Conflicting contexts : midwives' interpretation of childbirth through photo elicitation

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BACKGROUND The increasing rates of interventions during childbirth in Australia raise serious concerns about how to keep birth normal. As midwives are the primary care givers for women during labour, it is conceivable that they have a direct influence on birth outcomes. Limited research has been undertaken regarding midwives' beliefs about childbirth and how they interpret the process of labour. This research examines the thought processes and cognitive frameworks that midwives construct around childbirth in order to understand if midwifery care is influencing the use of interventions during childbirth. METHOD A qualitative interpretive study was undertaken using a technique called photo elicitation. The study involved interviewing 12 midwives recruited from a variety of metropolitan maternity hospitals in Sydney, Australia. Photo elicitation is used to draw out in-depth responses from the midwives about their beliefs in relation to labour and to explore how and why they make clinical decisions. During the interview, participants were shown a photograph of a labouring woman and asked specific questions about how they would care for her. This was in the form of semi structured open-ended questions. The data were analysed using thematic analysis, which provided a flexible yet rigorous method for the interpretation and application of the themes. FINDINGS Six themes emerged from the data that clearly indicated midwives felt challenged by working in a system dominated by an obstetric model of care that undermined midwifery autonomy in maintaining normal birth. These themes were: Desiring Normal, Scanning the Environment, Constructing the Context, Navigating the Way, Relinquishing Desire and Reflecting on Reality. Most midwives felt they were unable to practice in the manner they were philosophically aligned with, that is, promoting normal birth, as the medical model restricted their practice. Midwives described a sense of frustration and powerlessness about having to conform to the protocols and procedures that reflected the institutionalised culture of the hospitals. DISCUSSION As the profession of midwifery comes from a history of marginalisation there remains a culture of subordination that inhibits the visibility and validity of midwifery philosophy. This research offers the concept of parrhesia, a Greek word, meaning to speak without fear, as a constructive and pragmatic way to challenge the dominant obstetric model. Parrhesia is suggested by Foucault as a technique to challenge unequal power relationships (Foucault 1983). This research recommends that midwives become skilled and confident in using parrhesia as an effective method to articulate their beliefs and desires for normal birth in the increasingly technological environment of childbirth.
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