Consumerism is the growing phenomenon whereby recipients of services are becoming more involved and concerned with the quality of services offered to them, … “Knowledge in the hands of the people being served.” Consumers are beginning to realize that the political/economic system does not change unless they make certain demands upon it. This trend toward informed and vocal consumers is of growing importance to nurse-midwives.
In the medical community, consumer groups have primarily focused on Obstetrics and Gynecology. This is a highly charged area due to the efforts of the women's movement. The women's movement has recognized the importance of health care to women and that the essential component is control. Control of one's body is a subject whose role in consumerism would require an entire book to investigate and clarify. But briefly, control by patients is what has been identified as the missing element in health care as it presently exists.
Control of one's body is hindered by the jargon and mechanization of health care. People are bombarded with words and phrases that have no relation to their life — they are forced to accept the advice of strangers regarding their bodies. The risks of certain procedures may or may not be adequately explained. The quality of care is arbitrary and differs greatly from one community to the next as does the cost of care. Neither the health care professionals nor the consumers feel any control in the services rendered or the outcome of those services. The vast network of the health care system accentuates this problem and diffuses accountability. Against this system, the uninformed and less than politically aware woman is no match. In fact, it may be difficult for her to recognize her own needs, let alone assert them. It is only through the efforts of well organized groups of women, such as those engaged in health education and research, that needs are being identified and changes demanded. This kind of assertiveness has its effect and valuable changes are being made.
How does this relate to the majority of women for whom nurse-midwives provide services? The image of the average nurse-midwifery consumer, to make a generalization, is one of an indigent, politically naive, oppressed woman from a minority ethnic group. Although she has the same unmet needs as any other woman, she rarely is able to attain the support and strength other women receive by meeting in groups and sharing common experiences and problems. She is isolated with her own problems and feels no power in her ability to change the health care system. She needs an advocate, someone who will direct and encourage her participation in health, A nurse-midwife could serve this purpose; but it is no simple task.
Nurse-midwives are in a precarious political position. Because we have a small consumer contingency of support, we find ourselves dependent on a benevolent physician relationship both in gaining employment as well as maintaining favorable legislation. Our power base is really non-existent. For the most part, the women we serve are economically and politically powerless too. There is a trend, however, toward serving a higher socio-economic group, who wield more power and are more vocal. With the acknowledged support of a larger and more diverse population, we would have leverage to use in establishing collegial relationships with doctors rather than subservient ones. In seeking other consumer advocates, however, we must take caution not to turn our backs on the women we have predominately served. These women are not as free to make choices as middle class women. We must maintain an advocacy position for women and families wherever the setting. Also we must provide support to one another as women and as professionals. The techniques used will vary according to the people and the institutions involved.
Obstetrical, contraceptive and gynecological care are major concerns of women-at-large. Many female consumers have begun to recognize their responsibility for finding health care workers who are receptive to their need for reciprocal relationships in health. Nurse-midwifery being primarily a female profession appeals to many women as the ideal solution to their health care needs. Our philosophy speaks to the rights and choices of people in the ritual of pregnancy and childbirth as well as in family planning and women's health.
Symbolically, the relationship between physician and nurse is portrayed as the traditional male-female role. This contributes to our ambivalence regarding our advocacy problem. The components of this relationship are the passive nurse and the decision-making physician. The nurse-midwife is an extension of the nurse and if analyzed in this context is in a painful position … painful in the sense that we are somewhat alienated from both groups. We are not autonomous; but we are not recognized for the unique aspects and qualities we have to offer.
The present trend of working as an obstetric “team” tends to dilute our identity and portrays a group effort, when in fact, the same lines of power exist in decision-making. There is no room for major imput from nurse-midwives in deciding policies for obstetric units. We are encouraged to participate; but the participation is limited to the work to be done, not the way in which it is approached. This is not to criticize the idea of “team”; but the present relationships as they now exist are far from satisfactory. We can learn certain political “know-how” from the women's movement and attempt to lessen this problem. We should not feel threatened by feminists but identify our common concerns. Because of our heritage in nursing of soothing and comforting, we are not proficient in managing conflicts and tension. We need to learn how to distinguish between useful and non-useful conflicts. By learning this we could promote various techniques in encouraging change. This will require the need to take risks. As a profession, our role is relatively new and has been hard fought to attain. As a result we are hesitant to risk the loss of our present position. Our numbers are increasing as is our influence. Change, whether planned or not, follows certain patterns; but the results are always unpredictable.
Consumers can facilitate change by exerting pressure from the outside for needed exposure in the media as well as by word of mouth communication. Many changes have already been made. Nurse-midwives have improved many aspects of care for many women; but we are far from our ultimate goal. Where we have been encouraged to flourish, we have had great impact; but not every setting is agreeable to innovation. Our image must be perceived as ernest and unfalteringly in favor of women and not the status quo.
In Medical Nemesis by Ivan Illich, health care professionals are perceived as maintaining their positions at all costs. The maze of different titles, grants and technology with no apparent improvement in the manner of delivery of health care, would convince any observer of this seeming conspiracy. The insidious psychological impact the health care industry has imposed on our society is hard to separate from the practices in which we have become entrenched. This is why we must promote and encourage our clients to be informed and organized on their own behalf. They must become well equipped with knowledge in order to protect themselves from the self-perpetuating system of health care as it exists today.
There is a large variety of concerns among consumers of obstetric and gynecological care. In turn, a variety of different philosophies are required to meet these needs. We can not look upon each and every nurse-midwife as a reflection of one identity. As we have different strengths we have different commitments to a variety of approaches to care. We need to maintain unity within our numbers. A vital area of support is needed to individual nurse-midwives who are involved in controversial new approaches to women's health outside traditional settings. It is essential that we respect each other wherever we decide to express our talents as nurse-midwives and women. This is not to say we lower our present high standards of care because a certain request is made, but that we look at what is being offered to families in the guise of quality patient care.
Consumerism is a growing awareness. Its ability to influence change in the system will be dependent on its ability to transmit knowledge to more consumers as well as the receptivity of health care providers. The pressure it will exert will be felt first by the health practitioner who has primary contact with patients. These demands will influence the future of nurse-midwifery. These demands will either be met by nurse-midwives or our validity as women's health care advocates will fail.