The experience of vaginal breech birth A social, cultural and gendered context Jenny Davidson RM, BSc, PGCert, MA A thesis submitted in partial fulfilment of the requirements of the University of Brighton for the degree of Doctor of Philosophy July 2015 PhD: The Experience of Breech Birth ABSTRACT Breech birth has become a rare phenomenon in England over the last two decades. 3-4% of all babies present bottom or feet first at full term (37-42 weeks gestation) and despite conflicting research about the safest mode of delivery for breech presentation, the vast majority of breech babies will be delivered by planned caesarean section. The small number of qualitative research studies suggest that the experience of breech has complex meanings for childbearing women. This research intended to explore these elements further and to better understand this experience within a social, cultural and gendered context. A social constructionist theoretical framework with a feminist post-structural position guided the research design. A research case study methodological approach was adopted drawing from different sources to understand the case of vaginal breech birth experience. Participants from the South of England included eleven women who had given birth to breech babies, either at hospital and home, six midwives and two obstetricians who had provided care for women giving birth to breech babies. Thematic content analysis was used during and following the collection of data, which comprised of in-depth interviews as the primary source of data and documentary analysis as secondary contextual data. Vaginal breech birth is a challenging journey, best understood as three interconnected spaces shaped by the complex social relationships and cultural and gendered context of childbirth. Four themes emerged: Losing the way; Fighting fear and seeking trust; Deciding the right path to follow; and Towards a place of safety. These themes define the experience as one of moving between significant phases of Disrupted space, Uneasy space and Third space. The findings indicate that the prevailing risk paradigm has marginalised breech, disrupting the childbirth journey and creating a deep sense of loss. Vaginal breech birth eludes the narrow polarities of medicalised childbirth and natural birthing, fitting into neither and troubling both. The navigation of these messages is central to the uneasy space, which is a time of pause and consideration with a strong desire to hear different voices to that of a dominant medical view. This provides an opportunity for a less bounded form of birth where individuals seek to prioritise safety in the creation or holding of safe spaces, albeit temporarily and with some compromises. In working to address these challenges, care providers should consider broadening the options available to all women, working together as a team to create safe spaces for the multiple birthing options that women require. 2 PhD: The Experience of Breech Birth 3 PhD: The Experience of Breech Birth CONTENTS ABSTRACT ........................................................................................................................... 2 TERMS AND ABBREVIATIONS ........................................................................................... 8 ACKNOWLEDGEMENTS ................................................................................................... 10 DECLARATION .................................................................................................................. 11 INTRODUCTION TO THE THESIS ..................................................................................... 12 CHAPTER 1: LITERATURE REVIEW ................................................................................. 15 1.0 Introduction ........................................................................................................................... 15 1.1 UK Healthcare and Contemporary childbirth ................................................................... 16 1.2 Breech Birth .......................................................................................................................... 26 1.2.1 Breech birth care, management and skills ................................................................... 37 1.2.2 The experience of breech birth ...................................................................................... 40 1.2.3 Researcher’s perspective ................................................................................................ 44 1.2.4 Summary ........................................................................................................................... 46 CHAPTER 2: THEORETICAL PERSPECTIVES ...................................................................... 48 2.0 Introduction ............................................................................................................................... 48 2.1 Philosophical position ............................................................................................................. 49 2.2 Theoretical Framework ........................................................................................................... 50 2.3 Feminist research .................................................................................................................... 54 2.4 Summary ................................................................................................................................... 60 CHAPTER 3: METHODOLOGY .......................................................................................... 61 3.0 Introduction ............................................................................................................................... 61 3.1 Research design ...................................................................................................................... 62 3.2 Research questions ................................................................................................................. 64 3.3 Introduction to the research methodology approach .......................................................... 66 3.3.1 Feminist research and methodological approach ....................................................... 67 3.3.2 Research Case Study ...................................................................................................... 69 3.3.3 Considerations with using research case study .......................................................... 76 3.3.4 Consideration of alternative research methodologies ................................................ 78 3.4 Summary ................................................................................................................................... 81 CHAPTER 4: METHODS .................................................................................................... 82 4 PhD: The Experience of Breech Birth 4.1 Introduction ............................................................................................................................... 82 4.2 Data collection .......................................................................................................................... 82 4.2.1 Feminist approach to data collection ............................................................................. 82 4.2.2 Site and Populations Selection ...................................................................................... 83 4.2.3 Data Gathering Methods ................................................................................................. 87 4.2.4 Recruitment and consent ................................................................................................ 88 4.2.5 Interviews ........................................................................................................................... 92 4.2.6 Documents and documentary analysis ......................................................................... 95 4.3 Data analysis ....................................................................................................................... 97 4.3.1 Introduction ........................................................................................................................ 97 4.3.2 Thematic content analysis ............................................................................................... 97 4.3.3 Coding ................................................................................................................................ 99 4.3.4 Themes and development of findings chapter ........................................................... 102 4.3.5 Reflecting and reflexivity ............................................................................................... 103 4.4 Ethical considerations ........................................................................................................... 105 4.5 Summary ................................................................................................................................. 109 CHAPTER 5: RESULTS OF THE ANALYSIS OF THE DATA ........................................... 110 5.1 Introduction ............................................................................................................................. 110 5.2 Losing the Way ...................................................................................................................... 113 5.3 Fighting fear and seeking trust ...........................................................................................