Obedience: defying the crowd in midwifery practice

Most people will have observed the often impressive synchrony of the behavior of fish in a school or birds in a flock. The fact that the behavior of a fish is so well matched to that of the behavior of others is straightforward: perception directly affects behavior. When a fish perceives a change of direction in another fish it simply matches this change in direction. This direct link between perception and behavior can be easily witnessed in humans as well. We too match the behavior of others and we do this simply because perception directly affects action. The specific behavioral changes perception can bring about differ between humans and fish, but the underlying mechanism is essentially the same. Perhaps we share this important psychological mechanism with a haddock. (Dijksterhuis, 2001, p. 105)

This guest editorial discusses insights gained on the concept of obedience and how it affects the way midwives work within hierarchies. As a midwife and postgraduate in psychology, my past work has focused on social influence processes of midwives in clinical practice. The two particular areas of social influence of interest to me are obedience and conformity. Experimental research in social psychology indicates that the propensity to be obedient is very strong (Kilham & Mann, 1974; Meeus & Raaijamakers, 1995; Milgram 1963, 1965, 1974). In his experiments, Milgram set about discovering the extent to which people would be prepared to bend in terms of challenging their personal moral codes and to be obedient to the demands of an authority figure. Although several decades old, the series of Milgram experiments continue to be the key underpinning citations in the literature reviews even of more recent obedience studies.

In the classic laboratory experiments (Milgram, 1963, 1965, 1974), an authority figure issued instructions to participants in the role of teacher, to deliver electric shocks to a person who responded incorrectly to questions he asked. The context of authority investigated in the Milgram experiments may seem distantly removed from the ethos of the caring professions. Nonetheless, it is a pertinent issue, particularly when authority is at discord with what the junior considers to be a more suitable course of action. Obedience studies reinforce the assumption that senior staff overwhelmingly influence decisions of those more junior. These concepts of blind obedience to authority were transferred into the natural field setting of a hospital ward by Hofling, Brotzman, Dalrymple, Graves, and Pierce (1966). In their field experiment, a confederate doctor successfully directed 21 out of 22 nurses in the clinical area to prepare an ‘unauthorised’ medication to patients.

Examples of negative influence may be seen when senior staff obstruct the processes of providing safe choices to childbearing women. An example of this is when a healthy childbearing woman requests a natural birth, to ambulate during first stage of labour, or have several birth partners present at her delivery. Recent studies (Hollins Martin and Bull, 2004, 2005, 2006) clearly showed that when conflicts of opinion occur in clinical practice, obedience to authority is more often prioritized over the midwife being advocate for a childbearing woman’s safe and personal preference.

Obedience findings are transferable to the functioning of maternity hospitals and in relation to the quality of care childbearing women receive. Three decades after Milgram’s work, Hollins Martin and Bull (2005) assessed how accomplished a senior midwife was at socially influencing decisions of junior midwives (n = 60), in situations where their decisions breached personal opinions of best practice. A valid and reliable 10-item questionnaire was developed called the Social Influence Scale for Midwifery (SIS-M) (Hollins Martin, Bull, & Martin, 2004) and was used to categorize midwives’ responses to 10 fairly uncomplicated work-related decisions (Hollins Martin & Bull, 2005). Change in scores between postal and interview responses showed the success that the senior midwife had at socially influencing participant’ responses in a conformist direction, with higher scores achieved on the interview measure (Hollins Martin & Bull, 2004, 2005, 2006).

When an organization perpetuates the preferential position of authority, staff become disempowered in trying to implement evidence-based practice. One response is for the authority figure to do for the junior practitioner what they are unable to do for themselves. They must, where possible and when resources permit, integrate the women-centred aspect into their directives. Midwives who work in the frontline have direct contact with childbearing women and are more likely to be conscious of their individual preferences. Perhaps a clearer definition of roles would reduce uncertainty about the limits of a person’s responsibilities. In addition, conceivably university midwifery courses could include within their curriculum skills training on how to question direction in a thoughtful and effective way. Such assertiveness training could facilitate junior practitioners in acting out particular behaviors in given situations in advance of exposure. It could be argued that a simpler solution would be to flatten the hierarchy and release skilled midwives to function as the autonomous evidence-based practitioners they were educated to be. However, the concern is that based on the reported obedience experiments, the majority of maternity care experts will follow direction issued by authority figures and it may be time for a reasoned evaluation of existing organizational structures, in conjunction with an analysis of costs and possible availability to address this point.

Team-working is key to the successful delivery of healthcare. Also, as William Golding attempted to demonstrate in his book The Lord of the Flies, obedience contributes to the underpinning of all societies and in its absence chaos and anarchy will preside. Without stability, solidity and firmness, the well-being of childbearing woman becomes illusory. Nonetheless, it is not unreasonable to question how obedient midwives can be without losing their individuality and power of advocacy within the maternity unit. Midwives must not be allowed to become mindless drones who unthinkingly conduct orders issued from the ‘queen bee’. Such a concept coexists with bystander apathy (Darley & Latané, 1968). In the words of Milgram, the essence of obedience exists in the fact that a person comes to view himself as an instrument for carrying out another person’s wishes and by doing so he no longer regards himself as morally responsible for his actions (Milgram, 1974).

Experiments conducted by Asch (1951, 1952, 1956), Hofling et al. (1966), Hollins Martin and Bull (2005), Milgram (1963, 1965, 1974), Zimbardo (1971, 1974), Zimbardo and Gerrig (1999) and Zimbardo, Haney, and Banks (1973) show that human individuality is often subverted by blind obedience towards people in positions of power. In order for midwives to maintain their individuality and for a maternity unit to remain effective and stable, a balance between obedience and noncompliance must be found.

This issue of the Journal of Infant and Reproductive Psychology comprises a range of articles that address the better understanding of reproductive health and well-being and is directly relevant to the work and research carried out by health professionals, including midwives. The topics here include infertility, stillbirth, changes in partner relationships with pregnancy and parenthood, breastfeeding and early parenting. Individual authors’ concerns are evident in these contemporary interests and use of a variety of research methods and determined efforts aim to bridge the research–practice divide. Studies on these important topics and discussion of the findings reflect wider inter-professional perspectives on pregnancy and birth and the roles of the staff involved in providing care and support. I hope you enjoy reading both this editorial and the collection of research articles and that your interest may be sparked by the content and the topics debated.