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A birth centre's encounters with discourses of childbirth: How resistance led to innovation
Abstract
An ethnographic study of a free-standing birth centre uncovered a site of intense contestation. Two prominent childbirth discourses attempting to inscribe their orthodoxies on staff and women users encountered stern and persistent resistance. Using postmodern theory, this resistance is conceptualised as nomadic activity, as space is made at the margins of discourse for a difference and diversity to manifest. The relationship between discourse and women's agency is layered and non-linear as the presence of dissonant data indicates. The birth centre, however, actualises a number of contrasting ways of 'being' and 'doing' that appear to serve the interests of staff and women well. In particular, 'nomadic' midwifery practice and a 'care as gift' orientation challenges the biomedical model that defines the parameters of normal and the 'vigil of care' discourse that regulates the professional/patient relationship. Birth centres may encourage novel and eclectic ways of providing childbirth care.
... Considerando que a exploração teórica não contemplou nenhum estudo que abordasse especificamente a ambiência no contexto da saúde ou da obstetrícia, as publicações selecionadas apresentam elementos constituintes do conceito ambiência para trabalho de parto e parto normal institucionalizado, como o elemento das TNI. A maioria (11)(12)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(27)(28)30,(32)(33)(34)(35)37,(40)(41)(42)(43)(44) das publicações constitui-se de estudos empíricos, corroborando a propriedade dos antecedentes, dos atributos definidores e dos consequentes analisados. Com relação ao país de origem dos estudos, praticamente metade deles concentra-se na América (12,14,(16)(17)20,22,(26)(27)(30)(31)34,(36)(37)(38)41,43,45) , mais especificamente no Brasil (12,(16)(17)20,22,27,34,(36)(37)41,43) , concordando com a relevância deste estudo de formação de conceito. ...
... Sendo que a categoria "Espaço físico e social qualificado" apresenta quatro subcategorias: Tendo em vista que a assistência ao trabalho de parto e parto será centrada na parturiente e, mais ainda, ela será a protagonista, como antecedente, é imperativo promover sua autoestima e autoconfiança, por meio de incentivo e apoio da equipe, consciencializando sobre sua capacidade para o parto (30,39) . Outro antecedente da ambiência é a preferência da parturiente pelo parto normal somado às suas boas expectativas e da família em relação à instituição (40) . Ainda, como antecedente destaca-se a qualificação não só do espaço físico, mas também do social da instituição; compreendendo o local e os profissionais já no primeiro atendimento à parturiente até a completude do processo de parto. ...
... Significado atribuído à maternidade pela parturiente somado a autoestima e confiança no seu corpo, no processo de parto e nos profissionais de saúde, além da preferência e disposição à entrega ao trabalho de parto e parto com boas expectativas em relação à Instituição Significado atribuído à maternidade (39) ; Elevada autoestima (30) ; Autoconfiança (15,30,39) ; Confiança em seu corpo e no processo de parto (14,15,28) ; Confiança nos profissionais de saúde (11,19,39) ; Preferência pelo parto normal (21,31) ; Disposição para a entrega ao processo de trabalho de parto e parto (39) ; Boas expectativas em relação à Instituição (40) . ...
Objective:
to develop the concept ambience for labor and normal institutionalized delivery, identifying in the literature its antecedent, defining attributes and the consequent.
Method:
the method used was the analysis of literature, corresponding to the first stage of the qualitative method of concept analysis. The theoretical operation was performed in the databases CINAHL COCHRANE, LILACS, PsycINFO, and PubMed.
Results:
aspects of the parturient woman and the qualification of the physical and social space are presented as the antecedent. The defining attributes outline the assistance interaction process with Non-Invasive Technologies. As the consequent, we highlight the outcome for normal delivery, pain relief and comfort, woman satisfaction and well-being.
Final considerations:
the analysis of the antecedent, defining attributes and the consequent allowed the elaboration of an unprecedent theoretical proposition of this concept.
... Most of the studies addressed or touched on midwives and maternity nurses' job satisfaction and nine studies were about temporal pressures that organisational arrangements put midwives under and how this prevented them practising good midwifery care. Walsh (2006Walsh ( , 2007 provided a theoretical explanation for the differences in care provided in a freestanding midwifery unit and a hospital setting. He argued that 'production line' orthodoxies promoted a form of maternity assembly line in hospitals where women are 'processed', rather than cared for (Walsh, 2006). ...
... One important aspect of this review considered how researchers had defined and operationalised concepts of organisational culture. Sheridan (2010), Khokher et al (2009), Walsh (2007, Halliday (2002) and Wilson (2000) provided an explicit definition of organisational culture. Some studies explicitly took a 'shared assumption' approach, which could be seen as adopting an integrationalist perspective (Sheridan, 2010;Hallliday, 2002;Wilson, 2000). ...
... Gifford et al (2002) took a definition of organisational culture based on a CVF approach, which sees organisations as having a number of sub-cultures and hence can be seen as a form of the differentiation perspective. Walsh (2006Walsh ( , 2007 took a postmodern perspective on culture as one of contested dimensions and inherently fluid, an example of the fragmentation perspective. ...
Aim. To present the results of a scoping review of the research literature addressing the influence of organisational culture on the quality of maternity care.Background. Organisational culture is increasingly seen as key in both healthcare system operations and quality of care.Design. A scoping review using a modified version of Askey and O’Malley’s (2005) framework to identify: key concepts, gaps in the research and types and sources of evidence to inform practice, policymaking and research. Research databases used were: PubMed, Med Medic, MEDPILOT, Medline, CINAHL, PsycINFO, Cochrane, Social Sciences Abstracts, Web of Knowledge
and Scopus.Method. Development of a protocol specifying search terms and inclusion and exclusion criteria.Results. A total of 3521 papers were identified in the search. Following application of the inclusion criteria, 16 papers were eligible for full review. There was a focus on the organisational and cultural barriers to the practice of good maternity care. Most of the studies included consideration of how organisational culture could be influenced or changed and four of the studies evaluated some form of change of practice to find ways of enabling a ‘midwifery culture of practice’.Conclusion. This scoping review shows midwives and maternity nurses perceived organisational factors to be important determinants affecting practice. It highlights time pressures, procedural imperatives and professional conflicts to be the main organisational barriers to the practice of good maternity care.
... Reflecting on what well-functioning FMUs and case-loading teams have in common, some of the key elements are conditions that enable building relationships, autonomy, ownership, and interdependency. 37,38 The importance of having a sense of ownership and control over work patterns was evident in this study and consistent with other research on FMUs, [38][39][40] and with work on caseload midwifery. 34,35 Research on midwives' burnout suggests that the work setting is of critical importance for emotional well-being 19 and that "the most commonly reported source of satisfaction was relationships with colleagues and feeling like part of a team" (p. ...
... The social norms and the physical space in the FMU in this study encouraged relationship-based care and a sense of distributed decision-making rather than authority and top-down hierarchy, [38][39][40][41] which aided in the establishment of an equitable, rather than oppressive, organizational culture. Within this working environment, staff were engaged with their colleagues and the families in their care. ...
Background
Despite strong evidence supporting the expansion of midwife‐led unit provision, as a result of optimal maternal and perinatal outcomes, cost‐effectiveness, and positive service user and staff experiences, scaling‐up has been slow. Systemic barriers associated with gender, professional, economic, cultural, and social factors continue to constrain the expansion of midwifery as a public health intervention globally. This article aimed to explore relationships and trust as key components of a well‐functioning freestanding midwifery unit (FMU).
Method(s)
A critical realist ethnographic study of an FMU located in East London, England, was conducted over a period of 15 months. Recruitment of the 82 participants was purposive. Data collection included participant observation and semi‐structured interviews, and data were analyzed thematically along with relevant local guidelines and documents.
Results
Twelve themes emerged. Relationships and Trust were identified as a core theme. The other 11 themes were grouped into six families, three of which: Ownership, Autonomy, and Continuous Learning; Team Spirit, Interdependency, and Power Relations; and Salutogenesis will be covered in this paper. The remaining three families: Friendly Environment; Having Time and Mindfulness; and Social Capital, will be covered in a separate paper.
Conclusions
A relationship‐based model of care was crucial for both the functioning of the FMU and service users’ satisfaction and may offer a compelling response to high levels of stress and burnout among midwives.
... Pregnancy and childbirth are powerful, visceral experiences in a woman's life. In Western societies, pregnancy and childbirth have become an arena within which many key health and societal discourses are played out, particularly around medicalization [1], individual responsibility for health [2,3], and choice [4]. Many women across Western societies embrace complementary and alternative medicine (CAM) products and practices [5][6][7][8][9][10][11], partly as a response to these discourses, but also to give meaning and significance to those experiences and be provided with reassurance of the likelihood of a "normal" birth [12]. ...
... Other terms, such as "pregnant embodiment" [25,27], "embodied gender/selves" [45], and what Sointu terms "embodied authorship" [46,47], help counter the ways in which women's embodied experiences of pregnancy have been marginalized by essentialist and medicalized approaches to care [1,43,48]. Women's awareness of their femininity during pregnancy is said to increase, as well as feelings of well-being and bodily pride. For some women, pregnancy is perceived as a challenge with physical discomfort, impacting on perceptions of well-being [49] and body image [50]. ...
