When considering the potential for increasing self-esteem of women during the childbirth continuum, midwives will become aware of the potential they hold for enhancing community confidence and knowl-edge. As described briefly earlier in this chapter, Ann (Belenky et al.
1997) increased her knowledge in relation to childcare and parenting, and then felt able to be the advisor and share conformance with her family and friends:
I now feel very knowledgeable as far as kids go. I advise all my friends with kids, you know. I say ‘‘this is what I’ve learned at the centre’’. I’ve learned a lot. I feel like I could go in there, and they could hire me, you know, that’s how much knowledge they have given me.
Ann describes in real terms the process of increasing social capital.
Social capital refers to ‘the network and trust between people, which can be highly significant in building strong communities, combating social exclusion and providing a basis for long term economic development’
(Health Development Agency 2004). When midwives work closely with women, sharing information and facilitating the liberation of internal assets, they are contributing to the growth of social capital.
An example of utilising community development approaches through positive connection can be demonstrated through Jane (mother) and Brenda’s (midwife) story.
Brenda:
When I first met Jane [mother] she came to see me at a local community house, that was being used until the Children’s Centre was built. Jane had complex family issues that contributed to her suffering from anxiety and stress. I remember she was very tearful and obviously distressed, I was concerned if I had the necessary skills to help her.
I felt that I needed to support Jane because she was vulnerable due to the fact that she thought she was in an inescapable circle of motherhood, depression and being unable to cope. The support I gave was listening visits but sometimes they would change to talking visits and part of caring is sharing a little of yourself so people you care for know you are human too.
It seemed to me that in no time at all L (baby) was born and Jane had to cope with hormonal changes and a new baby and breastfeeding.
Jane had breastfed both of her older children, but felt she needed support so she came to the local group where she met lots of other local mums. Jane was so enthusiastic about breastfeeding and its benefits to both mum and baby that I just knew I had to have her on ‘my team’. I was facilitating local breastfeeding mums to do a twelve week peer support course and Jane was in the first group to graduate. I constantly asked Jane for support and help as this seemed to light a spark in her somewhere. I was aware she still had issues with family but I hope I was always supportive and understanding when the going got tough.
Jane:
It’s quite difficult for me to cast myself back to when things were so much different for me then. I was pregnant with my third child, and having previously suffered from depression, I was really scared of it returning. I had a lot of social problems and low self esteem, I felt I had failed as a parent before and didn’t have much confidence in my abilities this time around.
I was put in touch with Brenda through Sure Start, and the first time I met her I think I cried for over an hour. I was a wreck emotionally and didn’t see much of a future for myself. Brenda was so supportive and helpful; nothing was too much for her, she truly supported me in what is really my recovery, she made me feel important and always made herself available to me, especially after the birth of my daughter. She always had a smile and good advice. I had breastfed before but still needed my confidence building up. Brenda invited me to her baby massage group and breastfeeding group, and would even come and walk me down as I wasn’t confident walking into a room alone. I slowly found myself able to get involved and chat to people, something I had found difficult before.
Brenda was facilitating the La Leche League Peer Support Counsellor training locally and asked if I would like to be involved. I agreed to be on the first group of mums to do the training and really enjoyed it. I was thrilled to be in a position to help other local mums and I knew I wanted to go up onto the postnatal wards at although there were some hurdles, we overcame them. I worked as a breastfeeding support volunteer for almost two years and am now employed by Little Angels, a Social Enterprise breastfeeding peer support company, as a breastfeeding supporter, doing a job that I truly love, supporting local mums to successfully breastfeed.
I have also trained and participated in research in partnership with midwives, health visitors and the local university, and have estab-lished a service user group for the development of birth centres.
I received funding to become a Doula, as I want to support women in pregnancy and labour, and to empower women. I know how much having a baby can really change you life and your outlook on life, and I want to share my enthusiasm and passion. I consider Brenda to be one of my closest friends; she is a very special person who made a huge difference in my life. She helped me to see a future and to believe in myself.
Jane now has confidence and skills to share with many others, which in turn has the potential to have a positive effect on her family, and the wider community, thereby increasing social capital.
See Box 5.2 for a practice example of improving social capital.
Box 5.2 Example of promoting social capital
In 2009, Kings College University Hospital will be piloting an innovative way of providing antenatal care which encourages and promotes social capital.
The model of care is called ‘Centering Pregnancy’ and has been exten-sively rolled out in America. It involves women having their care in a group,
rather than individually. Women are encouraged to be active participants in their care, The group sessions are semi-structured and facilitate discus-sions around a range of issues such as diet, expectations around birth, breastfeeding in accordance with the women’s needs. Topics may also be sensitive such as domestic abuse, sexual health and depression (Schindler-Rising 1998). These topics are often more enabled in a group discussion which can be more general, and facilitate women to talk in the third person (Gaudionet al . 2008). One of the major advantages of this model of care is that women can learn from one another, it helps to build communities and enables support and problem-solving. Support develops naturally as the women develop friendships that continue long after the group has dis-banded. In ‘Centering Pregnancy’ it is assumed that the woman is an expert about what she needs and knows, not the professional. The midwives have an important role to facilitate the flow of discussion, and by doing so, capi-talise on the strengths and needs within the group (Schindler-Rising 1998).
‘Centering Pregnancy’, aims to tap into and encourage social capital and support with the hope that friendships made in the antenatal period will continue in the postnatal period. Social capital and health care are inter-twined in this model of care with the women at the centre, which focuses on information sharing and engendering confidence in new mothers.
Revisions to the way that antenatal care is delivered, in groups rather than one-to-one, particularly to vulnerable groups has been shown to impact on postnatal outcomes. One randomised control study conducted in two US states recruited 1047 women and found that there was a significant reduction in the risk of prematurity by 33% (this risk reduction was greater for Afro-American women); increased breastfeeding initiation rates (Ickovics et al . 2007) and a significant increase in mean birth weight (Ickovicset al . 2003).
And for the future?
postnatal care is acknowledged as being under-resourced and frag-mented. It could therefore seem an impossible task for midwives to spend extra time ‘developing communities’ or building social capital.
However, these approaches to care mirror the philosophy of woman-centred care, which is a fundamental requirement within maternity services and should not be viewed as a desired option. Midwives have a ‘magic moment’ of opportunity that is relatively short but concen-trated, where they can assist in building a woman’s confidence through the words they use, and the position they set themselves. Working in the community, delivering care in Children Centres, community halls, churches and mosques, and being part of open days makes it easier for midwives to be visible and known. In addition, working with rele-vant voluntary and statutory agencies enhances the ability to provide
consistent information and ensures that opportunities to engage and support women and families is facilitated.
For midwives and healthcare workers within maternity services, it is important to strive to promote an empowering facilitative model of care, wherever that care takes place, where the woman and her family is seen as true partners in ensuring their own health and future. If done well, the consequences have the potential to influence the mother’s esteem, the mother–infant dyad, the mother–partner relationship and the baby’s life, forever more.
Key implications for midwifery practice