training was available for new midwives and the skills of midwives continued to improve, although under the tutoring of obstetricians in the majority of cases (Donnison 1988, Tew 1990, Page 1998). In a sense midwives were lulled into a sense of security but controlled through “censored” knowledge, which became midwifery dominant discourses of the time. This seems like a deliberate act in detaching the “truth” to preserve a social, cultural or economic hegemony.

Foucault (1972) believed that what individuals or dominant groups will do, will affect the social system and its practices. However, he rationalises power through historic development rather than attributing power to groups or individuals. He states that the will for knowledge is a will to power, but knowledge is not predictive of power, but internal to human interest and may lead to empowerment. The knowledge of midwives was determined by the needs of society at the time and what society considered being valuable. Eventually, through the ages, political pressures determined that midwifery practices were better suited to hospital settings, under the jurisdiction of the medical profession.

Counter-hegemony

The struggle to control dominant knowledge, guided the course of midwifery education and practices, but in a sense midwives saw this as liberation for themselves, their culture and childbearing women, be it under the auspices of obstetricians. Foucault (1980) through his writings on power and knowledge believed that the contexts of domination developed in their own way and then became hegemonic and used by the “macro-context of domination”. But “truth” is only “truth” in the discourse that defines that sphere of knowledge and may be limiting. Smart (1986: 169) believes that “there can be no power-free or power-less” society or culture. Power over midwives was exercised but some resistance was inevitable within relations of power, which provide “counter-hegemonic strategies” and may create new “regimes of truth or will”.

Counter-hegemonic strategies were evident as midwives continued to seek formal education and training and had a measure of success by 1870, when the Women's Society had pressurised the Obstetrical Society into setting up an examination to test the competence of midwives. This, together with the endeavours of the Female Medical Society, helped to raise the status of midwives, but was unsuccessful in achieving State Registration and recognition for midwives. The struggle for recognition continued for several years, mostly opposed by doctors and medical colleges. It could be argued that emancipatory or liberatory empowerment is seen as conscious recognition of being overpowered and may distort or create a conflict of real interest for empowerment. Giroux (1991:191) states that “It is in contradiction of contesting hegemonic forms and practices on the very ground which contributes to their production and reproduction that the root of paradoxical nature of resistance lies”.

Although the 1902 Midwives' Act gave midwives the recognition they had sought for years, as some practitioners had feared, it placed midwifery firmly under medical supervision and restricted autonomous practice. It however, restricted unqualified women from practising and therefore improved standards and formalised and monitored education and services, (Page 1995), “within a carefully planned legal framework” (Leap & Hunt 1993, 16). A Central Midwives' Board (CMB), set up in the intervening years for England and Wales, was able to monitor professional conduct and exclude unsafe practice. The interrelation between institutional structures (the CMB) and social needs driven by a political agenda gave rise to formative practices. Such discourse is the root of midwifery regulatory bodies in existence today.

Midwifery Practice and Education

Midwifery education does not only produce midwifery knowledge but may instigate political struggles in producing practitioners for a public service which has to be seen to be democratic in its delivery. Social agendas are driven by ideologies, which claim their own knowledge and “truths” to produce dominant discursive assumptions and result in empowerment. Each culture will see its own knowledge and “truths” as the most empowering. Thus legislation changes practices and the required associated knowledge to ensure public demand is met. Foucault (1980) was opposed to the concept of ideology and perceived this as standing in opposition to something else which counts as the “truth” and therefore any new ideologies could now be the “reality” from the perspective of the perpetrator of this ideology. His thinking veered towards a Nietzschean philosophy of presenting multiple realities of the “truth”.