In Western societies, women's use of complementary and alternative medicine (CAM) during pregnancy and labor is increasingly ubiquitous, yet there have been few in-depth explorations of the lived experience of women who use CAM and little critical analysis of CAM's contribution to women's overall experience of pregnancy and childbirth. This paper explores women's narrative accounts of CAM use during pregnancy and childbirth to help uncover the meanings they attribute to CAM use. A qualitative narrative methodology was selected for this study, as it gives prominence to meanings that individuals assign to life events. A purposive sample of 14 women who were familiar with using a range of CAM modalities during pregnancy and childbirth took part in the study. This paper highlights different ways the women engaged with CAM, and how their embodied experiences became the mechanism by which CAM use, value, and safety were judged. CAM use in relation to embodiment became one way the women could reorder their world during pregnancy and childbirth. Moreover, CAM use among pregnant women may lead to the perception of more control and agency, but it also reinforces essentialist and naturalist conceptions of women's identities and bodies.
... From a Foucauldian perspective, health centres are increasingly recognised as institutional sites of power and control. Health practitioners and patients have been noted to exchange dominant and counter-dominant discourses about health models and practices during health encounters (Walsh, 2007). Medical facilities are sites where 'health-related beliefs are formulated and negotiated' (Kisch, 2009 p747). ...
... These informal circles of health deliberations are crucial because they constitute the space where patients make decisions about treatment (Walsh, 2007). These decisions influence the users' selection of medical facility, compliance with treatment and evaluation of the efficacy of treatment (Kleinman, 1978, cited in Kisch, 2009). ...
With a history of social and political marginalisation, mobile populations are most deprived of access to adequate health service provision. While they have undergone sociopolitical changes that bring them closer to mainstream health provision, their perception of the available health provision is still rarely sought by policy makers. This paper addresses these gaps by exploring the perceptions that Bedouin women have of reproductive health services in the Bekaa valley of Lebanon. Historically at the margins of health policy making, Bedouin populations in Lebanon have recently been facing significant sociopolitical changes to their ways of life that affect their perceptions of access and use of health services. In the past 40 years, the Bedouin have gradually settled in informal permanent or quasi-permanent settlements and engaged with modernised sedentary modes of living overlapping with their own. Their entitlements to social provision and political participation were also renegotiated in the post-conflict political era (post-1990) through an inconsistent naturalisation process managed by dominant political players. These changes have been significant in reshaping the positioning of the Bedouin as a social group in the broader Lebanese society. Against this backdrop, the paper asks the following question: How do women negotiate their reproductive health issues in relation to the dominant Lebanese mixed-provider health model? The paper argues that Bedouin women's perceptions of, and engagement with, the health system are hindered more by the inconsistencies and shortfalls of the health system than by any specific barriers stemming from their ways of life. Their access and use of health services are underpinned by institutional discrimination against their ethnic group at various levels of health provision.
... In addition to outcomes relating to safety, birth centres provide more positive experiences of maternity care for women/birthing people and cost less than traditional hospital care (Overgaard et al. 2012a, b;Macfarlane et al. 2014a, b;Rocca-Ihenacho et al. 2018). MUs can also encourage innovative ways of providing care and foster fulfilment and empowerment for midwives (Walsh 2007(Walsh , 2009). However, Walsh et al. (2020) found significant obstacles to MUs reaching their full potential. ...
Innovation has the potential to transform midwifery by empowering midwives, by providing solutions for issues in midwifery regulation, practice and education and by improving the quality of care to midwifery service users. This chapter provides some exciting examples and case studies of innovations in midwifery. It explains the concepts of responsible innovation in health, frugal innovation and disruptive innovation and provides guidance for midwives who wish to turn their ideas into innovations. It highlights some lessons in midwifery innovation from the COVID-19 pandemic, summarises key principles and makes recommendations for policy and practice.
... Neoliberal meta-narratives that privilege reproduction and motherhood shape national maternal health policy-making, while muting questions of abortion care. Normalizing narratives shape the interpretation and appropriation of policy issues (Walsh, 2007;Levinson et al., 2009). ...
Unsafe abortion practices remain the major contributor to maternal death in Uganda, impeding the achievement of universal health coverage and quality of maternal health care. Using an ethnographic design and critical discourse analysis, we explored the operations of power in setting maternal healthcare priorities, as evident at the 2018 Reproductive, Maternal, Neonatal, Child and Adolescents Health Conference. Observational data were collected of the policy-making activities, processes and events and key informant interviews were conducted with 27 participants. We describe how neoliberal and state governance through the structure and organization of policy-making, epistemic governance and universal concepts of ‘high-impact’ interventions, results-based financing, cost-effectiveness and accountability converge to suppress the articulation of local conditions associated with unsafe and risky abortion. By defining maternity along the continuum of birth and emphasizing birthing women, priority-setting was directed towards interventions promoting women’s normative role as mothers while suppressing unmet abortion care needs. Finally, discursive and communicative materials controlled how women of reproductive age in Uganda managed reproduction.
... Likewise, there are various values associated with the birthing process that can be different from what the medical institutions impose. Advocates of alternative birth place criticize the obstetric and gynecological community for maintaining and rationalizing "dominance over the birthing process" while pathologizing the maternal body and the "natural" process of giving birth 67 . Forcing a facility-based delivery has to do more with feeding certain biases than with addressing medical risks. ...
This work examines the ethical aspects of restricting homebirth. It focuses on how restricting homebirth can breach the principle of autonomy because pregnant citizens1 not only risk losing control over the medical decisions facing them, but also autonomy over their actions and control over their bodies. Using Berlin’s discussion on freedom, this work discusses the rather hidden oppressive nature of birth restrictions that appears when it is framed as helping pregnant individuals choose a moral option as per the advice of medical authorities at the expense of seeing an institutional failure to provide informed choice or options for birthing places for their so-called “best interest”. Three main arguments are offered why restricting homebirth can potentially violate autonomy: (1) imposing the authority to decide on the maternal body issues; (2) imposing standards on motherhood and pregnancy; and (3) imposing how to ascribe value to risk. These arguments highlight how the state and medical institutions have established authorities in the birthing process to justify restricting homebirth. When the state and medical institutions are framed as the moral authority for birth places, contrasting preferences of pregnant individuals are bound to be judged with guilt-ridden sentiments, shame and other value-laden labels related to one’s choice rather than be seen as a reflection of the quality of institutional support. Homebirth restriction reflects that a pregnant person’s decision of birthplace is not isolated from the availability of one’s choice. Indeed, there is an ethical interest in restricting homebirth, as this could be benevolent at best and discriminatory at worst.
... An 'us and them' culture between MUs and OUs found in the case study sites reprises an existing theme in the midwifery literature, highlighted in research into both midwifery-led care 47 and birth centres. 184 Research and policy have previously asserted the importance of team work for ensuring a safe maternity service, 128,185 but this has sometimes been invoked to resist separate midwifery-led spaces in maternity hospitals 21 and to install obstetricians as heads of teams. 186 Walsh and Devane 47 have written about the need for mutual respect, trust and collaboration at the interface of midwifery-led care and obstetric-led care, a relationship that mirrors the interface between primary and secondary care. ...
Background
Midwifery-led units (MUs) are recommended for ‘low-risk’ births by the National Institute for Health and Care Excellence but according to the National Audit Office were not available in one-quarter of trusts in England in 2013 and, when available, were used by only a minority of the low-risk women for whom they should be suitable. This study explores why.
Objectives
To map the provision of MUs in England and explore barriers to and facilitators of their development and use; and to ascertain stakeholder views of interventions to address these barriers and facilitators.
Design
Mixed methods – first, MU access and utilisation across England was mapped; second, local media coverage of the closure of free-standing midwifery units (FMUs) were analysed; third, case studies were undertaken in six sites to explore the barriers and facilitators that have an impact on the development of MUs; and, fourth, by convening a stakeholder workshop, interventions to address the barriers and facilitators were discussed.
Setting
English NHS maternity services.
Participants
All trusts with maternity services.
Interventions
Establishing MUs.
Main outcome measures
Numbers and types of MUs and utilisation of MUs.
Results
Births in MUs across England have nearly tripled since 2011, to 15% of all births. However, this increase has occurred almost exclusively in alongside units, numbers of which have doubled. Births in FMUs have stayed the same and these units are more susceptible to closure. One-quarter of trusts in England have no MUs; in those that do, nearly all MUs are underutilised. The study findings indicate that most trust managers, senior midwifery managers and obstetricians do not regard their MU provision as being as important as their obstetric-led unit provision and therefore it does not get embedded as an equal and parallel component in the trust’s overall maternity package of care. The analysis illuminates how provision and utilisation are influenced by a complex range of factors, including the medicalisation of childbirth, financial constraints and institutional norms protecting the status quo.
Limitations
When undertaking the case studies, we were unable to achieve representativeness across social class in the women’s focus groups and struggled to recruit finance directors for individual interviews. This may affect the transferability of our findings.
Conclusions
Although there has been an increase in the numbers and utilisation of MUs since 2011, significant obstacles remain to MUs reaching their full potential, especially FMUs. This includes the capacity and willingness of providers to address women’s information needs. If these remain unaddressed at commissioner and provider level, childbearing women’s access to MUs will continue to be restricted.
