From Medical School to Community Practice: the Hidden Curriculum and Midwifery Education
Passion, Justice, and the “Hidden Curriculum”
Over the past couple of weeks I have had excellent discussions with midwifery colleagues on the cultural, ideological, and psychological changes student midwives experience as they navigate the “hidden curriculum” in medical education. In 1998 Hafferty defined the hidden curriculum as “a set of influences that function at the level of organizational structure and culture” (Hafferty, 1998, p. 404); Mossop et al (2013) build on Hafferty’s work, applying the concept of the cultural web to reveal core elements of the hidden curriculum, including “routines”, “rituals”, “control systems”, and “power structures” (p. 135) as important influences on the development of the professional identity, authoritative knowledge, and clinical practice.
In 2003 I began the UBC Midwifery Education Program eager to expand upon my women’s health activism and social justice work. The daily rituals and routines of obstetrics in the hospital environment moulded me into a practitioner with a high level of functioning in the tidy boxes of obstetric diagnoses and distanced me from the messy world of the social determinants of health. My rotations in Maternal Fetal Medicine and Obstetrics left me very comfortable in world of rare obstetric complications and high-level medical interventions, with a tool-box full of medical knowledge and technological skills. In keeping with the call of Paul Glasziou et al (2011), I did experience my UBC medical education as a “life course”; we were taught to be life-long medical learners, to critically appraise medical literature, to convey this vast literature to our patients, and formulate evidence-based clinical care plans. However, I chose to go to midwifery school, not to medical school! It took me 5 years post-graduation to realize that the practitioner I had become was not the practitioner I aspired to be, and that the radical traditions of midwifery I loved were not actively being reflected in my daily practice.
A Life-Long Learner: Back to the Community
My midwifery education was fraught by challenges; my world shrank as I was increasingly immersed in the hospital delivery ward, and my visions of social justice became increasingly focussed on preventing maternal morbidity and mortality. When I graduated I faced serious questions of whether or not it was even possible to use my knowledge and skills in the service of greater good, in the reclamation of woman-centered birth culture, to challenge the positivist nature of biomedical epistemology, and to open up possibilities of meaningful social transformation.
Midwifery can be considered a radical tradition with deep affinity towards a process Shultz describes as a “battle” to “include indigenous knowledges as legitimate epistemic contributions” (2013, p. 47). Advanced medical technology and practice has the potential to save many lives in the birthing room, but this same medical system continues to play an important role in the oppression of women, in colonial and neo-colonial expansion, unsustainable ‘development’, and the active suppression of different ways of knowing and cultural healing practices.
My year spent working in community-based health programs in peasant communities was a painful and wonderful challenge to my limited ‘Western’ midwifery practice. In the real world of exploited and oppressed peasant communities maternal mortality is indeed an important site of struggle, but ultimately this struggle is dwarfed by greater problems of severe hunger, land theft and landlessness, feudal exploitation, militarization, and political repression.
Midwifery, Solidarity, and Education as a Problem-Solving Process
Now I work in a small collective of midwives who support me in striving to combine midwifery activism and social justice, connecting imperatives to transform birth culture, empower systemically-marginalized families, build communities based on collaboration, and stand in solidarity with indigenous struggles. For our collective, our ongoing midwifery education is a daily practice centered in the communities we serve. As a collective we seek to break out of the confines of our professional practice and find a deeper meaning for midwifery (Uttal, 2011) through engaging our communities on how to work together to solve the major crisis facing the Western ‘culture’ of childbirth where cesarean section rates surpass 40% in some hospitals (PSBC, 2014) and maternal morbidity includes post-traumatic stress disorder from iatrogenic birth trauma and state-led child apprehensions.
I hope that the midwifery students in our practice have a refreshing experience of a different sort of ‘hidden curriculum’ grounded in human rights, liberatory epistemology, and community-based health and healing practice. While discussions on the role of the ‘hidden curriculum’ have been inspiring for me these past weeks, I’d like to deepen these conversations to include the ‘hidden histories’ of Western educational institutions and the ‘hidden structures’ that shape our world. Midwives have the potential to transform birth culture, learn from different views and cultures of birth, and stand in solidarity with indigenous communities demanding their rights and protecting our planet from imminent destruction, but only if we give it our concerted efforts.
- Glasziou, P.P., Sawicki, P.T., Prasad, K., & Montori, V.M. (2011). Not a Medical Course, but a Life Course. Academic Medicine, 86(11), p. e4.
- Hafferty, F.W. (1998). Beyond Curriculum Reform: Confronting medicine`s hidden curriculum. Academic Medicine, 73(4), pp. 402-407.
- Mossop, L. Dennick, R., Hammond, R., & Robbe, I. (2013). Analysing the Hidden Curriculum: Use of a cultural web. Medical Education, 74, pp. 134-143.
- Perinatal Services BC. (2014). Perispectives [On-line Newsletter]. January 6, 2014. Available here.
- Schultz, L. (2013). Engaged Scholarship in a Time of the Corporatization of the University and Distrust of the Public Sphere: A decolonizing response. In, Shultz, L. & Kajner, T. (Eds.), Engaged Scholarship: The politics of engagement and disengagement. Comparative and International Education (Series Title). Dordrecht, Netherlands: SensePublishers.
- Utell, J. (2011). Practical Wisdom and Professional Life. The Chronicle of Higher Education [On-Line Journal]. February 25, 2011. Available here.