Such forms of power can be examined through Foucault's (1979) thinking around disciplinary forms of power, which, Gilbert (1995), believes take two forms. The first is the emergence of disciplines or specific bodies of knowledge such as teaching and educational knowledge, and the second is disciplinary model for the practices of the culture ie the monitoring of health through information gathered with the onset of legalising Registration of births etc. Both midwives and childbearing women are within disciplinary powers and subject to observation, judgement and examination to be objectified and therefore categorised. The third Midwives' Act in 1926 saw the onset for more rigorous monitoring of practice and the setting up of post qualification courses for midwives and a Midwife Teachers Certificate through an examination set by the Midwives' Institute. With the 1936 Act and onset of Registration of births, marriages and death, published percentage rates of maternal and infant mortality and morbidity were available, indicating a high rate of maternal death due to puerperal fever at that time. It was evident that proper training of midwives and obstetricians was still necessary. The CMB therefore set up a Midwife Teacher's Diploma achieved through examination and Statutory Residential Refresher courses of seven days every five years, for all qualified midwives. Those returning to practice also had to undertake a course designed by the CMB. Supervisors of Midwives also had to obtain certain qualifications before being eligible to supervise practice (Leap & Hunter 1993).

Ethics, principles and practices of midwifery culture and education are in constant transformation, always dominated by the struggle between the need for public safety and political agenda at the time. By 1929 the structure and length of midwifery courses and training had changed. The need to create new forms of knowledge ensured that new possibilities and directions began a diverse course in the history of midwifery education. It did not embrace the interests of midwives at each turn but strove to attain an ideology within its practices and culture, to a lesser or greater success at various times, within the context of its setting. The context of change will always have a bearing on who is empowered and which discursive assumptions are dominant. As such, Dreyfus & Rainbow (1986: 115) suggest that in keeping with Foucauldian principles, an archaeological review of these events would give an outside view of these (midwifery) practices, which is a common starting point to “proceed, understand and act”. But in taking a genealogical perspective, sees cultural perspectives as more basic than any theory underpinning them, and therefore the theory must be understood as part of on going history of the culture and society being examined.

In his latter works Foucault (1979,1980) makes “truth” or “regimes of truth” the conditions of empowerment. However, the Codes of Midwifery Practice as “regimes of truth”, is subordinate to power, the power of regulation or disciplinary power. This may be in opposition to the culture/ discourses of midwifery, which count as “truths” and which empower those within the midwifery culture and would effectively ensures autonomous practices. Taylor (1986) suggests that shifting power would be possible if shifting “truths” were allowed through critical analysis of dominant discourses from the past and shaping new discourses for the future. This could be seen as a move from hegemony to counter-hegemonic or, heterogeneous practice; thus midwives being empowered and able to empower. Foucault (1980: 131) identified that “we are subjected to the production of truth through power and we cannot exercise power except through the production of truth” ... “we are forced to produce the truth of power that our society demands, of which it has needs in order to function”. Taylor (1986) thus argues that knowledge manufactured by power also produces its “untruths”. It could be said that there are no new “truths” but reconstruction within these “truths” of dominant discourses, and are therefore “reconstructed truths”, and it may be that a political agenda co-exists within, or drives, this reconstruction of “truth”in the shape of policies and codes of practices.

Referring to Foucauldian methodology, Gale (2001) suggests that examining policies and social conditions under which these emerge could be carried out through archaeological and genealogical approach. Chronological underpinning is important in understanding the strategies and conditions, which led from one event to the next., as is genealogical analysis which examines the formation, implementation and consequences of these developments in midwifery education. As Foucault (1994: 22) states it is through genealogy that, not only continuities between past and present which are examined, but also the discontinuities, through a “painstaking rediscovery of struggles together with the rude memory of their conflicts”.

The National Health Agenda

With the onset of the National Health Service (NHS) in 1948, through which better maternity care was widely available and health and birth outcomes improved. However, little regard was given to the autonomy of the midwife or the psychological well being of mother and baby during this life event of childbirth. The discontinuity between autonomy of midwifery practice in the past and the lack of autonomy for midwives and childbearing women, which resulted from these changes, are evident. The Labour government of 1948 saw the necessity of centralising the health service, making provisions accessible to all. This had implications for stepping up midwifery education to provide enough staff to cater for the expectations of childbearing women and their families (Gabe, Calman,& Bury 1991). In a sense this centralisation of a health service is in keeping with Foucault's (1980) analysis of modern society. Dreyfus & Rabinow (1986) suggest that in his analysis Foucault, diagnosis “bio-power” as the form of power and knowledge through which practices occur to bring about health, security and productivity. Meaning is given to the sort of changes that bring about desired practices. Hoy (1986) offers the idea that an ideology is created which is the result of “an oppressive exercise of power” to create dominant hegemonic discourses. As such, it is difficult to identify evidence that the NHS has been instrumental in creating better outcomes in childbirth (Oakley 1976, Tew 1990, House of Commons Health Committee 1992, Leap & Heptinstall 1997, Campbell & Macfarlane 1994, Tucker 1996, Thomas 1998, UKCC 2000, Porter 2001, Horn 2002). Women's opinions were rarely sought in the past but evidence suggests that at least antenatal care, which had commenced in clinics in 1935, was seen to be ineffective, frustrating and in some cases unnecessary, by both midwives and women (Foster 1995).