Future work
Work is needed on optimum approaches to improve decision-makers’ understanding and use of clinical and economic evidence in service design. Increasing women’s access to information about MUs requires further studies of professionals’ understanding and communication of evidence. The role of FMUs in the context of rural populations needs further evaluation to take into account user and community impact.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research ; Vol. 8, No. 12. See the NIHR Journals Library website for further project information.
... All reported findings (not including author analysis and discussion sections) were coded thematically, using Nvivo 11, using codes generated inductively through the coding process. One team member carried out an initial pilot coding of two papers chosen at random: Annandale, 1998 andWalsh 2007, and the codes were checked by a second member of the team. Following this pilot, the rest of the papers and theses were coded, generating 45 open thematic codes (see Supplementary table 5). ...
... In the US and Quebec, birthing houses are destined above all for highly motivated, educated, middle-class women who believe they will be empowered by the experience of natural childbirth (Sibbald, Ping, 2010;Arnal, in press). In the UK and France, they are part of the national health system and are centrally promoted, among other things, because birth without medical interventions is perceived as less expensive, enabling significant savings for the national health system (Walsh, 2007;Charrier, 2015). ...
Within the context of the creation of birthing houses around the world and different models of care for childbirth, the author proposes an analysis that contributes to the discussion about the place for birth, especially in urban Brazil.
... The second factor is the ethos of my care providers. Care providers who see value in physiologic birth are more likely to align their practice to facilitate and protect the processes of physiologic birth so as to make it a reality for the women with whom they work ( Foureur, 2012;Leap, 2016;Walsh, 2007 ). For example, when I experienced a lengthy pre-labour, and I had the desperate feeling I was ' travelling through pits of nothingness… through some kind of shadowland ' (Journal, 2014) , and asked my care providers for help, they were able to recognise this as a normal physiologic birth process. ...
Objective: To discuss the concept of ‘transcendent birth’, an as yet poorly articulated and under recognised psychosocial wellness phenomenon of childbirth. Design: an auto-ethnographical examination of the primary authors’ journaled experiences as a student midwife and childbearing woman. Setting: three maternity care units in South Eastern Australia as well as the home of the primary author. Findings: The phenomenon of transcendent birth is linked with physiologic birth. Maternity care can hinder or facilitate physiologic birth, and therefore transcendent birth. Key conclusions: Transcendent birth is more likely in maternity care models which value the childbearing woman and physiologic birth. Implications for practice: Women's access to transcendent birth is demarcated by women's position in society, cultural knowledge of transcendent birth and the valuing of transcendent birth as a maternity care outcome.
... While the quality of review studies varied, this review offers an important overview of current knowledge regarding the aspects of QPI that contribute to the development of PTSD-PC. The relationship between a woman and her midwife, core to QPI, is considered distinct from other healthcare professional/client relationships (Kirkham, 2000), with a shift from the theoretical model of vigil of care, or surveillance perspective, to that of care as gift, characterised by trust and generosity (Fox, 1999), and focused on engaging and responding to the other (Walsh, 2007). Therefore, the finding that interpersonal difficulties, especially being ignored, were the strongest predictors for developing PTSD-PC is especially important. ...
Objective: Review primary research regarding PTSD Post-Childbirth (PTSD-PC) that focussed on Quality of Provider Interaction (QPI) from the perspective of women who developed PTSD-PC, or midwives.
Background: Up to 45% of women find childbirth traumatic. PTSD-PC develops in 4% of women (18% in high-risk groups). Women’s subjective experiences of childbirth are the most important risk factor in the development of PTSD-PC, with perceived QPI being key.
Methods: A systematic search was performed for PTSD-PC literature. Reviewed papers focussed on either women’s subjective childbirth experiences, particularly QPI, or midwives’ perspectives on QPI. Study quality was assessed using the Critical Appraisal Skills Programme (CASP) tools, and a narrative synthesis of findings produced.
Results: Fourteen studies were included. Three features of QPI contribute towards developing PTSD-PC: interpersonal factors; midwifery care factors; and lack of support.
Conclusion: QPI is a significant factor in the development of PTSD-PC and the identified key features of QPI have potential to be modified by midwives. The development of guidelines for midwives should be grounded on evidence highlighted in this review, along with further high-quality qualitative research exploring QPI from the perspective of women with PTSD-PC, but also midwives’ knowledge and needs regarding their role within QPI.
... Our exploratory analysis indicated that the training element participants perceived would have the greatest impact on their practice was the establishment of a visible community of practice, focused on promoting normality in childbirth and womancentred care by sharing evidence and strategies. The participants viewed involvement with a group of like-minded people as transformative and strengthening, counteracting the resistance to normal birth noted by our participants and in other studies of establishment of birth centre culture (Walsh, 2007). The need for a visible and active community of practice resonates with ethnographic research around free-standing midwifery units in an urban setting (Rocca-Ihenacho, 2017), and the development of skill and expertise in complex physiological births (Walker et al., 2017). ...
Objectives:
to gain understanding about how participants perceived the value and effectiveness of 'Keeping Birth Normal' training, barriers to implementing it in an along-side midwifery unit, and how the training might be enhanced in future iterations.
Design:
exploratory interpretive.
Setting:
inner-city maternity service.
Participants:
31 midwives attending a one-day training package on one of three occasions.
Methods:
data were collected using semi-structured observation of the training, a short feedback form (23/31 participants), and focus groups (28/31 participants). Feedback form data were analysed using summative content analysis, following which all data sets were pooled and thematically analysed using a template agreed by the researchers.
Findings:
We identified six themes contributing to the workshop's effectiveness as perceived by participants. Three related to the workshop design: (1) balanced content, (2) sharing stories and strategies and (3) 'less is more.' And three related to the workshop leaders: (4) inspiration and influence, (5) cultural safety and (6) managing expectations. Cultural focus on risk and low prioritisation of normal birth were identified as barriers to implementing evidence-based practice supporting normal birth. Building a community of practice and the role of consultant midwives were identified as potential opportunities.
Key conclusions and implications for practice:
a review of evidence, local statistics and practical skills using active educational approaches was important to this training. Two factors not directly related to content appeared equally important: catalysing a community of practice and the perceived power of workshop leaders to influence organisational systems limiting the agency of individual midwives. Cyclic, interactive training involving consultant midwives, senior midwives and the multidisciplinary team may be recommended to be most effective.
... UK, New Zealand, and Australia studies have reported high satisfaction rates and positive experiences of women using out-ofhospital birth centres (Barlow et al., 2004;Skinner and Lennox, 2006;Deery et al., 2007;Smythe et al., 2009;Birthplace in England Collaborative Group, 2011). Some studies suggest that women who make out-of-hospital birth choices have a sense of autonomy that contributes to a positive experience (Walsh, 2007;Murray-Davis et al., 2012). Studies on birth settings consistently recommend midwife-led birth centres for maternity care because of safety and the positive experience of women (Stapleton et al., 2013;Birthplace in England Collaborative Group, 2011). ...
... This study is now over 20 years old and was carried out within an American Birth Centre. Whilst many of the issues Annandale for a systematic review of existing research), Denis Walsh's doctoral work (Walsh 2004;2007a) is the only ethnography of a freestanding midwife-led unit to date, although an ethnographic study of the organisational culture of a freestanding ...
... Birth centres offering 'family-centred care' to eligible, low-risk, women within a 'wellness' model can now be found in most European countries, Canada, Japan, Australia, New Zealand and Brazil (Kirkham, 2003; Hodnett et al, 2005; Cunningham, 1993; Koiffman et al, 2009). The model has been documented in overviews (Kirkham, 2003); commentaries from specific settings (Groh, 2003; Shallow, 2003); qualitative research (Annandale, 1987Annandale, , 1988 Coyle et al, 2001a Coyle et al, , 2001b Creasy 1997; Deery et al, 2007; Esposito, 1999; Walsh, 2006a Walsh, , 2006b Walsh, , 2006c Walsh, , 2007) mixed methods studies (Saunders et al, 2000), and systematic reviews (Hodnett et al, 2005; Walsh and Downe, 2004). However, more than a generation since the ABM began in the US, the model is still seen as alternative rather than mainstream. ...
A time-limited ethnographic study was undertaken at the Lewes Birth Centre, an inner-city birth centre in England. The study explores how the birth centre was created, what birth centre care meant to the women and men who opted for it, and to the midwives working there. Birth centres are thought to share a general framework of beliefs, derived from a 'social model of care'. In principle they promote well-being, see birth primarily as a normal physiological process and a social phenomenon rather than a clinical event, and seek to minimise the routine use of invasive interventions. In-depth research is needed to show how different service models work in practice.
... Research evidence showed that Cyprus health system is outdated and inefficient and concludes that there is a need for the creation of a relevant policy (Golna model of care (Davies-Floyd, 1994, 2003Walsh, 2007). The technocratic or biomedical model treats pregnancy and childbirth as an illness and argues that women should give birth only in the hospital with obstetricians (Johanson et al., 2002;Wagner, 2001). ...
OBJECTIVE: To explore Greek Cypriot women’s perceptions of their right to choose the place of
childbirth.
DESIGN: This study is qualitative and is based on Husserl’s phenomenological approach. The field
work extended over a 6-month period in 2010–2011.
SETTING: In all cities of the Republic of Cyprus.
PARTICIPANTS: Purposive sample of 55 women within 1 year after birth. Forty-eight women were
recruited for semistructured interviews and six of them took place in first focus group. The second
group consisted of seven women that did not participate in interviews.
