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A Feminist Narrative Inquiry of NHS Midwives Supporting and Facilitating Women’S Alternative Physiological Birthing Choices

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A Feminist Narrative Inquiry of NHS Midwives Supporting and Facilitating Women’S Alternative Physiological Birthing Choices ‘Practising outside of the box, whilst within the system’: A feminist narrative inquiry of NHS midwives supporting and facilitating women’s alternative physiological birthing choices. by Claire Lauren Feeley RM, BSc (Hons), MSc Volume 1 A thesis submitted in partial fulfilment for the requirements for the degree of Doctor of Philosophy at the University of Central Lancashire. August 2019 i ii Abstract This thesis presents the findings of an original study that explored NHS midwives practice of facilitating women’s alternative physiological birthing choices - defined in this study as ‘birth choices that go outside of local/national maternity guidelines or when women decline recommended treatment of care, in the pursuit of a physiological birth’. The premise for this research relates to dominant sociocultural-political discourses of medicalisation, technocratic, risk-averse and institutionalisation that has shaped childbirth practices in the UK. For midwives working in the NHS, sociocultural-political and institutional constraints can negatively impact their ability to provide care to women making alternative birth choices. A meta-ethnography was carried out, highlighting a paucity of literature in this area. Therefore, the aim of this study was to generate practice-based knowledge to answer the broad research question: ‘what are the processes, experiences, and sociocultural-political influences upon NHS midwives’ who self-define as facilitative of women’s alternative birthing choices’. Underpinned by a feminist pragmatist theoretical framework, a narrative methodology was used to conduct this study. Professional stories of practice were collected via self-written narratives and interviews to understand the processes of facilitation (the what, how, why), their experiences of carrying out facilitative actions (subjective sense-making), and what sociocultural-political factors influenced their practice. Through purposive and snowball sampling, a diverse sample of 45 NHS midwives from across the UK was recruited. A sequential, pluralistic narrative approach to data analysis was carried out, and a theoretical model was developed using the whole dataset. The findings were subjected to three levels of analysis. First, ‘Narratives of Doing’ highlight how and what midwives did to facilitate women’s alternative choices. The sub-themes reflect the temporal nature of a wide range of actions/activities involved when caring for women making alternative birthing decisions. The second analysis; ‘Narratives of Experience’ - highlighted the midwives polarised experiences captured as ‘stories of distress’, ‘stories of transition,’ and ‘stories of fulfilment’. For the third level of analysis, a theoretical model of ‘stigmatised to normalised practice’ was developed using notions of stigma/normal, deviance/positive deviance. A six-domain model was developed that accounted for the midwives sociocultural-political working contexts; micro, meso, and macro. iii The implications of this research related to a number of identified constraints, protective factors, and enabling factors for midwifery practice. Key barriers included negative organisational cultures that restricted both midwives’ and women’s autonomy. Disparities between the midwives’ philosophy and their workplace culture were highlighted as a key stressor and barrier to delivering woman-centred care. Protective factors related to the benefits of working in supportive, like-minded teams that mitigated against their wider stressful working environments. Facilitating factors included positive organisational cultures characterised by strong leadership where midwives were trusted and women’s autonomy was supported. Therefore, this study has captured what has been achieved, and what can be achieved within NHS institutional settings. Through the identification of both challenges and facilitators, the findings can be used to provide maternity professionals and services with insights of how they too can facilitate women’s alternative birthing choices. iv Publications & presentations resulting from this thesis Peer reviewed journal publications: Feeley, C., Thomson, G., Downe S (2019). Caring for women making unconventional birth choices: A meta-synthesis exploring the views, attitudes, and experiences of midwives. Midwifery, (20) 50-59 Peer reviewed published abstracts: Feeley, C (2018). What evidence informs midwifery clinical practice when women make birthing decisions that are outside of guidelines? An empirical study of UK midwives working in the NHS. BMJ Evidence-Based Medicine, 23 (Supp 1): A1-A37 Professional publications: Feeley, C (2017) Exploring basic legal and ethical concepts in maternity care. The Practising Midwife. 