It seems that with the passage of time and maternity care development, midwives were powerless to prevent the use of more technology to intervene and actively manage childbirth even in routine cases (Hunt & Symonds 1995). Midwives were increasingly trained to mass-produce the labour process under medical supervision (Foster 1995). A utilitarian philosophy was developed. However, in the seventies, in the heyday of the “obstetric nurse”, feminist movements had already started to campaign for the rights of women to “normal” care and delivery (Garcia, Kilpatrick & Richards 1990). The most prominent of these was the Association for Improvement in Maternity Services (AIMS), which was first set up in 1960. Empowerment for midwives and childbearing women was sought and for Foucault (1980), that power is a system not an agent, and in structuring empowerment for others, empowerment is achieved. Hoy (1986: 139) agrees with Foucault that in “overcoming dominant repression, progress and freedom is achieved”. Empowerment does not necessarily, gives way to “truth”, and progress is not seen as an exercise in overcoming dominant practices. It is a vehicle in creating ideologies and establishing hegemonic practices. Therefore, empowerment did not necessarily mean freedom for midwives as development in practices and education brought with it responsibility. It gave rise to alternative possibilities and therefore viewed may be viewed as being transformative. However the acquisition of knowledge does not always lead to empowerment. In examining Foucault's (1980) theorises on how knowledge may lead to empowerment he argued that historic examination does not always give a better understanding of today's notions of empowerment as compared to the past. He believed however, that the growth of knowledge gives rise to the possibilities of freedom and autonomy.

In coming to understand the forces that control power it is necessary to observe the daily practices and events to understand systems of power. In forming regulatory bodies, midwives were given a voice but no total empowerment for either midwives or women is ever possible.

Knowledge, Power and Dominant Discourses

Through a Foucauldian examination, knowledge is seen to be created by dominant discourses and beliefs and values would become part of this knowledge. Thus according to Foucault, power and knowledge cannot be separated and the quest for knowledge and power is motivated through human interest. Midwives began to question practices and consequently the nature and content of curricula changed over the years. This questioning approach is examined through Foucault's understanding of a dual analysis of forms of knowledge and its relationship to power, which sees humans as self examining and therefore are made subject and their practices directed to achieve hegemony. In other words for midwives to be empowered, Gilbert (1995) believes that, they need to identify the discursive practices that shape them and become both subject and object of their practice.

Gilbert (1995) suggests that empowerment for the professional, places the practitioner in a position of moral superiority, but can create tension and conflict. In terms of health and a midwifery service, cultural beliefs have instilled the idea that dependency is not moral and harmful to society and individuals. Therefore the effects of power and the forms of social practices that result are specific and bound by specific bodies of knowledge, which are seen to result in practical and theoretical competence. Thus, Gilbert (1995) believes that empowerment and models of power come in two competing paradigms. Personal growth and therefore personal empowerment through a humanistic approach and the concept of “synergy” as the political model of empowerment, which is the combined energies of the community within a culture, and which also utilises a humanistic approach. Gilbert suggests that a Freirian philosophy underpins such humanistic approaches of empowerment, but swings between Marxists and Christian ideologies and I believe would bring into question the beliefs and morals underpinning empowerment and which relate to the practices and culture of midwifery.

Such quests, for midwifery empowerment, whilst embracing humanist beliefs and morals, were shaped through the Changing Childbirth Document (DH 1993), which recommended radical changes to maternity care provision to be implemented within five years. The key themes of this report were to have enormous implications for the way in which midwives would practice and are educated. Universal “truth” had become “specific truth” through a body of individuals and as Foucault (1980: 133) would describe as new forms of intellectual activities, which would give rise to new status for midwives, changes in their work conditions and personal lives and the “politics of truths” in society.