RESULTS: Women’s perceptions were categorized into four themes: (a) informed choice for birth
place, (b) trusting relationship with health professionals, (c) medicalization of childbirth, and (d) safety
of the mother and baby.
CONCLUSIONS: There is no equity and accessibility in Cyprus maternity care system because it does
not provide correct information and accessibility to all birthplace choices. This study demonstrated
the need to explore women’s views before formulating policy for maternity care. These views will be
helpful for the creation of an innovative evidence-based maternity care policy, taking into account
women’s needs, and will be helpful to raise awareness among health professionals for maternity care
improvement.
IMPLICATIONS FOR PRACTICE: Ensuring the right for birthplace choices is a social and political
necessity that enhances the existing health care systems and health professionals to provide quality and
holistic maternity care. Conducting more studies on maternity care in Cyprus will reinforce the aim for
improving the health of the women, neonates, and society.
KEYWORDS: place of birth; informed choices; hospital birth; home birth; birth center; medical model
... Having an influence on birthing positions throughout birth seems more significant, which can be interpreted as being involved in what is happening. With this finding, our study adds to a further understanding of the concept of control in relation to childbirth (Green, 1999;Walsh, 2007). In the discussion on the meaning of control in childbirth, some emphasise the consumer making the decisions as the central issue of control (Weaver, 1998;VandeVusse, 1999). ...
Objective:
to explore whether choices in birthing positions contributes to women's sense of control during birth.
Design:
survey using a self-report questionnaire. Multiple regression analyses were used to investigate which factors associated with choices in birthing positions affected women's sense of control.
Setting:
midwifery practices in the Netherlands.
Participants:
1030 women with a physiological pregnancy and birth from 54 midwifery practices.
Findings:
in the total group of women (n=1030) significant predictors for sense of control were: influence on birthing positions (self or self together with others), attendance of antenatal classes, feelings towards birth in pregnancy and pain in second stage of labour. For women who preferred other than supine birthing positions (n=204) significant predictors were: influence on birthing positions (self or self together with others), feelings towards birth in pregnancy, pain in second stage of labour and having a home birth. For these women, influence on birthing positions in combination with others had a greater effect on their sense of control than having an influence on their birthing positions just by themselves.
Key conclusions:
women felt more in control during birth if they experienced an influence on birthing positions. For women preferring other than supine positions, home birth and shared decision-making had added value.
Implications for practice:
midwives can play an important role in supporting women in their use of different birthing positions and help them find the positions they feel most comfortable in. Thus, contributing to women's positive experience of birth.
... The future is uncertain regarding trends in intrapartum care. The postmodern era that we are moving into is characterised by choice, eclecticism and a suspicion of grand narratives that propose to answer all the questions (Walsh 2007b). Both technocratic birth and natural birth are childbirth versions of a grand narrative. ...
Introduction and historyMedicalisation of childbirthBacklashModels of childbirthPlace of birth debateContemporary challengesConclusion
References
... as to be tempered with flexibility if pathology ensues. One of the difficulties for childbearing women and childbirth professionals is the equivocal nature of the space between physiology and pathology. Arguably, this space is as much socially constructed as identifiable as an objective transition between the normal and abnormal (Davis-Floyd 2003).Walsh (2007a)illustrated this in a paper about the clinical judgement of a birth centre midwife regarding a woman's transfer to hospital. The area is highly conflicted as the variations in risk criteria for booking at home and birth centres across the UK illustrate (Campbell 1999). In this space are not only uncertain research findings about what con ...
The experience of childbirth is one of the most corporeal of the human condition. Against a backdrop of profound change in the milieu of birthing over the past 30 years, especially in the developed world, a number of discourses now compete for the status of the safest, most fulfilling birth experience. Supporters of biomedical and 'natural' approaches make their respective claims to those, with obstetricians broadly aligning their professional interests with the former and midwives with the latter. There is mounting evidence that childbearing women's experiences of birth are often shaped in the uneasy space between the two. Within sociological discourse in health, embodiment is a dominant theme but, to date, research has concentrated mainly on new reproductive technologies, and there is a dearth of recent research and theorising around the act of parturition itself. This paper argues that because of this, there has been a polarising tendency in current discourses which is having a largely negative impact on women, professionals and the maternity services. A call is made for an integration of traditional childbirth embodiment theories, mediated through compassionate, relationally focused maternity care, especially when labour complications develop.
Purpose
Servicescape is well recognized by marketing scholars as a key influence in transformative service outcomes. However, the concept of enabling transformative health outcomes through physical servicescape design is often overlooked. The purpose of this study is to integrate marketing's servicescape research with birth territory theory and the enabling places framework, conceptualizing a Co-Curated Transformative Place (CCTP) framework.
Design/methodology/approach
This cross-disciplinary conceptual paper uses three places of birth (POB) servicescapes for low-risk birthing women to ground the CCTP framework.
Findings
Positioned within transformative service research, this study shows how POB servicescapes are CCTPs. The organizing framework of CCTP comprises four key steps founded on agile and adaptive co-curation of physical place resources.
Research limitations/implications
This study extends the servicescape conceptualization to incorporate the continuum of terrain, introducing adaptive and agile co-curation of places.
Practical implications
The materiality of place and physical resources in CCTP are usefully understood in terms of co-curated substantive staging according to service actor needs. The CCTP servicescape maximizes desired value outcomes and quality experience by adaptive response to service demands and service actors’ needs.
Originality/value
Theoretical discourse of health servicescapes is expanded to focus on the material components of place and their foundational role in generating resources and capabilities that facilitate the realization of service value. In the CCTP, service actors flexibly select, present and adapt physical artifacts and material resources of the service terrain according to dynamic actor needs and service responsibilities, enabling transformative outcomes. Co-curation facilitates reciprocal synergy between other dimensions of place and servicescape.
This article analyzes the contemporary transformation of the medicalization of pain relief in the organization of the perinatal care system in Quebec. The consequences of this transformation are analyzed specifically through the common recourse to epidural anesthetics to relieve women’s pain during childbirth. Relying on 6 months of ethnographic fieldwork, 26 semi-structured interviews and 24 life history interviews, I discuss the relevance of the concepts of medicalization and demedicalization for a theoretical analysis of this transformation. By taking into account in the analysis the three levels of medicalization suggested by Conrad and Schneider (conceptual, interactional and institutional), I argue that the expertise related to the relief of pain during childbirth is transferred from health professionals to women through a naturalization of women’s competences process. Beyond the notion of social control, I revisit the use of the concept of medicalization to analyze how pain during childbirth could be simultaneously the subject of a double and continuous process of demedicalization and of medicalization. I conclude that the transformations of the Quebec perinatal system cannot be completely part of a demedicalization process but rather part of a form of medicalization where the different levels of medicalization are modulated.
Previous research demonstrates that biomedicalisation and diagnostic processes are intertwined in American mental health care, but few studies examine practitioners’ negotiations. This study examines how Mental Health Practitioners (MHPs) negotiate the Diagnostic and Statistical Manual (DSM), diagnosis, standardisation and biomedicalisation‐in‐practice. Feminist grounded theory analysis of 42 semi‐structured interviews with licensed adolescent MHPs reveals accounts of discursive, everyday resistance to the DSM technology and standardisation, which I regard as key aspects of biomedicalisation. Findings demonstrate MHPs seemingly practice what I term diagnostic dissonance: a deep conflict between their professional theoretical orientations and the biomedical model legitimated in the DSM technology and insurers’ diagnostic standardisation. MHPs enact dissonance by undermining the DSM, working around standardisation and by coding the social. Coding the social refers to the employment of V‐codes – illegitimate secondary diagnoses – which convey social and relational conditions of mental distress. MHPs’ contestations of the DSM and standardisation are responses to a healthcare infrastructure that decontextualises mental health. Practitioner resistance to biomedicalisation‐in‐diagnosis is important because the biomedicalisation of mental health takes focus away from the social and relational conditions and solutions to individual and community health and illness.
OBJECTIVE: To explore Greek Cypriot women’s perceptions of their right to choose the place of childbirth.
DESIGN: This study is qualitative and is based on Husserl’s phenomenological approach. The field work extended over a 6-month period in 2010–2011.
SETTING: In all cities of the Republic of Cyprus.
PARTICIPANTS: Purposive sample of 55 women within 1 year after birth. Forty-eight women were recruited for semistructured interviews and six of them took place in first focus group. The second group consisted of seven women that did not participate in interviews.
RESULTS: Women’s perceptions were categorized into four themes: (a) informed choice for birth place, (b) trusting relationship with health professionals, (c) medicalization of childbirth, and (d) safety of the mother and baby.
CONCLUSIONS: There is no equity and accessibility in Cyprus maternity care system because it does not provide correct information and accessibility to all birthplace choices. This study demonstrated the need to explore women’s views before formulating policy for maternity care. These views will be helpful for the creation of an innovative evidence-based maternity care policy, taking into account women’s needs, and will be helpful to raise awareness among health professionals for maternity care improvement.
IMPLICATIONS FOR PRACTICE: Ensuring the right for birthplace choices is a social and political necessity that enhances the existing health care systems and health professionals to provide quality and holistic maternity care. Conducting more studies on maternity care in Cyprus will reinforce the aim for improving the health of the women, neonates, and society.
