Why ‘Lie on Your Back’ is the Tradition: Hearing from Midwives in Uganda

Hey there! Let’s chat about something fascinating, something that gets right to the heart of how babies come into the world, but from a perspective we don’t always hear: the midwives’. We all know, or maybe we’ve heard, that being upright and moving around during labour can be really helpful. Think gravity assisting, feeling more in control, maybe even a bit less ouchy. The big health bodies like the WHO totally back this up, recommending all sorts of positions – sitting, kneeling, walking, you name it – especially for low-risk mums.

But here’s the twist: despite all this good stuff being out there, you still see a lot of women giving birth lying flat on their backs, particularly in hospital settings, and especially in places like Uganda. It makes you wonder, right? If these other positions are so great, why isn’t it the norm everywhere? That’s exactly what a really insightful study dug into, chatting with midwives in a Ugandan hospital to get their take. And let me tell you, it’s not as simple as just not knowing the benefits. It’s a whole mix of things – tradition, confidence, resources, and the everyday reality of a busy hospital ward.

Why the Back? It’s More Than Just a Bed

So, what did the midwives say? Well, it turns out the supine position (that’s the fancy word for lying on your back) is often the default, especially when things get serious in the second stage of labour. One midwife put it pretty starkly, describing it as being “like tradition: lie on your back, hold your leg, and push.” They grew up knowing this as *the* way to deliver. It wasn’t about choice for the mother; it was just how it was done.

But it’s not just blind tradition. The midwives had practical reasons too, even if they weren’t always ideal for the mum. For starters, it felt safer to *them*. Concerns popped up about supporting a baby if the mother was squatting – “If the mother is squatting, how are you receiving this baby, so it’s not traumatised if it falls down?” Good point, right? They worried about complications like cord prolapse or infection if the mother was moving around too much, especially after her waters had broken. So, keeping her in bed felt like a way to keep things contained and, in their view, safer.

The Confidence Factor: Knowing Your Stuff (and Seeing Your Mates Do It)

Interestingly, the midwives weren’t totally against other positions. They actually encouraged mobility and upright positions in the first stage of labour, knowing it could help things along. “Ok, we encourage them to walk around, sit on the bed, once in a while lie on the left lateral position, yes. To aid the descent of the presenting part.” See? They get it!

The big shift happened when they felt confident and knowledgeable about *how* to support a different position. If they understood the advantages and disadvantages, and felt skilled enough to handle it, they were more open. And here’s a really human part of it: peer influence matters! Midwives said that if their colleagues were supporting different positions, they’d feel much more comfortable trying it themselves. “if the other midwives’ opinion about something is positive, it would be very easy for me to adopt.” It’s like needing that collective nod of approval to step outside the norm.

The Resource Reality: When There’s Not Enough to Go Around

Okay, let’s talk about the nitty-gritty of the workplace. Hospitals, especially in low-income settings, are often stretched thin. Staff shortages are a huge problem. Imagine being the only midwife looking after ten women in active labour! In that scenario, anything that makes your job quicker and more manageable becomes the go-to. And guess what? The dorsal (back-lying) position is often the easiest for the midwife when they’re juggling multiple patients. They can move from bed to bed, receiving babies relatively quickly.

One midwife painted a vivid picture of the challenges: “Dorsal position, yes. And I think it’s also the most comfortable position for the midwives. Because now, like in this setting,[…] you can find you are the only qualified midwife, and then you have like ten mothers in active labour or five. Then you find that they can push in 5 minutes. So, you just spread them on those beds, and when you see that head coming from there, just make sure you use many gloves, like three. Yes. When you see the other one is very fast coming, just take off one glove, just receive the baby, put on the mother’s abdomen, and cover the baby, then come and conduct another one.” Phew! You can feel the pressure just reading that, can’t you?

Beyond just staff, the physical environment plays a big role. Squatting or kneeling on a dirty floor in a shared ward? Not exactly appealing, and definitely a risk for infection. Birthing stools were available in this hospital, but midwives were unsure how to use them safely, worrying about where to place them and how to receive the baby without it falling. They even talked about putting the stools *on the beds* because the floor wasn’t suitable! Resources, or the lack thereof, massively influence what feels feasible and safe.

Balancing Act: Safety vs. Choice

Midwives also base their decisions on the mother’s clinical condition and characteristics. They watch for physiological cues, like when the waters break, which often signals a shift from encouraging mobility to keeping the mother in bed. This wasn’t about ignoring the mother; it stemmed from a deep concern for her and the baby’s well-being, even if their approach (like confining her to bed) might not align with current best practices for low-risk labour.

While they sometimes asked about preferences, especially for women who had given birth before (“We encourage them, which position they prefer, but squatting and kneeling is for grand multiparas.”), they often felt the need to guide or even direct the mother. They felt a responsibility to ensure safety, sometimes telling mothers to close their legs or adopt specific positions. This sense of duty, combined with their comfort zone, often meant sticking to the familiar supine position, which allowed them to perform practices they felt were essential, like supporting the perineum or immediately placing the baby on the mother’s abdomen.

It’s a tricky balance, isn’t it? They want the best for mum and baby, but their training, the environment, and the sheer workload push them towards practices that might not be the most empowering or comfortable for the mother.

Shifting Norms: The Weight of Tradition and the Power of Peers

This study really highlighted how powerful norms are in a hospital setting. There’s a pressure to conform to the established way of doing things, what the researchers linked to Foucault’s idea of “normalisation.” The protocols, the routines, the sheer weight of how things have always been done – it all shapes what midwives feel is “normal” or acceptable practice. The supine position isn’t just a habit; it’s embedded in the institutional culture, almost like a rule, even if it’s unwritten.

There’s even a historical layer to this, potentially linked to colonial influences where Western biomedical practices, like the supine position, were introduced and traditional, often upright, birthing methods were suppressed or seen as backward. That legacy can still subtly influence training and practice today.

However, it’s not all rigid. Remember how peer opinion mattered? That shows social norms among the midwives themselves are also influential. If they see their colleagues successfully and confidently supporting other positions, they are more likely to try it. This suggests that changing practices isn’t just about top-down rules; it’s also about building confidence and positive experiences within the team.

What Needs to Happen? More Than Just a Training Session

So, where do we go from here? The study makes it clear that simply telling midwives about the benefits of upright positions isn’t enough. They need practical training to build their confidence and skills in supporting these positions safely and effectively. They need misconceptions about risks to be addressed head-on.

But even the best training won’t fix everything if the basic resources aren’t there. Hospitals and governments need to tackle the fundamental issues: staffing shortages, inadequate space, lack of clean environments, and necessary equipment. Asking overworked midwives in under-resourced settings to adopt new, potentially more demanding practices without addressing these challenges is a recipe for frustration.

Ultimately, fostering respectful, woman-centred care means creating a supportive environment where midwives feel empowered and equipped to offer choices and support women in positions that work best for them, not just the position that’s easiest in a stretched system or feels like the ingrained “tradition.” It’s about bridging the gap between the biomedical model’s focus on control and the midwifery model’s trust in women’s abilities. It’s a big task, but understanding the midwives’ perspective is a crucial first step.

Source: Springer