In attempting to understand the changes that midwives perceived to be empowering, I refer to Foucault's (1980) argument that power after investing itself can find itself exposed and therefore retreats to reshape itself. Such struggles of empowerment are evident when, to maintain autonomy midwives began to suffer burnout at the cost of their personal lives due to pressure to meet recommendations (Sandall 1996). As Hoy (1986: 86) states this is “logic to events without design”. Midwives now seek alternative practice strategies to alleviate the burnout effect, by working in teams or “buddy” systems.

Many recommendations for practice come through various Government policies and publications. Midwives are urged to be involved in the public health agenda. These include “Saving Lives our Healthier Nation (DH 1999a), a government white paper setting out a new approach to public health, in particular for the poorest of society. Another publication is “Making a Difference (DH 1999b), which set out a national strategy for nursing, midwifery and health visiting, calling for an enhanced midwifery role in maximising women's health and contributing to public health strategies. A more recent publication is “The NHS Plan” (DH 2001) which proposed a strategy for the future of the NHS, including plans for improved health and reduction in inequalities in health.

Conclusions

In shaping new discourses, an archaeological examination, forces regrouping of statements and practices and new discursive practices are developed. Foucault argued for examination of events which when first examined appear to be discontinuities in ideologies but in effect if viewed through his principles of genealogy are seen to demonstrate new continuities. In this respect genealogical examination has a wider scope than archaeological interpretation. It unveils relationships between systems of truth and concepts of power, which are inevitable politically underpinned in most respects.

Alexander (1999: 240) suggests that Foucault's analysis of power may offer women (midwives) an outlet to seek political change and self-determination in resisting dominant discourses. The possibilities of resistance create a space for “struggle, conflict and change”. Counter-hegemony or heterogeneity results due to an ability or possibility for the subject to transformation. However, even when dominant midwifery discourses prevail they can never be said to be a total monopoly over “truth”. They only claim to produce “truths” and normative practices about objective knowledge. Foucault (1980) however suggests that through a consciousness of self-knowledge spaces are created in which discursive practices are challenged and new discourses are created.

Evaluation of new curricula in midwifery education has been the subject of many research projects over the last few years (Fraser et al 1997, Pope et al 1996). The main outcomes to come from such research are that students are not deemed to be competent at the point of registration. Consequently, the United Kingdom Central Council (UKCC 1999) set up an enquiry to determine the way forward for pre-registration midwifery education that would ensure that practitioners would be fit for practice in a bid to protect the public through adequate professional standards. In 1999 the Commission for Nursing and Midwifery Education published a report “Fitness for Practice” in response to this enquiry making thirty-three recommendations for improvement. As a consequence the Nursing & Midwifery Council (NMC 2002), which replaced the UKCC in 2001, was responsible for developing social care policies and education policies across the United Kingdom. In line with all the above recommendations through varies sources, the need for a new meaningful curricula in midwifery was identified.

One of the main and fundamental ingredients in new midwifery curricula and midwifery practice is reflection. In Foucault's (1980) latter writings he advocated self-reflection as a means to change and progression. He carried out an ascending analysis of power and how each event arrived to its conclusion and then moved forward. He concluded that power is not homogeneous but networked and that self-reflection permits rediscovery of social relations. The notion of ethics, which is integral to moral behaviour and principles, relevant to every professional, is woven into the fibre of principles underpinning midwifery curricula. Such self-examination reveals the person as a whole, drawing on imposed moral codes of the professional and personal beliefs, based on normative systems of regulation and education. Rabinow (1984) believed that Foucault based his thinking on Christian beliefs that drove humans to aspire to ideal moralities through a self-regulating and active process. Davidson (1986) argues that this may not have always been the case as morals and laws within society, and ruled ethics of behaviour later by knowledge and understanding, and more importantly a duty to oneself. Knowledge tends to drive activity and with activity most ethical beings will reflect. Hacking (1986) believes that it is this consciousness that drives morality and self-knowledge. Thus practitioners would construct their own ethical positions and I believe, that within these discursive practices would create their own freedom, in both midwifery practices and its educational system.