Based upon interview data collected from 50 respondents, this study examines how expectant mothers navigate the divide between natural and non-natural childbirth when faced with the dilemma of using chemical pain management. The vast majority of participants in this study had strong intentions of delivering without any type of chemical pain management, but when faced with intense physical pain and/or coaxing from medical authorities, made the decision to use an epidural. Respondent accounts illustrate that the decision to use an epidural effectively removed them from membership in the "natural childbirth club." In order to better understand this process of group inclusion/exclusion, I draw upon the symbolic interaction frameworks of George Herbert Mead (1934) and Norbert Wiley (1995), paying special attention to their theories of the self. This study concludes that the decision to use chemical pain management in the childbirth process is often done so at the expense of changes in identity with respect to the Generalized Other of the "natural childbirth" community.
The article examines the medicalization of pregnancy and childbirth and the tendency to humanize or demedicalize childbirth. The concept of childbirth dramatically changed in Western countries over the last century. Pregnancy and childbirth were still considered to be a natural phenomenon at the beginning of the 20th century. In the second half of the 20th century, which coincides w ith more i ntense development of gynaecology and obstetrics and the related technology, pregnancy and childbirth became the subject of the jurisdiction of medicine. Medicalization in Peter Conrad's terms is a process by which non-medical problems become defined as medical, which is also related to the implementation of medical interventions. A descriptive research method was used to perform a literature review related to the medicalization of pregnancy and childbirth. In addition to a general overview of the theme, the review focused on the Slovenian context. Discussions about the medicalization of pregnancy and childbirth and natural childbirth create ambivalence, since technological advances also help to save lives. The feminist critique sees the medicalization of pregnancy and childbirth in the function of control over women's bodies and reproduction. The process of humanization therefore focuses on woman and her ability to make independent decisions related to pregnancy and childbirth. Through the literature review, it is indicated that there is a need for further empirical research to explain more clearly the interweaving of these two perspectives, especially in Slovenia, where such studies are extremely limited.
Abstract
Background
Evidence from the Birthplace in England Research Programme supported a policy of offering ‘low risk’ women a choice of birth setting, but a number of unanswered questions remained.
Aims
This project aimed to provide further evidence to support the development and delivery of maternity services and inform women’s choice of birth setting: specifically, to explore maternal and organisational factors associated with intervention, transfer and other outcomes in each birth setting in ‘low risk’ and ‘higher risk’ women.
Design
Five component studies using secondary analysis of the Birthplace prospective cohort study (studies 2–5) and ecological analysis of unit/NHS trust-level data (studies 1 and 5).
Setting
Obstetric units (OUs), alongside midwifery units (AMUs), freestanding midwifery units (FMUs) and planned home births in England.
Participants
Studies 1–4 focused on ‘low risk’ women with ‘term’ pregnancies planning vaginal birth in 43 AMUs (n = 16,573), in 53 FMUs (n = 11,210), at home in 147 NHS trusts (n = 16,632) and in a stratified, random sample of 36 OUs (n = 19,379) in 2008–10. Study 5 focused on women with pre-existing medical and obstetric risk factors (‘higher risk’ women).
Main outcome measures
Interventions (instrumental delivery, intrapartum caesarean section), a measure of low intervention (‘normal birth’), a measure of spontaneous vaginal birth without complications (‘straightforward birth’), transfer during labour and a composite measure of adverse perinatal outcome (‘intrapartum-related mortality and morbidity’ or neonatal admission within 48 hours for > 48 hours). In studies 1 and 3, rates of intervention/maternal outcome and transfer were adjusted for maternal characteristics.
Analysis
We used (a) funnel plots to explore variation in rates of intervention/maternal outcome and transfer between units/trusts, (b) simple, weighted linear regression to evaluate associations between unit/trust characteristics and rates of intervention/maternal outcome and transfer, (c) multivariable Poisson regression to evaluate associations between planned place of birth, maternal characteristics and study outcomes, and (d) logistic regression to investigate associations between time of day/day of the week and study outcomes.
Results
Study 1 – unit-/trust-level variations in rates of interventions, transfer and maternal outcomes were not explained by differences in maternal characteristics. The magnitude of identified associations between unit/trust characteristics and intervention, transfer and outcome rates was generally small, but some aspects of configuration were associated with rates of transfer and intervention. Study 2 – ‘low risk’ women planning non-OU birth had a reduced risk of intervention irrespective of ethnicity or area deprivation score. In nulliparous women planning non-OU birth the risk of intervention increased with increasing age, but women of all ages planning non-OU birth experienced a reduced risk of intervention. Study 3 – parity, maternal age, gestational age and ‘complicating conditions’ identified at the start of care in labour were independently associated with variation in the risk of transfer in ‘low risk’ women planning non-OU birth. Transfers did not vary by time of day/day of the week in any meaningful way. The duration of transfer from planned FMU and home births was around 50–60 minutes; transfers for ‘potentially urgent’ reasons were quicker than transfers for ‘non-urgent’ reasons. Study 4 – the occurrence of some interventions varied by time of the day/day of the week in ‘low risk’ women planning OU birth. Study 5 – ‘higher risk’ women planning birth in a non-OU setting had fewer risk factors than ‘higher risk’ women planning OU birth and these risk factors were different. Compared with ‘low risk’ women planning home birth, ‘higher risk’ women planning home birth had a significantly increased risk of our composite adverse perinatal outcome measure. However, in ‘higher risk’ women, the risk of this outcome was lower in planned home births than in planned OU births, even after adjustment for clinical risk factors.
Conclusions
Expansion in the capacity of non-OU intrapartum care could reduce intervention rates in ‘low risk’ women, and the benefits of midwifery-led intrapartum care apply to all ‘low risk’ women irrespective of age, ethnicity or area deprivation score. Intervention rates differ considerably between units, however, for reasons that are not understood. The impact of major changes in the configuration of maternity care on outcomes should be monitored and evaluated. The impact of non-clinical factors, including labour ward practices, staffing and skill mix and women’s preferences and expectations, on intervention requires further investigation. All women planning non-OU birth should be informed of their chances of transfer and, in particular, older nulliparous women and those more than 1 week past their due date should be advised of their increased chances of transfer. No change in the guidance on planning place of birth for ‘higher risk’ women is recommended, but research is required to evaluate the safety of planned AMU birth for women with selected relatively common risk factors.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
Objective
To investigate how midwives and midwifery managers were attempting to provide choice for women, through the creation of a service with a distinct culture from the obstetric unit (OU) prior to the opening of a new alongside midwifery unit (AMU).
Methods
Fifteen purposively sampled midwives and midwifery managers from three practitioner groups: prospective birth centre midwives, obstetric unit midwives and midwifery managers involved in the AMU set-up were interviewed using semi-structured interviews.
Results
Through the development of the AMU, staff perceive that low-risk women will be provided with a choice of ‘safe normality’ for their birthing experience. Staff are attempting to create a culture of care that is distinct from the OU while still benefiting from the perceived safety of close proximity medicalised care. This distinct culture is being created through the choice of an AMU over other alternatives; the design of the AMU and the environment created; and the selection of appropriate staff that have competence and confidence in their ability to deliver women-led care. However, there is a risk that the distinct culture of care may be in jeopardy due to the blurring of boundaries between the AMU and OU. This is partly as a result of the practical issues associated with a case mix skewed towards high-risk women in a deprived inner city context and the strong belief by OU midwives that ‘safe normality’ is already available within the OU.
Conclusions
The AMU appeals strongly to the perceptions of midwives and midwifery managers as providing good quality midwife-led care and a safe place of birth that offers choice that will be accepted by the women they care for.
This article endeavours to evaluate and critique the evidence and the associated limitations with many studies that look at time limits during the second stage of labour. It also seeks to examine the consequences of using delayed spontaneous pushing versus the Valsalva manoeuvre, in conjunction with time restraints in relation to maternal morbidities and neonatal complications. It discusses how midwives can best support and empower women in the second stage of labour and how information giving can lead to empowerment, informed decision making and woman's autonomy.
This study applies poststructuralist and postmodern ideas to issues of health and health care to provide a radical re-think of how health is to be understood. It offers a perspective in which health is seen as an affirmation of potential rather than a narrow biopsychosocial construct. The author develops his notion of archehealth, providing an account of a wide range of post-structuralist and postmodern theoretical perspectives and their relevance to the field of health. The book is divided into three sections; the first section explores issues of power and control in health settings; the second loooks ta resistance to such power and control; the final section addresses ways in which post-sztructuralist and postmodern approaches may be used as research methodology. In each chapter the author explains and apllies a selection of theoretical perspectives. These include Foucault, Derrida, Lyotard, Deleuze, Guattari, Cixous, Haraway, Kristeva, Beck, Barthes, Tyler, Landow, Bauman, Cascardi, Baudrillard and Atkinson.
In this article, our concern is to describe how body(ies) and self are performed in women’s birth narratives through the mediation of a number of significant elements, including technical devices. We will show how, in these narratives, (1) action is distributed among a series of actants, including professionals and technology; (2) that dichotomies appear which cannot be reduced to one of body/mind, but are more adequately described in terms of ‘body-in-labour’/’embodied self’, each of them being locally performed through the mediation of medical practices, knowledge and technologies, the definition of these elements and of their relations being specific to each obstetrical configuration; (3) that part of professionals’ activities is devoted to the detailed management of the articulation between the body-in-labour and the embodied self, and to monitoring their joint transformations.
