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When referring to this work, full bibliographic details including the author, title, awarding institution and date of the thesis must be given e.g. AUTHOR (year of submission) "Full thesis title", University of Southampton, name of the University School or Department, PhD Thesis, pagination http://eprints.soton.ac.uk UNIVERSITY OF SOUTHAMPTON FACULTY OF HEALTH SCIENCES Voicing the silence: the maternity care experiences of women who were sexually abused in childhood by Elsa Montgomery Thesis for the degree of Doctor of Philosophy October 2012 UNIVERSITY OF SOUTHAMPTON ABSTRACT FACULTY OF HEALTH SCIENCES Midwifery Thesis for the degree of Doctor of Philosophy VOICING THE SILENCE: THE MATERNITY CARE EXPERIENCES OF WOMEN WHO WERE SEXUALLY ABUSED IN CHILDHOOD Elsa Mary Wells Montgomery Childhood sexual abuse is a major, but hidden public health issue estimated to affect approximately 20% of females and 7% of males. As most women do not disclose to healthcare professionals, midwives may unwittingly care for women who have been sexually abused. The purpose of this study was to address the gap in our understanding of women’s maternity care experiences when they have a history of childhood sexual abuse with the aim of informing healthcare practice. This narrative study from a feminist perspective, explored the maternity care experiences of women who were sexually abused in childhood. In-depth interviews with women, review of their maternity care records and individual and group interviews with maternity care professionals were conducted. The Voice-centred Relational Method (VCRM) was employed to analyse data from the in-depth interviews with women. Thematic analysis synthesised findings, translating the women’s narratives into a more readily accessible form. The main themes identified were: narratives of self, narratives of relationship, narratives of context and the childbirth journey. Medical records provided an additional narrative and data source providing an alternative perspective on the women’s stories. Silence emerged as a key concept in the narratives. This thesis contributes to ‘Voicing the silence’. The particular contribution of the study is its focus on the women’s voices and the use and development of VCRM to listen to them. It highlights where those voices are absent and where they are not heard. Women want their distress to be noticed, even if they do not want to voice their silence. The challenge for those providing maternity care is to listen and respond to their unspoken messages and to hear and receive their spoken ones with sensitivity. i Contents ABSTRACT ................................................................................................................................ i Contents ................................................................................................................................ iii List of tables ........................................................................................................................ix List of figures ......................................................................................................................ix DECLARATION OF AUTHORSHIP ...............................................................................xi Acknowledgements ....................................................................................................... xiii 1. Chapter One: Introduction ................................................................................. 1 1.1 Prologue ............................................................................................. 1 1.2 Background ........................................................................................ 3 1.3 Childhood sexual abuse and childbearing women ............................... 4 1.4 Defining childhood sexual abuse ........................................................ 5 1.5 Prevalence of childhood sexual abuse ................................................. 7 1.6 Implications for maternity care ........................................................... 9 1.7 The experience of pregnancy and birth ............................................... 9 1.7.1 Control ....................................................................................... 11 1.7.2 The need for information ........................................................... 13 1.7.3 Support ...................................................................................... 13 1.7.4 Experience of pain ...................................................................... 15 1.8 Summary .......................................................................................... 16 2. Chapter Two: Literature review ................................................................... 17 2.1 Introduction ..................................................................................... 17 2.2 Search strategy ................................................................................. 18 2.3 Critical review of the studies ............................................................. 19 2.4 Summary .......................................................................................... 28 3. Chapter Three: Research design ................................................................. 29 3.1 Introduction ..................................................................................... 29 3.2 Identifying the problem .................................................................... 30 3.3 Feminist research ............................................................................. 30 3.4 Narrative research ............................................................................ 33 3.4.1 The nature of narrative ............................................................... 33 3.5 In-depth interviews ........................................................................... 35 iii 3.5.1 Non-hierarchical relationships and the issue of power ................ 36 3.6 Analytical approach........................................................................... 37 3.6.1 Narrative analysis ....................................................................... 37 3.6.2 The Voice-Centred Relational Method ......................................... 39 3.7 Maternity care records ...................................................................... 42 3.8 Interviews with maternity care professionals ..................................... 45 3.9 Summary .......................................................................................... 46 4. Chapter Four: Generating the data ............................................................ 47 4.1 Introduction ...................................................................................... 47 4.2 Accessing stakeholders ..................................................................... 47 4.2.1 Public and Stakeholder involvement ............................................ 48 4.3 Identification and recruitment of participants .................................... 49 4.3.1 Women who were sexually abused in childhood .......................... 49 4.3.2 Sampling .................................................................................... 49 4.3.3 Inclusion criteria ......................................................................... 50 4.3.4 Exclusion criteria ........................................................................ 51 4.3.5 Personal disclosure ..................................................................... 52 4.4 Accessing women ............................................................................. 52 4.4.1 Contacting women ...................................................................... 53 4.5 Accessing maternity care professionals ............................................. 54 4.5.1 Midwives .................................................................................... 54 4.5.2 Obstetricians .............................................................................. 55 4.6 Generating data ................................................................................ 55 4.6.1 In-depth interviews with women ................................................. 55 4.6.2 Interviewing maternity care professionals ................................... 57 4.6.3 Maternity care records ................................................................ 59 4.7 Ethical issues .................................................................................... 60 4.7.1 Maintaining the wellbeing of participants ................................... 60 4.7.2 Maintaining my wellbeing ........................................................... 62 4.7.3 Anonymity .................................................................................. 62 4.7.4 Confidentiality ............................................................................ 62 4.7.5 Healthcare professionals............................................................. 63 4.7.6 Data confidentiality