11(10), 8-11. Feeley, C (2017) Guideline-centred care or woman-centred care? The Practising Midwife, 20(7): 8-11. Feeley, C (2017) No means no…let’s talk about consent. The Practicing Midwife, 20 (4), 25-27. Peer reviewed conferences: Feeley, C (2018) What evidence informs midwifery clinical practice when women make birthing decisions that are outside of guidelines? - An empirical study of UK midwives working in the NHS. Oral presentation Evidence Live Conference, Oxford University 20-22nd June. Feeley, C (2018) Seeking to understand my positioning as a midwife-researcher whilst researching on and with fellow midwives: an exploratory presentation. Oral presentation- Qualitative Research Symposium, 31st Jan, Bath, UK Feeley, C., Thomson, G., Downe, S (2017) Caring for women making unconventional birth choices, the views, attitudes and experiences of midwives- a metasynthesis. Poster presentation- RCM Conference Oct 31st, Manchester, UK. Feeley, C., Thomson, G., Downe, S (2017) Caring for women making unconventional birth choices, the views, attitudes and experiences of midwives- a metasynthesis. Oral presentation – UCLAN Normal Birth and Labour Conference, 2nd-4th Oct, Grange- over-Sands, Cumbria, UK. Invited speaker conferences: v Feeley, C (2019) Midwives supporting and facilitating women’s alternative birthing decisions in the UK- A feminist narrative inquiry. The Art and Science of Midwifery Student Conference, 29th Jan, Bedford University, Bedford, UK. Feeley, C (2018) Midwives supporting and facilitating women’s alternative birthing decisions in the UK- A feminist narrative inquiry. UCLan Student Midwifery Conference, 13th September, Preston, UK. Feeley, C (2018) Midwives supporting and facilitating women’s alternative birthing decisions in the UK- A feminist narrative inquiry. International Day of the Midwife symposium, Luton and Dunstable University Hospital, 4th May, Luton, UK. vi Acknowledgements Firstly, this thesis is a thank you to my midwives- whether they realised it or not, their ‘practicing outside of the box’ facilitated a much wanted joyful and empowering birth. Without them, it is unlikely this work would have been carried out. I am hugely grateful for my supervisory and research team, Assoc Prof Gill Thomson, Prof Soo Downe and Dr Carol Kingdon. Gill and Carol were there at the start of my postgraduate journey and have encouraged me through to the end. Gill’s consistent support throughout both studies have been invaluable to me personally and professionally. Within this study, Gill’s attention to the details and Soo’s devil advocacy approach both stimulated a constant interrogation of my work, strengthening my emerging researcher identity and skill development. I am incredibly grateful to my friends and family, in particular James. Parenting whilst doing a PhD brought us many challenges, and I’m grateful for his patience. This work definitely would not have been completed if not for our informal ‘PhD support group’! Steph, Louise, and Naoimh were incredible all the way through. I am immensely grateful to the participants who gave up their time to contribute to this study. Many faced a number of competing challenges in order to participate in this study. Thank you so much for time, energy, and most of all for the work you are doing on a daily basis to support women’s birthing choices. You have been inspirational. I have also received so much support from the wider maternity community, so a big thank you to Sheena and Anna Byrom, The Practicing Midwife – I am so grateful for the opportunities you have given me. Thank you to Kati Edwards for her amazing poetry which she has allowed into this thesis, her poetry sums up the importance of this study. In addition, the RCM, Association of Radical Midwives and Birthrights organisation also supported this work by advertising the study. With their wide reach, I was able to recruit a fantastic range of midwives to the study. vii Contents Abstract ................................................................................................................ iii Publications & presentations resulting from this thesis ............................ v Acknowledgements .......................................................................................... vii Contents ............................................................................................................. viii Tables ................................................................................................................... xi Figures ................................................................................................................. xii Acronyms ........................................................................................................... xiii Glossary .............................................................................................................
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