Each society has its own consensual understanding of birth and its determinants: caregivers, location, participants and loci of decision-making, which in the Western world are based on biomedical knowledge. However, two competing cultural models of childbirth, the biomedical/technocratic model and natural/holistic model, mediate women's choices and preferences for the place and caregiver in childbirth. This article explores the way in which these cultural models of birth and the existing practical possibilities for choices shape women's and men's understanding of home birth. Based on interviews with 21 Finnish women and 12 Finnish men, the reasons for and experiences of planning and building toward a home birth are examined through an analysis of birth narratives. The analysis focuses especially on the women's definitions of what is 'natural' and their relationship with health services where biomedical practices and knowledge are the norm. The analysis shows that the notion of 'natural birth' holds various meanings in Finnish women's narratives namely self-determination, control, and trust in one's intuition. I seek to demonstrate that just as the biomedical management of childbirth exhibits distinct cross-cultural variation, so also does resistance to biomedical hegemony, as such resistance is strongly embedded in the local socio-cultural situation.
Over the past few centuries childbirth has become increasingly influenced by medical technology, and now medical intervention is the norm in most Western countries. Richard Johanson and colleagues argue here that perhaps normal birth has become too "medicalised" and that higher rates of normal birth are in fact associated with beliefs about birth, implementation of evidence based practice, and team working.
This article examines the work narratives of midwives practicing in the United States, specifically in the State of Florida. We focus analytic attention on how the discourse of medicine is used as a resource in constructing a sense of legitimation for midwifery. Data are drawn from in-depth interviews with 26 direct-entry, licensed midwives and certified nurse-midwives.
Historically, social scientific literature on midwifery has placed a midwifery, or a holistic, model of childbirth in polar opposition to a technocratic or medical model. In practical work, however, midwives demonstrate knowledge of, and make use of, a discourse of medicine to serve their purpose-at-hand. In these ‘narratives of legitimation’, the medical model does not emerge as an entity definable as separate and necessarily at odds with the midwifery model. Rather, the medical model is a resource through which midwives work narratively to construct the validity of their profession.
The midwives interviewed use the discourse of medicine in three specific ways. First, they draw upon it as a contrast device, setting themselves and their work apart from the medical establishment. Second, midwives use the medical model to communicate necessary daily aspects of their work. Finally, they construct a story of medical collaboration to equate their work with that of physicians.
Joining the discussion regarding the future of alternative and traditional medical practices and beliefs, the author explores how operating within the dominant sociopolitical system challenges alternative health care providers' definitions of themselves, their practices, and their systems of beliefs. Specifically, this case study articulates the experiences of one group of birth care providers (both certified nurse and nonlicensed, apprentice-trained midwives) as a web of paradox that simultaneously marginalizes parts of their occupational identity while allowing them to operate within the dominant sociopolitical system.
Considerable financial and philosophical effort has been expended on the evidence-based practice agenda. Whilst few would disagree with the notion of delivering care based on information about what works, there remain significant challenges about what evidence is, and thus how practitioners use it in decision-making in the reality of clinical practice.
This paper continues the debate about the nature of evidence and argues for the use of a broader evidence base in the implementation of patient-centred care.
Against a background of financial constraints, risk reduction, increased managerialism research evidence, and more specifically research about effectiveness, have assumed pre-eminence. However, the practice of effective nursing, which is mediated through the contact and relationship between individual practitioner and patient, can only be achieved by using several sources of evidence. This paper outlines the potential contribution of four types of evidence in the delivery of care, namely research, clinical experience, patient experience and information from the local context. Fundamentally, drawing on these four sources of evidence will require the bringing together of two approaches to care: the external, scientific and the internal, intuitive.
Having described the characteristics of a broader evidence base for practice, the challenge remains to ensure that each is as robust as possible, and that they are melded coherently and sensibly in the real time of practice. Some of the ideas presented in this paper challenge more traditional approaches to evidence-based practice. The delivery of effective, evidence-based patient-centred care will only be realized when a broader definition of what counts as evidence is embraced.
Over the past few centuries childbirth has become increasingly influenced by medical technology, and now medical intervention is the norm in most Western countries. Richard Johanson and colleagues argue here that perhaps normal birth has become too “medicalised” and that higher rates of normal birth are in fact associated with beliefs about birth, implementation of evidence based practice, and team working
Until the 17th century, birth in most parts of the world was firmly in the exclusively female domestic arena, and hospital birth was uncommon before the 20th century, except in a few major cities. 1 2 Before the invention of forceps, men had been involved only in difficult deliveries, using destructive instruments with the result that babies were invariably not born alive and the mother too would often die. Instrumental delivery with forceps became the hallmark of the obstetric era. In the 19th and 20th centuries, medical influence was extended further by the development of new forms of analgesia, anaesthesia, caesarean section, and safe blood transfusion. The introduction first of antiseptic and aseptic techniques and later of sulphonamides, coupled with changes in the severity of puerperal sepsis, lowered the maternal mortality that had made hospitals dangerous places in which to give birth.3
#### Summary points
Obstetricians play an important role in preserving lives when there are complications of pregnancy or labour
In developed countries, however, obstetrician involvement and medical interventions have become routine in normal childbirth, without evidence of effectiveness
Factors associated with increased obstetric intervention seem to include private practice, medicolegal pressures, and not involving women fully in decision making
Emerging evidence suggests that higher rates of normal births are linked to beliefs about birth, implementation of evidence based practice, and team working
Maternal mortality in the West fell substantially during the 20th century. The World Health Organization and Unicef …
Headings like the one above tend to grab attention, but it is not a sound basis for informed opinion. The story appeared on a midwifery e-mail network and was related to a study published in the British Journal of Obstetrics & Gynaecology (Gottvall et al, 2004). A birth-centre midwife was reporting that the study's findings was likely to influence local consideration of whether to allow primigravid women to book at her birth centre.
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This article is designed to explore ideas in the recent sociology of morality about the conjunction of ethics and embodiment in everyday life. While it draws on an interpretation of the ethical encounter as a relation of moral proximity, it extends this conception of ethics beyond the dyad to include a discussion of gift giving and generosity in the present context. This is done in order to analyse a concrete empirical event in terms of the web of moral and social codes that inform it. The event in question is a well-known New Zealand breastfeeding case in which a woman breastfed another woman's baby `without her consent'. As well as drawing attention to the ethical risks in encounters between strangers and others in contemporary social life, this particular breastfeeding case also brings to the fore the invisibility of breastfeeding as an embodied ethical practice.
The doctor–patient relationship has come under considerable scrutiny in recent research as a ‘site’ for the analysis of consumerism in medical encounters. The research reported in this article examines consumerism in obstetric encounters through an analysis of the birthing narratives of 50 women. The analyses reveal that there are clear, socially patterned variations in the character of the relationships between birthing women and their doctors. There is considerable evidence to support the notion of childbearing women as both consumers and as ‘patients’ in a medicalized encounter. There is also strong evidence that women’s use of maternity services is highly reflexive, and characterized by conscious ‘risk assessment’. These findings have important implications for the analysis of trust, risk and medical dominance in obstetric encounters.
Based on interviews with 40 first-time mothers, the authors develop an argument that supplements the critique of medicalized childbirth by focusing on the social context in which women give birth. Particularly important about that context is women's privatized responsibility for babies' well-being, and a dearth of social supports for mothering, including the sharing of that responsibility by fathers. Contextualizing childbirth in this way makes clearer not only why many women are favorable toward medical intervention but also the decisions women make during hospital births. The women we interviewed displayed widely ranging reactions to giving birth in the hospital. Describing their experiences, these women often emphasized pain and anxiety. Both conditions appear to have been relieved as effectively by social support as by medical assistance. Furthermore, women who had generally supportive partners were less likely to receive medical intervention during the birth and less likely to suffer postpartum depression.
Drawing on empirical research data on the work of flight attendants, this paper will explore Marcel Mauss's theory of ‘gift’ exchange relations, with particular reference to his concern with the ‘exchange of aesthetics’ (Mauss 1954), as an analytical model which may contribute to our understanding of ‘women's work’ in contemporary Western societies, of which, we shall argue, the work of female flight attendants is a notable example. It will begin by locating the authors' analytical and theoretical concerns with ‘women's work’ within the context of recent empirical research. It will then go on to outline briefly a Maussian model of exchange relations and to identify the potential utility of this analytical model for the study of women's work. This paper then goes on to offer an analytical account of empirical research into the work of flight attendants and to analyse the ways in which airline service provision constitutes a critical case study of women's work, certain elements of which involve a form of ‘gift’ exchange relations which operate, not as an alternative to, but inside — and in the interests of — commodity exchange relations. Finally, in the light of recent feminist work, this paper will conclude by suggesting the wider implications of this analytical model for the study of gender and work.
This paper analyses the birthing narratives of 50 Australian women to explore their representations of their birthing experiences. Through the analysis, issues of power, identity and control in childbirth are explored, particularly with respect to the major discursive categories framing childbirth. The birthing narratives of the women in this study revealed significant differences in orientation to first birth according to women’s social class, but also revealed significant shifts in identity and empowerment with subsequent births. These findings differ significantly from existing accounts of power relations in childbirth, which have tended either to universalise women, or, in more recent post-structuralist accounts, to abandon the notion of socially structured differences between women altogether. The findings of this research indicate that social class has a strong effect in the shaping of identity, but that these differences can be transcended by the experience of childbirth itself, which is a critical reflexive moment in many women’s lives.
Critiques of logical positivism form the foundation for a significant number of nursing research papers, with the philosophy being inappropriately deemed synonymous with empirical method. Frequently, proposing an alternative method to those identified with the quantitative paradigm, these critiques are based on a poor foundation. This paper highlights an alternative philosophy to positivism which can also underpin empirical inquiry, that of post-positivism. Post-positivism is contrasted with positivism, which is presented as an outmoded and rejected philosophy which should cease to significantly shape inquiry. Though some acknowledgement of post-positivism has occurred in the nursing literature, this has yet to permeate into mainstream nursing research. Many still base their arguments on a positivistic view of science. Through achievement of a better understanding of post-positivism and greater focus on explicating the philosophical assumptions underpinning all research methods, the distinctions that have long been perceived to exist between qualitative and quantitative methodologies can be confined to the past. Rather methods will be selected solely on the nature of research questions.
Who cares? Offering emotion work as a ‘gift’ in the nursing labour process
The emotional elements of the nursing labour process are being recognized increasingly. Many commentators stress that nurses’‘emotional labour’ is hard and productive work and should be valued in the same way as physical or technical labour. However, the term ‘emotional labour’ fails to conceptualize the many occasions when nurses not only work hard on their emotions in order to present the detached face of a professional carer, but also to offer authentic caring behaviour to patients in their care. Using qualitative data collected from a group of gynaecology nurses in an English National Health Service (NHS) Trust hospital, this paper argues that nursing work is emotionally complex and may be better understood by utilizing a combination of Hochschild's concepts: emotion work as a ‘gift’ in addition to ‘emotional labour’. The gynaecology nurses in this study describe their work as ‘emotionful’ and therefore it could be said that this particular group of nurses represent a distinct example. Nevertheless, though it is impossible to generalize from limited data, the research presented in this paper does highlight the emotional complexity of the nursing labour process, expands the current conceptual analysis, and offers a path for future research. The examination further emphasizes the need to understand and value the motivations behind nurses’ emotion work and their wish to maintain caring as a central value in professional nursing.
Background: Home-like birth settings have been established in or near conventional labour wards for the care of pregnant women who prefer and require little or no medical intervention during labour and birth.
Objectives: Primary: to assess the effects of care in a home-like birth environment compared to care in a conventional labour ward. Secondary: to determine if the effects of birth settings are influenced by staffing or organizational models or geographical location of the birth centre.
Search strategy: We searched the Cochrane Pregnancy and Childbirth Group trials register (18 May 2004) and handsearched eight journals and two published conference proceedings.
Selection criteria: All randomized or quasi-randomized controlled trials that compared the effects of a home-like institutional birth environment to conventional hospital care.
Data collection and analysis: Standard methods of the Cochrane Collaboration Pregnancy and Childbirth Group were used. Two review authors evaluated methodological quality. Double data entry was performed. Results are presented using relative risks and 95% confidence intervals.
Main results: Six trials involving 8677 women were included. No trials of freestanding birth centres were found. Between 29% and 67% of women allocated to home-like settings were transferred to standard care before or during labour. Allocation to a home-like setting significantly increased the likelihood of: no intrapartum analgesia/anaesthesia (four trials; n = 6703; relative risk (RR) 1.19, 95% confidence interval (CI) 1.01 to 1.40), spontaneous vaginal birth (five trials; n = 8529; RR 1.03, 95% CI 1.01 to 1.06), vaginal/perineal tears (four trials; n = 8415; RR 1.08, 95% CI 1.03 to 1.13), preference for the same setting the next time (one trial; n = 1230; RR 1.81, 95% CI 1.65 to 1.98), satisfaction with intrapartum care (one trial; n = 2844; RR 1.14, 95% CI 1.07 to 1.21), and breastfeeding initiation (two trials; n = 1431; RR 1.05, 95% CI 1.02 to 1.09) and continuation to six to eight weeks (two trials; n = 1431; RR 1.06, 95% CI 1.02 to 1.10). Allocation to a home-like setting decreased the likelihood of episiotomy (five trials; n = 8529; RR 0.85, 95% CI 0.74 to 0.99). There was a trend towards higher perinatal mortality in the home-like setting (five trials; n = 8529; RR 1.83, 95% CI 0.99 to 3.38). No firm conclusions could be drawn regarding the effects of staffing or organizational models.
Authors’ conclusions: When compared to conventional institutional settings, home-like settings for childbirth are associated with modest benefits, including reduced medical interventions and increased maternal satisfaction. Caregivers and clients should be vigilant for signs of complications.
Citation: Hodnett ED, Downe S, Edwards N, Walsh D. Home-like versus conventional institutional settings for birth. The Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD000012.pub2. DOI: 10.1002/14651858.CD000012.pub2.
Features include the selection and sampling of cases, the problems of access, observation and interviewing, recording and filing data, and the process of data analysis.
First published in 1967, Writing and Difference, a collection of Jacques Derrida's essays written between 1959 and 1966, has become a landmark of contemporary French thought. In it we find Derrida at work on his systematic deconstruction of Western metaphysics. The book's first half, which includes the celebrated essay on Descartes and Foucault, shows the development of Derrida's method of deconstruction. In these essays, Derrida demonstrates the traditional nature of some purportedly nontraditional currents of modern thoughtâone of his main targets being the way in which "structuralism" unwittingly repeats metaphysical concepts in its use of linguistic models. The second half of the book contains some of Derrida's most compelling analyses of why and how metaphysical thinking must exclude writing from its conception of language, finally showing metaphysics to be constituted by this exclusion. These essays on Artaud, Freud, Bataille, Hegel, and Lévi-Strauss have served as introductions to Derrida's notions of writing and différenceâthe untranslatable formulation of a nonmetaphysical "concept" that does not exclude writingâfor almost a generation of students of literature, philosophy, and psychoanalysis. Writing and Difference reveals the unacknowledged program that makes thought itself possible. In analyzing the contradictions inherent in this program, Derrida foes on to develop new ways of thinking, reading, and writing,ânew ways based on the most complete and rigorous understanding of the old ways. Scholars and students from all disciplines will find Writing and Difference an excellent introduction to perhaps the most challenging of contemporary French thinkersâchallenging because Derrida questions thought as we know it.
Many currently accepted obstetrical practices exemplify a maximin strategy: making the best of the worst possible outcome, regardless of the actual probability of that outcome occurring. But a survey of recent obstetrical research fails to document superior clinical results when this strategy is employed in routine obstetrical care. Most research has studied obstetrical technologies in isolation rather than as parts of systems of interconnected interventions: this approach has tended to underestimate the risks of intervention and to overestimate the utility of a maximin strategy. Physicians practicing obstetrics should adopt a flexible approach and match the degree and type of intervention to actual patient needs. Better methods of assessing preventable prenatal risk are needed to allow identification of the rare-obstetrical patient requiring maximal intervention.
The aims of the study were to examine women's experiences of their labour and the birth of their baby. The use of qualitative method ensured that the research focused on the perspectives of the participants. The purposive sample consisted of 11 women volunteers in a maternity unit of a general hospital. Unstructured, tape-recorded interviews provided an opportunity for the informants to express their thoughts and feelings. The constant comparative method, a feature of Grounded Theory, was used to analyse the data. The research demonstrated that women trust midwives because the latter are seen as experts who 'know best'. In doing so, women place themselves in the hands of professionals giving them the authority to make decisions about procedures, drugs and types of care. This belief in the professionals' expertise influences the type of relationship between the women and midwives. Nevertheless, women also want to take an active part in the control of labour. The study identified a need for a flexible relationship between women in labour and their midwives.
taking evidence provided by an ethnographic study based on women's experiences of pregnancy and childbirth, and using ritual theory in the analysis of the relationship between the medical metaphor, inherent in contemporary birth settings, and the views and expectations of childbirth which the women bring with them to that setting.
small scale qualitative study using ethnographic research techniques.
GP surgeries, two consultant-led, hospital-based antenatal units, labour suites and postnatal wards, plus the homes of the women involved from the north east of England.
40 primigravid women providing two sample groups. Half of the women were actively involved in antenatal class programmes run by the National Childbirth Trust and the NHS and the other half did not attend any antenatal classes.
within the sample there was a clear cultural diversity which carried significant implications on how the women assembled their understanding of pregnancy and birth antenatally. However, this division lost clarity at the onset of labour, rendering delivery experiences more similar than might have been expected. Ritual theory offers significant insight into this phenomenon, analysing birth as a rite of passage provided a necessary tool to explain why this pattern emerged in the data.
cultural diversity suggests an element of caution should be used when advocating the notion of 'informed choice' across the board, sensitivity to existing cultural values is imperative. Despite an emphasis on informed choice, midwifery practice continues to offer the medical metaphor as the dominant cultural prop in the labour ward.
Helping women to make informed choices during pregnancy is an important and complex part of a midwife's role that does not appear as yet to have been investigated in depth. The purpose of this study was to use a grounded theory approach to investigate the processes involved when midwives engage in facilitating the making of informed choices for women in the United Kingdom. Interactions between midwives and pregnant women were observed and recorded and focused interviews were conducted with the midwives. Data were analysed according to the grounded theory method. The core category was identified as protective steering, whereby midwives were concerned to protect the women in their care, as well as themselves, when choices were made. Substantive categories were orienting, protective gatekeeping and raising awareness.
The process of birth provides a structure around which social and cultural forces guide its expression. These social and cultural forces reflect the organization of power in a society while creating the potential for diversity in birth beliefs, practices, and experiences. In this article, marginalized women contrast their experiences in the cultures of two divergent birth systems: the technocratic hospital system and a freestanding midwifery managed birth center system. The women in this study come from many different cultures, yet they share a common desire to (a) control the birth environment, (b) establish supportive interpersonal connections with providers, (c) have a safe birth, and (d) be treated with dignity and respect. However, the descriptions in this article illustrate the gender, race, and class power inequities experienced when technocratic cultural forces conflicted with oppressed women's basic needs for respect and control.
To explore the experience of a known midwife for labour and birth as provided through the partnership caseload model of care in women who had a previous baby under an alternative system of care.
A qualitative study using an ethnographic approach. Data were collected by tape-recorded interviews.
The maternity unit at Leicester Royal Infirmary NHS Trust, Leicester, UK in 1998.
10 multiparous women cared for by Birth Under Midwifery Practice Scheme (BUMPS) midwives were interviewed between eight- and 12 weeks' postpartum.
Women's perceptions and experiences were predominantly influenced by the relationships they had with their midwives who they described as 'friends'. All other themes were filtered through these relationships, including previous negative experiences of maternity care, the valuing of a known midwife for labour and birth, their positive birth experiences, expressions of delight at their care, their liking of home antenatal care, and the appreciation of their existing children and partners meeting their midwives.
Partnership caseload midwifery practice has significant positive impact on women's experience of childbirth. The midwife/woman relationship that has evolved in this context is highly valued by women and challenges traditional professional roles. The model should be explored in other settings to see if its benefits to women are transferable.
This article describes three paradigms of health care that heavily influence contemporary childbirth, most particularly in the west, but increasingly around the world: the technocratic, humanistic, and holistic models of medicine. These models differ fundamentally in their definitions of the body and its relationship to the mind, and thus in the health care approaches they charter. The technocratic model stresses mind-body separation and sees the body as a machine; the humanistic model emphasizes mind-body connection and defines the body as an organism; the holistic model insists on the oneness of body, mind, and spirit and defines the body as an energy field in constant interaction with other energy fields. Based on many years of research into contemporary childbirth, most especially through interviews with physicians, midwives, nurses, and mothers, this article seeks to describe the 12 tenets of each paradigm as they apply to contemporary obstetrical and health care, and to point out their futuristic implications. I suggest that practitioners who combine elements of all three paradigms have a unique opportunity to create the most effective obstetrical system ever known.
to describe the extent to which women using maternity services perceive that they have exercised informed choice.
twelve maternity units in Wales.
postal survey of women using maternity services, covering women's views of the extent to which they exercised informed choice overall, and at eight decision points during their care.
1386 women at approximately 28 weeks gestation (antenatal sample) and 1741 women at approximately 8 weeks post delivery (postnatal sample).
54% of women perceived that they exercised informed choice overall in the antenatal sample (95% CI: 51-57%) and 54% overall in the postnatal sample (95% CI: 52-56%). Perceptions of informed choice differed by decision point, varying between 31% for fetal heart monitoring during labour and 73% for the screening test for Down's syndrome and spina bifida in the baby. There were differences by maternity unit, even when the characteristics of women attending these units were taken into account. Multiparous women, women from manual occupations and women with lower educational status were more likely to feel that they exercised informed choice during antenatal care. These sub-groups of women were also more likely to report a preference for not sharing decision-making with health professionals.
a large minority of women felt that they had not exercised informed choice overall in their maternity care. The perception of informed choice differed by decision point, maternity unit and characteristics of the woman.
attaining informed choice is more of a challenge for some decision points in maternity care than others, particularly fetal monitoring. The difference in levels of informed choice between maternity units highlights the importance of maternity unit policy in the promotion of informed choice.
Proponents of the global Safe Motherhood Initiative stress that primary keys to safe home birth include transport to the hospital in cases of need and effective care on arrival. In this article, which is based on interviews with American direct-entry midwives and Mexican traditional midwives, I examine what happens when transport occurs, how the outcomes of prior transports affect future decision-making, and how the lessons derived from the transport experiences of birthing women and midwives in the US and Mexico could be translated into improvements in maternity care. My focus is on home birth in urban areas in Mexico and the US. In both countries, biomedicine and home-birth midwifery exist in separate cultural domains and are based on distinctively different knowledge systems. When a midwife transports a client to the hospital, she brings specific prior knowledge that can be vital to the mother's successful treatment by the hospital system. But the culture of biomedicine in general tends not to understand or recognize as valid the knowledge of midwifery. The tensions and dysfunctions that often result are displayed in midwives' transport stories, which I identify as a narrative genre and analyze to show how reproduction can go unnecessarily awry when domains of knowledge conflict and existing power structures ensure that only one kind of knowledge counts. This article describes: (1) disarticulations that occur when there is no correspondence of information or action between the midwife and the hospital staff; and (2) fractured articulations of biomedical and midwifery knowledge systems that result from partial and incomplete correspondences. These two kinds of disjuncture are contrasted with the smooth articulation of systems that results when mutual accommodation characterizes the interactions between midwife and medical personnel. The conclusion links these American and Mexican transport stories to their international context, describing how they index crosscultural markers, and suggest solutions, for "the trouble with transport."
To review the evidence for a relationship between organisational culture and health care performance.
Qualitative comprehensive review: all empirical studies exploring a relationship between organisational culture (broadly defined) and health care performance (broadly defined) were identified by a comprehensive search of the literature. Study methods and results were analysed qualitatively to provide a narrative review with integrative discussion.
Ten studies met the inclusion criteria. There was considerable variation in the design, study setting, quality of reporting and aspects of culture/performance considered. Four of the ten studies reviewed in detail claimed to have uncovered supportive evidence for the hypothesis that culture and performance are linked. All the other studies failed to find a link, though none provided strong evidence against the hypothesis.
There is some evidence to suggest that organisational culture may be a relevant factor in health care performance, yet articulating the nature of that relationship proves difficult. Simple relationships such as 'strong culture leads to good performance' are not supported by this review. Instead, the evidence suggests a more contingent relationship, in that those aspects of performance valued within different cultures may be enhanced within organisations that exhibit those cultural traits. A striking finding is the difficulty in defining and operationalising both 'culture' and 'performance' as variables that are conceptually and practically distinct. Considerably greater methodological ingenuity will be required to unravel the relationship(s) between organisational culture(s) and performance(s). Current policy prescriptions, which seek service improvements through cultural transformation, are in need of a more secure evidential base.
Almost since its inception, the concept of modernity was found to display tensions between its emancipatory potential to liberate the human subject from the manacles of tradition, and the application of reason to co-ordinate and control the natural world through scientific knowledge. This paper presents a qualitative analysis of in-depth interviews with 12 midwives about their role in the Irish maternity services and argues that, in a period of late modernity, these tensions continue to manifest themselves in the context of the midwife's role. Although the contemporary period is marked by a loss of faith in scientific truths, widely contested obstetric knowledge and practices continue to exercise mastery over nature while undermining a central feature of the midwife's role-the liberation of the autonomous subject. Drawing on the theory of communicative action developed by the critical theorist Jürgen Habermas, it is argued that the midwife's role in facilitating the autonomous choices of women through communicative action is impeded by the colonization of the lifeworld of labour and childbirth by the technocratic system of obstetrics. Although participants reported that their role involved empowering women and facilitating choices through dialogue congruent with communicative action, data also suggested that participants used strategic communication with clients aimed at achieving particular ends. The use of strategic communication was linked to the way in which the midwife's role is determined to a large extent by the practices and protocols of obstetrics, and also to the notion of client passivity. The instrumental rationality of obstetrics is linked to an outcome orientation to power and money, and a political economy perspective of medicine. It appears that communicative action between midwives and obstetricians is important in bringing about structural changes to facilitate the conditions for communicative action between midwives and their clients.
Over the last two decades, childbirth worldwide has been increasingly concentrated in large centralized hospitals, with a parallel trend toward more birth interventions. At the same time in several countries, interest in midwife-led care and free-standing birth centers has steadily increased. The objective of this review is to establish the current evidence base for free-standing, midwife-led birth centers.
A structured review, based on Cochrane guidelines, was conducted that included nonrandomized studies. The comparative outcomes measured were rates of normal vaginal birth; cesarean section; intact perineum; episiotomy; transfers; and babies remaining with their mothers.
Of the 5 controlled studies that met the review criteria, all except one was a single site study. Since no study was randomized, meta-analysis was not performed. The included studies all raised quality concerns, and significant heterogeneity was observed among them. For the outcomes measured, every study reported a benefit for women intending to give birth in the free-standing, midwife-led unit.
The benefits shown for women recruited into the included studies who intended to give birth in a free-standing, midwife-led unit suggest a question about the efficacy of consultant unit care for low-risk women. However, the findings cannot be generalized beyond the individual studies. Good quality controlled studies are needed to investigate these issues in the future.